Links I liked

 

Heat map based density plots in R (link)
101 awesome public health blogs (link), many of these are old and dead (like me!) so this one with only 75 blogs was a bit more useful (link)
Tech can’t solve all problems, but it can help with some. (link)
R, working with raster files in Shiny (link)
Why health care costs so much (link)

And some great shamisen action from Ichikawa Chikuyou.

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Kenya 2017 Election Violence: Some Data Analysis

I’m getting used to the new version of ArcGIS (which is a vast improvement!) and gave it a test run on some data from the ACLED (Armed Conflict Location & Event Data Project) database, specifically on this years round of violence surrounding the Kenyan election. ACLED keeps real time data on violence and conflict around the globe, the latest entry in 2017 is Nov 24, just five days ago.

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The first election occurred on August 8th, 2017. The opposition contested the results of the election, claiming problems in vote tallying by the IEBC, resulting in a nullification by the Supreme Court. A new election was called and was to be conducted within 60 days of the nullification. Raila Odinga, the opposition leader, claimed that the election again would not be fair, dropped out of the race and called for a national boycott. The election went ahead as place on October 26, 2017 and Uhuru Kenyatta was declared the winner.

NairobiViolence

 

 

There was violence at every stage of the process, both by rioters in support of the opposition and by the police and military who were known to fire live rounds into groups of demonstrators. Opposition supporters were known to set fire to Kikuyu businesses. Local Kikuyu gangs were reported to be going house to house rooting out people from tribal groups from the West and beating them in the street. Tribal groups in rural areas were reported to be fighting amongst one another. The police response has been heavy handed and disproportionate leading to a national crisis.

As of now, though not nearly as violent as the post election violence of 2007-08, the violence has not yet abated.

In the database, there were 420 events logged, including rioting, protests and violence against civilians by the state, police and local tribal militias. There are 306 recorded fatalities in the data base, but this number should be approached with some caution. There were likely more. The database is compiled from newspaper reports, which don’t count fatalities and don’t cover all events.
ViolentTSI made two maps (above), one for Nairobi, and the other for Kenya. They include all non Al-Shabaab events (a Somali Islamist group the Kenya Defense Force has been fighting for several years.) I also included a time series of both events and fatalities.

Some excerpts from the notes:

“Police raided houses of civilians in Kisumu, beating civilians and injuring dozens. Live bullets were used on some civilians, including a 14 year old boy. Of the 29 people injured, 26 had suffered gun shots.”

“One man was found dead in a sugar cane plantation one day after ethnic tensions between the Luo and Kalenjin communities got into an ethnic clash. The body had been hacked with a panga.”

“Rioters started throwing stones at the police in the morning, protesting against the elections to be held the next day. The police responded with teargas and water canons. The rioters were mostly from the Luo ethnic group and they took the opportunity to loot several stores, attack residents and to burn a store owned by an ethnic Kikuyu. One woman was raped.” *This was in Kawangware, not far from my apartment. I was eating at a local bbq place when this happened. 

 

 

“Police forces attacked supporters of the opposition that went to the Lucky Summer neighbourhood to check on a ritual of beheading of a sheep that was taking place (suspectedly by the Mungiki sect). The police shot at the civilians. The police confirmed that it shot a man and that the group performing the ritual had sought protection.”

“As a revenge to the previous event, the Kikuyu joined forces and attacked the Luo. The ethnic tensions and violence led to one severely injured person. Residents claims three were killed and dozens, including three school children, were injured.”

Links I liked

Scarlet fever is back (link)
Lake Chad’s humanitarian disaster (link)
Mapping the drug overdose epidemic (link)
Undernutrition in TZ. Only 8% young kids are adequately nourished (link)
Inverse distance weighting in R (and resizing maps) (link)

And some music from Lucas:

A visit to the local witchdoctor: treating snakebites in Kwale, Kenya

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Wound from a puff adder bite

Humans have had to deal with the threat of snakebites as long as humans have existed. While deaths from snakebites are rare, the outcomes are so severe and the nature of the animal so mysterious, that humans have developed all sorts of ways of dealing with them.

Witchdoctors, or Mganga as they are known in East Africa, are the first line for snakebite treatment here. The Waganga are fairly useless for treating many serious health issues, but they have carved out a niche for themselves for a few public health problems.

Our survey in Western Kenya confirms that nearly 100% of people who have been bitten by a snake visit the Mganga, regardless of whether they visit a formal health facility or not.

I went and sat down with an established Mganga here in Kwale and he was gracious enough to answer all of my questions openly and (mostly) honestly.

Hello, thank you for taking the time to speak with me today. Is English OK?

No, my English is not very good. Can we do this through a translator?

Of course. So, what happens when a patient comes in for treatment for a snakebite?

When the patient comes in, I first apply the “njiwe na njoka” (lit: snake stone). The stone sucks all the poison out of the wound. When you put it on the bite, it will stick. When the stone has absorbed all the poison, it will fall off.

What do you mean? Like it just sticks to the flesh without tying it?

Yes, if there is poison, the stone will stick to the body. When all the poison is gone, the stone will fall off. After it is done, I take the stone and wash it with milk several times and then use it again for the next patient.

What is the snake stone? Is it like a rock? I’ve seen people use charcoal in the villages. They tie it to the wound, it doesn’t appear to stick on its own.

No, this is different. This is a stone from the snake. The stone is in the skull of the snake, like that of a fish.

(Note: I did not know this, but some species of snakes have otoliths, like most fish. Snakes (and fish) are deaf in the traditional sense. The otolith is a piece of calcium which grows as the animal ages and sit on top of a bed of nerves. When there are vibrations, the otolith vibrates, stimulating the nerve bed so that the animal can “hear” motion around it. Not all snakes have otoliths but some species of burrowing snakes do.)

Where do you get the stone? Can you just buy it in the market?

The snake stones come from the Maasai, from big snakes in Maasai land. My teacher travels to Maasai land to get them and brings them back.

If the wound is fresh, I apply the stone. However, if it has been two or three days since the bite, I can’t use the stone anymore. Then I have to use a special medicine made from herbs and crushed snake heads. I mix it all together, then crush it into a powder and keep in a gourd.

When the patient comes in, I use a new razor blade to make small scratches on the wound. Then I rub the powder in it and bandage the wound. The wound will try to heal over time, so you have to make the scratches to be able to apply the powder.

Do you use the razor blade again?

No, I always use a new blade. (He was emphatic on this point.)

What is the powder made from?

Snakeheads. When we kill a snake, we keep the heads to make the powder. We mix it with roots, bark and leaves from special plants from deep in the forest. My teacher is a security guard in one of the forests and can get them when he can find them.

Wait, so your teacher is a forest ranger? Can’t he get by being an Mganga?

Yes. He is a forest ranger.

So he took the job so that he can get the plants from the forest whenever he needs them.

 (Silence)

OK, so how many bites do you see per month?

It depends, some months I get more than others but mostly one every three months or so.

Do you refer them to the health facility for formal treatment?

Yes, I do. I treat them, then they go to the facility, then they come back to me. (I’m suspicious on this point, though the Mganga in question appears more together than most.)

Is there a religious component to this?

Well, there are two kinds of bites, those where the snake just bites and there is no witchcraft and those where someone has used magic to send the snake to bite you.

How do you know the difference?

If the bite heals quickly, there is no witchcraft. But if the bite is treated and does not improve then there is definitely witchcraft involved. At that time, I have to use powerful magic to get rid of the curse.

What do you do?

I send the snake back to the person who applied the curse. When we hear that someone nearby has been bitten, we know who applied the curse.

(Note: this is not uncommon. Witchcraft is often associated with hatred and revenge but the person applying the curse risks becoming cursed themselves. It is possible that snakebites are seen as a never ending battle of malevolent spiritual forces. What this does is sow distrust among people, even families and the Mganga is seen as the only cure. The result is that the Mganga are never without work.)

How did you learn this craft?

I was sick for a long time with stomach and head problems. I went to the hospital and it never got better so then I went to an Mganga. I improved. The Mganga suggested that I become on and I started training under him.

Thank you very much for your time.

 

 

10 things about the Kenyan Coast

I made this trip out to the coast, first to do some damn work and second because I can get out of Nairobi and be spared spending Nairobi money for a while. A week’s worth of not-Nairobi-money is money in the bank. In Nairobi, you simply walk outside and 1000 schilling notes start flying away.

Some things I noticed (I’ll get to the snakes in a minute):

  1. It’s damn hot out here. Nairobi is cold. Here, it’s like being immersed in a sauna continuously, except for the hours of 3 to 5 am, which become cold for some reason.
  2. Fish from the sea is good. There are ample stocks of mackerel out here. I always want to make 塩サバ and have a side of okra. Or ゴーヤ. Or 山芋. Or something.
  3. Somalis are cool dudes. As in, they want to do business, they want to make sure you are happy and that you come back again. Kenyan business people are really just interested in getting your money right then probably because they might be out of business tomorrow. They don’t care if you come back. But then, if you don’t keep customers, you will go out of business. Welcome to the world of business in Kenya.
  4. Somalis make somali coffee, as in, not Nescafe. They put coffee grounds in hot water and steam the shit out of it. It’s refreshing. Though I noticed that they were pulling water from a plastic jerry can on the floor. One has to wonder where the water comes from.
  5. As much as possible, avoid the tomatoes and onions they put on the pilau (a dish like 混ぜご飯.) Yesterday, as I was eating my pilau, I ate the tomatoes and onions. I knew that things would turn out badly. Imodium is my friend right now.
  6. Mombasa is a weird place. I always expect to see people with dancing monkeys or snake charmers on the street, but then you look closer and it really is Kenya. They really tried to make a nice city at one point, but the city services never caught up. Trash is a constant problem. But there’s this weird mix of Arab, Brit and Indian architecture. It truly is an international city. They also like perfume. And they love ice cream. I think because they don’t drink and smoke, they can actually smell and taste things.
  7. Tarbousch: I always used to get the Biryani there, but the waiter convinced me to try the chicken schwarma. Perhaps the best shwarma I’ve ever had. I ordered two in the end.
  8. Police: Are stupid. Like really dumb. My tuk tuk driver failed to stop for the police, likely because he couldn’t here them over the cacophony of tuktuk motors everywhere. I apologized to the policemen to be friendly. He tried to arrest me for the tuk tuk driver’s failure to stop. The policeman was obviously a complete moron. I had to start fake calling the Kenyan Ministry of Health to “report him.” Eventually he let me go. I hate those guys. Likely, he wanted money.
  9. Mombasa is remarkably music free. Given Somalia’s rich musical history and the ubiquity of Taraab music in Zanzibar, you would assume the Mombasa might have some kind of musical culture, but it does not. Plenty of people seem to buy stereos and the matatus blast out Bongo (TZ) music, but there’s a stunning lack of performance culture of any kind here. Again, I blame Moi.
  10. Living in Nairobi will make you really mean. You just stop being nice to people you don’t know. It’s a cancer really.

Waning interest in the development industry in Kenya?

I was reading Chris Blattman‘s blog this morning where he had a cool post on the increasing use of  development jargon in published material. Words like “impact,” “stakeholder,” and “capacity” are all over the place here on the continent.

These terms are so pervasive, that people drop them in everyday conversation, almost creating a language on their own.

Honestly, I’m not really sure what “capacity” is supposed to mean, let alone am I able to identify who is and who isn’t a “stakeholder.” The cynical me says that a “stakeholder” is a person who is able to scrape off development funds into their own pockets, which seems to be a national pastime here. “Capacity” is as condescending as it sounds. Who decides who has the “capacity” to do things anyway? Are people who lack skills “incapacitated?”

The most annoying to me are “self help groups” which are, in essence, simply small business cooperatives. Not sure why their existence has to be treated as writing some past individual wrong. Given that it is mostly illegal to have a business here in Kenya (due to onerous laws on trade left over from the Brits and overzealous bureaucrats looking for bribes), it is possible that a “self help group” simply avoids many of the most costly permitting laws but more likely that a development group felt the need to give a fancy name to something completely normal.

That, however, is an aside.

If Google Trends is to be believed, interest in the development industry is waning in Kenya. I searched for trends in four terms, “capacity,” “sustainable development,” “stakeholder,” and the almighty “per diem.”

Development organizations often pay people to attend “seminars” on this or that topic in the form of “per diems” which are often not small. A fairly educated Kenyan can make a decent wage from attending these seminars on a regular basis. Harry Englund of Churchill College wrote a cool book on the subject called “Prisoners of Freedom.”

Anyway, here’s the graph. I found it kind of reassuring. Countries like Kenya can’t claim independence while holding out their hands waiting for development money to come through. Kenya is not a poor country. It doesn’t need many of these development projects when it is perfectly able to stand on its own. If these trends are to be believed, there is reason to be hopeful.
development

Snakebite follow up in Mbita, Western Kenya

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A staged picture. With Paul Diela, our team manager in Mbita.

As I’ve noted in previous posts, we’re doing some research on snakebites in two areas of Kenya. I came out to Mbita in Western Kenya to do some routine management things for the demographic surveillance system that I run. This gave me an opportunity to go out and visit some houses of people who had indicated that someone in the family had been bitten by a snake in the past.

 

Today brought us to the Gembe East area of Mbita District in Homa Bay County, an area most associated with malaria transmission (of which I’ve written papers on). The Usao area we visited today is probably the poorest area of Gembe East. Roads are almost non-existent and the cell network is even harder to find. Among kids, skin infections are common, as are untreated wounds and eye infections. One kid has an eyeball so swollen that he couldn’t blink.

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Discarded ACT (malaria medication) pack

Discarded Coartem and Artefan packs litter the area. When I’m in the villages I always check the trash. It’s a great indicator of the public health situation. I often think that people should give up on surveys and just start mapping drug waste out here. At least we wouldn’t need to go through any (or at least few) bureaucratic hurdles.

 
We hired a single staff member at the last minute, assisted by a graduate student from Japan, hired a car and took off this morning to get here.

To find the snakebites, we compiled a list of houses where people had reported snakebites and then coordinated with our DSS staff to find them. Our registration system allows us to easily find houses in our survey areas, a real asset when one is doing these kinds of follow up surveys.

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Survey work.

The first house we went to was vacant, everyone had taken off to do their daily chores. I became worried at this point since this area is so challenging to get to. Our list indicated that the neighboring house had a snakebite victim so we went over there and found the lady more than willing to talk.

Her son had been bitten ten years earlier by a puff adder in the space between her house and the water. Fortunately he didn’t suffer any permanent damage, but given that two houses right next to one another both experience snakebites, the area has to be considered somewhat dangerous.

She didn’t take the child to a clinic, instead enlisting the help of the local witchdoctor. Local practitioners treat snake bites by making small cuts around the wound, ostensibly to cut off routes that the venom can use to spread, then they apply a salve containing local herbs. The nature of the herbs is unknown. I plan to try and find one of these guys and see what it could possibly be.

Giving up, we returned to the market area, and suddenly several people came out of the woodwork claiming to have been bitten in the past. Some of them were in our list. Lucky day.

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Puff adder wound, note scaling of the skin.

One gentleman had been bitten on the leg several years previous. He didn’t suffer any major damage, but the skin surrounding the wound is now scaly and tend to come off. Again, the culprit was a puff adder. The locals claim that the snake causes a persons skin to become snake-like, even shedding occasionally, just as a dog bite (rabies) causes a person to bite like a dog (it’s disconcerting how familiar people are with the symptoms of rabies here).

Our regular DSS survey worker pointed out that many people don’t want to report snakebites, presumably because of the associations with witchcraft. He also noted that when people hear about other people reporting bites, they tend to want to report them too. We had one lady who claimed that she hadn’t been bitten, but today was eager to talk about it. Just about everyone has some story about a snake, it appears.

After doing about six surveys, almost all of which were puff adder bites, we moved on. Most of the wounds we saw were minor. Some wasting of the legs, some skin problems, but no paralysis or debilitating long term issues.

A 12 year old boy, however, had been bitten on the hand by a puff adder about three years ago. Fortunately, his mother took him to the clinic immediately. He spent a month in the hospital, likely on intravenous antibiotics because the venom had destroyed most of the tissues in his left arm. Amputation was avoided, but he no long has full use of the arm and the hand is permanently deformed.

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Puff adder wound, three years post envenomation

The survey worker tried to get the child to identify the snake by showing him a picture of other many kinds of snakes, but it had all the hallmarks of a serious puff adder bite. Clearly there was rotting of the tissue all the way up to shoulder and the joints were permanently bent. The elbow no longer moves due to the lack of muscle tissue and cartilage. The kid otherwise is a normal 12 year old boy. He is lucky to be alive.

Only two of the ten surveys today indicated that people went to a clinic for treatment. Someone noted that getting to the clinic is nearly impossible unless you have a motorcycle, and most of the people here just don’t have the means to call one. They opt for the witchdoctors, who make snakebites a principal part of their practice. Whether it is effective or not is unknown. Likely many minor bites might have resolved themselves on their own. Serious bites likely result in death so we’ll never know.

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A cow. 

 

 

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