New publication: “Long-Term PM2.5 Exposure Is Associated with Symptoms of Acute Respiratory Infections among Children under Five Years of Age in Kenya, 2014”
In early December, I was asked to submit a paper to a special issue on “Air pollution and health in Africa and the African Diaspora” which is great! But the deadline was Dec 31st, which is absolutely crazy. I pulled an amazing team together and somehow we made the deadline and now, here we are…. published!
Here’s the “video abstract.”
Introduction: Short-term exposures to air pollutants such as particulate matter (PM) have been associated with increased risk for symptoms of acute respiratory infections (ARIs). Less well understood is how long-term exposures to fine PM (PM2.5 ) might increase risk of ARIs and their symptoms. This research uses georeferenced Demographic Health Survey (DHS) data from Kenya (2014) along with a remote sensing based raster of PM2.5 concentrations to test associations between PM2.5 exposure and ARI symptoms in children for up to 12 monthly lags. Methods: Predicted PM2.5 concentrations were extracted from raster of monthly averages for latitude/longitude locations of survey clusters. These data and other environmental and demographic data were used in a logistic regression model of ARI symptoms within a distributed lag nonlinear modeling framework (DLNM) to test lag associations of PM2.5 exposure with binary presence/absence of ARI symptoms in the previous two weeks. Results: Out of 7036 children under five for whom data were available, 46.8% reported ARI symptoms in the previous two weeks. Exposure to PM2.5 within the same month and as an average for the previous 12 months was 18.31 and 22.1 µg/m3, respectively, far in excess of guidelines set by the World Health Organization. One-year average PM2.5 exposure was higher for children who experienced ARI symptoms compared with children who did not (22.4 vs. 21.8 µg/m3, p < 0.0001.) Logistic regression models using the DLNM framework indicated that while PM exposure was not significantly associated with ARI symptoms for early lags, exposure to high concentrations of PM2.5 (90th percentile) was associated with elevated odds for ARI symptoms along a gradient of lag exposure time even when controlling for age, sex, types of cooking fuels, and precipitation. Conclusions: Long-term exposure to high concentrations of PM2.5 may increase risk for acute respiratory problems in small children. However, more work should be carried out to increase capacity to accurately measure air pollutants in emerging economies such as Kenya.
I traveled out to Kwale on the Kenyan Coast and celebrated Eid (the end of Ramadan) with my friend Juma and his family in Mwachinga. It was a great time for everyone (except the goat). It rained on and off, but the ladies made up some great Pilau and the men had some conversations about Islam and witch doctor Senators. Juma even gave us a detailed family history. Finally, everyone had a serious discussion on the impacts of social media on family relations.
After a grueling 12 hour bus ride from Nairobi to Mombasa, the highlight of the trip was a two hour tuk tuk ride across the ferry and all the way out to Kwale Town. I’m still not sure how it made it up all the hills.
I didn’t hear about this until the very last minute, but was lucky enough to get the invitation letter in time to at least make it to the last day.
The Kenya Medical Research Institute (KEMRI) has, for the past five years, held a research dissemination event intended to highlight KEMRI sponsored and Kenya based research.
Research led by Africans is sadly scarce. R&D funding in SSA is the lowest in the world. In a context where so few people are able to receive an education of sufficient quality to allow post graduate studies, African researchers are few and the resources available to them are low.
Kenya has committed 2% of GDP to R%D. Contrast this with South Korea, which at one point committed 23% of GDP to R&D efforts. While KEMRI is truly a leader in the context of African research, the low level of commitment on the part of the national government makes it tiny in the context of worldwide research.
The presentations I have seen so far have been excellent, but of course, much of this research survives on the good graces of international funding and training. Most of the research presented was performed within the CDC.
So this begs the question, when will and can African countries take ownership of their research? Is this even possible given the dysfunctional nature of politics here?
The story of Africa and African identity (in a global context) is written by the rest of the world. As a foreign researcher, I quite aware that I am part of this phenomenon.
Presenters have pointed to two main issues (which I agree with). First, African countries cannot proceed to develop their research sectors (or any other sector really) unless Africans take charge of in country and continent wide research priorities. It is important to note that foreign research often takes on issues which were of importance in the colonial period (childhood infectious diseases) despite a growing burden of chronic diseases and diseases of aging which will break the budgets and economies of African countries.
While I do not suggest that attention be diverted from the incredible burden of infectious disease in African countries, it is telling that research priorities are still driven by the international community. Central Province in Kenya is quite well developed. Even my taxi drivers ask me why we don’t do research in Central, given the incredible problems of heart disease, cancer and alcoholism up there. Unless Kenyans spearhead the main issues impacting their country, these problems will go unadressed.
Second, as noted before, governments have to make firm commitments to support domestic research. As of now, African countries wait for international funding to support their projects, which shifts the conversation away from domestic priorities to international priorities. This is a tall order here, of course.
Of interest, though, besides the macro level problems of funding and support, presenters passionately call for people with Masters and PhD to use the degrees. “Why don’t you do research? What is wrong with you?”
I can’t speak to this issue effectively. But my sense is that many capable people don’t sense the urgency of doing research and lack the personal initiative to make it happen. I’ve seen it happen that researchers wait to have foreigners write their research for them, and simply wait to have their name rubber stamped on the paper, taking credit for work that they did not do. This is an unacceptable situation that we, unfortunately, enable. Certainly there are issues of experience and capability, but we shouldn’t handle capable African researchers with kid gloves, particularly this well educated young generation.
Sadly, the history of aid and foreign involvement here has set this precedent. This is an era that needs to come to an end. In the private sector, it has. In the public sector, these problems persist. Older researchers, many of whom came of age during the beginnings of the post-independence era, here are screaming that point at the top of their lungs.
I wanted to go and see what this jigger thing was really about so I had my guys rent a car and we drove into Mtsangatamu town. Mtsangatamu (I still can’t pronounce it properly) lies along the edge of the Shimba Hills Wildlife Reserve and, according to my data, is a hot spot for tungiasis, or infections from the so called “jigger flea.”
It is a beautiful area. Filled with tropical trees and overgrowth, the landscape looks almost uncontrollable, despite the soil being so sandy that not a drop of water stands anywhere. The air is blistering hot.
People don’t get out here much, though the packed buses that pass by every few minutes indicate that the area isn’t entirely isolated. We drop off some gas for one of our drivers, who has to slowly fill his tank, drop by drop, with the tiniest of plastic funnels. Some development project should provide proper plastic funnels to these guys.
For some reason, we drive into the bush along a foot path, until we find ourselves wedged between a number of small pine trees. “We have to walk now,” I am told while I wonder why we drove this far anyway. Walking would have been easier.
We exit the car, walk through what a patch of neatly arranged trees. A tiny tree farm. I never see this in Western, ever. Coming out, we walk into a compound laid out in a manner wholly uncharacteristic of Kenya. A two story building sporting an upstairs patio complete with a winding staircase to the top, the place looked like the type of patchwork architecture that you associate with off-gridders in the US rather than Kenyan peasants.
The Mighty Paraffee turns out to be a kid of about 24, chilling out in the shade. He built this place himself, installed power, has a guest room and an upstairs shower and toilet. His room is decorated with reggae stars and pictures of the saints. Indian music is blaring out of the building. I’ve seen creative interiors from reggae fans in Kenya, but this is something else. This kid should be in architectural school. He even made sure to place the building under a giant tree to keep it cool.
I never figure out what the family does for money and no one can tell me, but the mother is exceedingly proud.
No jiggers here. We walk on. After about a kilometer, we find a poor family sitting outside their house. Children aren’t in school and no one speaks any English indicating that none of them go.
Hassan (one or our workers) brings over a little girl and tells me to look at her feet. Fatuma is 10 years old and her feet are infested with jiggers. She says the don’t hurt much in the day, but they itch at night. Her brother apparently has them, too. Her mother and her aunt do not.
Everyone is barefoot and they all sleep in the same house. I’m wondering if there might be something about the skin which makes kids susceptible while adults are spared.
I notice a group of goats in a pen and start asking questions about animals.
Tungiasis is a zoonotic disease. It is passed from wildlife to domesticated animals to people who bring it into the household and infect their other family members. Or so it is though. Not many people have really explored the question sufficiently. Of course, this is why I’m here.
They have about 15 goats, a few chickens and I notice a young dog and a cat walking around. I ask if they ever notice whether the dog ever has jiggers. They say no.
“What kinds of wildlife do you see around here?” One of the kids was killed by an elephant last year. There are wild dogs and hyenas which come and try to get the goats. Wild pigs dig up the cassava at night.
Pigs. That has to be it. A big mystery has been why there is such a tight relationship between distance to the park and jiggers infections. Wild pigs come out of the forest, raid the fields of the locals and get water from the river, and then recede back into the darkness before morning. 5km is approximately the distance that a pig could feasibly travel and return home in one night.
Pigs travel through and around the compound, dropping eggs, they mature and are probably picked up by dogs, but are most likely picked up by kids walking in the bush. They then bring them back home and pass them on to their family members.
Hassan associates jiggers with mango flowers, but I probe him further and find that the flowers coincide with the very dry season, which could explain why pigs are making the trek to the river and why they prefer the fields since both water and food are probably scarce in the forest.
I have to send a student out to investigate this further.
An old man comes out. He looks nearly 90, but is mostly likely on 60 at most. He has arthritis in his back. He shows me his feet which are moderately infected, mostly only between the toes. He asks for medicine. I tell him I’ll send some along. He offers me some boiled cassava which I graciously take. My colleague refuses because there are no cashew nuts with it, but I suspect that he’s worried about getting sick. I become concerned.
We take some pictures and go.
On the way back, we run into an elderly lady. She’s sitting next to her husband, who is busy getting lit on homemade beer at 11 in the morning. She shows me her feet. The spaces around her feet are infested with jiggers. It must be horribly painful.
She points out that she doesn’t have a whole lot of feeling in her left foot. I notice that her skin in this area is clear; the bone is visible through her skin. I ask what happened. She says that she got bitten by a snake 40 years ago. She was pregnant. I ask her if the baby was ok. “The baby is standing there!”
I consider making a joke about a snake baby, but think better of it. I’m just amazed that both of them survived. The wound was horrible looking.
Somehow, we manage to pull ourselves out of the trees and move on. There are some baboons removing mites from one another on the road on the way back, and I take some pictures. My colleague is about to pass out from the heat. I offer to drive.
African countries are blessed with ample cropland and resources, but suffer from crippling and unforgivable levels of poverty, have some of the shortest lifespans on the planet and the highest rates of infant mortality in the world. Meanwhile, Japan, Korea, Sweden, Switzerland and Singapore are wholly the opposite, yet mostly lacking in everything that Africa has. Clearly, the picture is more complicated than merely having access to a natural resources.
However, within countries, the picture might be different. African countries are complex and diverse places. Poverty is often confined to the most unproductive regions, areas with poor soils, poor rainfalls or dangerous terrains.
I was just working with some socio-economic data from one of our field sites, and noticed some interesting patterns (note the map up top). In Kwale, a small area along the Coast, socio-economic levels vary widely, but neighbors tend to be like neighbors and patterns of socio-economic clustering emerge.
Note that the poorest of the poor are concentrated to an area in the middle, which I know to be extremely dry, difficult to get to, difficult to farm and generally tough to live in.
I tried to see if socio-economic status (as measured through a composite material wealth index a la Filmer and Pritchett but using multiple correspondence analysis rather than PCA) was related to any environmental variables that I might have data for.
I fit a generalized additive model using the continuous measure of of wealth from the MCA as an outcome. Knowing that very few things in nature or human societies are linear, I also applied smoothing to the predictors to relax these assumptions. The results can be seen in the plot at the bottom.
A few interesting things came out. While it is hard to tell much about the poorest of the poor, we can tell something about the most wealthy. The richest in this poor area, tend to live in areas with the richest vegetation (possibly representing water), a high altitude (low temperature), high relief (no standing water) and in locations distant from a wildlife reserve (far from annoying and dangerous wildlife).
I’m not sure the wildlife reserve is meaningful (unless the reserve was an area undesirable for human habitation to begin with), but the others might be and represent a trend seen in other Sub-Saharan contexts. Areas without malarious swamps and ample farm land tend to do the best. Central Province, one of the most developed areas of Kenya, would be an example.
But the question has to be, does a harsh environment doom people to poverty, or do people self shuffle into and compete for access to more favorable areas? Is environmentally determined poverty (or wealth) an accident of birth, or the result of competitive selection?
Alright, back to work. Oh wait, this is my work. Well….
I just finished reading “Decolonizing the Mind,” a short book from perhaps Kenya’s greatest living writer, Ngugi wa Thiong’o. Ngugi is an interesting figure. Born into a peasant Kikuyu family in the fabricated colonial village of Kamiriithu in Central Province, he managed to take advantage of new educational opportunities during the colonial period and attended Makere University in Uganda and eventually Leeds in the UK. He returned to Kenya and eventually became Chairman of University of Nairobi’s Literature Department.
Though highly critical of colonialism, having been in the heart of the worst of Kenya’s experience with it, he was even more critical of Kenya’s post-colonial trajectory. He started a political theater in his hometown and was eventually jailed under the dictator Daniel Arap Moi.
In “Decolonizing the Mind,” Thiongo seeks to dissociate Kenya’s literature from that of the colonialists. He seeks to create a new African literature, by and for Africans. He would eventually abandon writing in English, choosing instead to write works in his native Gikuyu. Despite Thiongo’s call for an African literature, his European pedigree can’t be denied. He is Brechtian in both rhetoric and action. Hs politics are wholly Marxist and it can even be noted that his medium itself (the novel) is decidedly un-African. Moreover, despite his clear hostility to Europe and the United States, it is interesting the he would be jailed by his own countrymen and then would receive asylum and employment from the US.
I found his ideas of language, however, quite interesting. The colonialists, like the Americans, worked to debase indigenous cultural practices to further an imperialist agenda. Locals were weakened through the apparent dominance of English as a language for communication and business, and the language itself was presented in such a way that social hierarchies were reinforced.
This phenomenon continues to this day. Children are taught from an early age, to greet white people on the street with a scripted “How are you?” “I’m fine, and you?” The formal distance between the stilted Kenyan English spoken in Palirament and the guttural Sheng spoken on the streets of Nairobi is hardly an accident. English the language of oppression, control and government exploitation, and Sheng the language of resistance.
Given my recent experiences at Governmental and NGO meetings, however, what strikes me is how language continues to be used as a tool of control, but hat this vocabulary has been internalized by Kenyans themselves. I grit my teeth now when I head the term “capacity building,” which basically implies that people lack the capacity to help themselves without the good graces of NGOs and governmental organizations. It implies that people are helpless without the assistance of formal authoritarian structures. This is, of course, untrue (though one has to allow for the possibility that people often do things that run counter to their long term self-interest).
People may argue that the term is innocuous, but in my experience “capacity building” is often used in place of “training.” To me, words matter, and where “capacity building” carries with it the implications that there is an inherent defect to be rectified, training implies that the capability exists, but the knowledge not yet there. To put this in perspective, I don’t think that anyone would call any of my academic degrees to have been an exercise in “capacity building.” I can’t help but think that white people are trained, while black people are “capacity built.”
Worse yet is “gender empowerment,” which implies that women weren’t sufficiently capable of managing their own affairs prior to the arrival of some dubious microloan project. Again, in my experience, women all of the world are sufficiently empowered. It’s the men who need to be de-powered. The term is condescending and fails to appropriately recognize the inherent capabilities of individuals while at the same time avoids challenging the paternalistic structures which created economic disparities reprehensible practices like FGM, the buying and selling of women and the inability for women to hold men accountable for violence. In essence, the term blames the victim.
Both “capacity building” and “gender empowerment” reinforce the weakness of the individual and offer that the poor of Africa’s only hope lie in international organizations and their own authoritarian though wholly inept governments. It’s worth noting that the strategy is very similar to that of Christianity, which requires followers to believe themselves powerless and to blame for whatever awful fate has befallen them.
Sadly, both of these terms have worked themselves so deeply into the consciousness of people in SSA, that questioning their validity is futile, which is exactly the nightmare that Thiong’o writes of in “Decolonizing the Mind”. Pointing out that “training” is a more appropriate term than “capacity building” to locals will be met with black stares.
While I sit here in Nairobi Java House (which now has a branch in Kisumu…. Kisumu Java House?) eating my standard “Chicken and sun dried tomato sandwich with ABSOLUTELY NO MAYONNAISE” I’m thinking about an exchange I just has with a guy in the line for check-in.
The guy was a tall, obviously northern Kenyan who turned out to be from Marsabit, one of the most remote and lawless areas of Kenya. He works at an American university on HIV things in Kenya. We started talking camels and public health and I just couldn’t help but ask.
“How did you….” I was almost ashamed to try and finish the sentence which I kind of interjected since my interest overrode wherever the conversation was going.
“I was sent to boarding school when I was six.” I didn’t even have to finish it. He knew exactly what I was asking.
To be from a place like Marsabit and working for a major American University is no small feat. First, I have never met anyone from Marsabit and the few times I’ve met people from remote places like Pokot and Turkana, I’ve been tempted to just shake that persons hand and congratulate them. Coming up through University in a place where most kids don’t go to school at all deserves a special prize.
“One cell phone is the only piece of technology you’ll see for miles. It’s an oral culture. Communication is absolutely essential and cell phones are the most prized possession a herder will have outside of his camels.”
His brother has 60 camels. I asked if we might go up there and take some blood. I could stand a trip up to Marsabit, even if armed guards have to accompany.
I’ve been coming here for close to three years, and I’m struck at the rapidity of change here. There used to be only two ferry trips a day to Luanda Port, where you can catch a minibus to Kisumu, Nyanza’s largest city. Now, there’s not only multiple trips a day, but also two ferries, a small one and a large one.
You can also catch a ferry to neighboring Mfangano island, a small but heavily populated place which was formerly mostly isolated from the mainland.
The power still comes on and off, but blackouts are shorter and more infrequent. There are multiple places to see music now, a direct result of people having more money. Local and national acts are taking advantage of Mbita’s increased affluence.
Mirroring much of Kenya, though, construction of a few “high rise” buildings has been completed, but it’s kind of unclear as to who is going to move in. “Mbita Towers” is mostly empty.
People look better, the cars are in better shape, there are more buses going to Kisumu and Nairobi and there is a larger variety of foods and goods available at the local market. This is due in part to the semi-completion of a road connecting nearby Homa Bay to Mbita. There are still a few rough spots between, but it’s mostly passable now. Someone told me that just four years ago it took two days to get from Nairobi to here, despite there being only 400 km between them.
No doubt, this isn’t due to the good graces of any particular development project at all, but rather to the increased affluence of Kenya as a whole. Kenyatta’s government would inexplicably love to credit the Chinese, and they should be credited for constructing some of the road infrastructure, but the real credit has to be given to the development of the domestic economy and Kenya’s status as the most liberal economy in the region.
Kenyans are increasingly not only connected with the world, but also to each other. Cell phones, for example, have allowed Kenyans greater mobility so that they can take advantage of money-making opportunities elsewhere, and mobile banking allows money to flow out of Nairobi, where it was traditionally concentrated.
Kenya still ranks low on “ease of doing business” indicators, and continues to be excessively bureaucratic. New rules seem to appear each day, the goals of which are often unclear and seem to be aimed only at corrupt officials on every level of government. A recent ban on tinted windows, supposedly aimed at terrorism, and an onerous highway speed limit of 80 km/h for small trucks, billed as reducing traffic fatalities, are providing a steady source of cash for hungry highway policemen. It’s worth noting that the latter rule doesn’t apply to SUV’s, the vehicle of choice for Kenya’s elite.
Fortunately, many people simply ignore the government and carry on like it doesn’t exist. This is particularly true out here. My taxi driver completely ignored the speed rules and sped on at 120 km/h. Of course, there’s not a policeman to be seen anywhere out here outside of the the local bar at 3 p.m. The relative peace out here makes them mostly unnecessary, anyway.
Over the course of the day it went from white to brown to red to black. I’m thanking Columbia clothing that the rest of my isn’t black as well.
It sounds really trivial; I got a sunburn. But I’m a really pale guy, and there’s a reason for that. The bulk of my genetics come from northern Europe, an area which is mostly dark, and even when it’s not dark, the sun is filtered through a thick wall of air and moisture.
My skin is not suited to Kenya’s blistering sunlight. My Japanese colleagues inexplicably do their best to keep themselves from tanning. Honestly, I’m jealous of their ability to brown in the sun and don’t really understand why they don’t take full advantage of their innate ability to protect themselves.
In short, I was born pale white, but wish I were black or at least able to brown. It would make field work easier.
Which brings me to this. I often hear people engaging in common conversations about what humans “were meant to do,” as if we were created as complete biological entities designed to perfectly perform specific assigned tasks within the narrow confines of specific environments.
This is a creationist view, but it’s interesting that even non-Christians in the West readily use the same assumptions and terms that are common to religious fundamentalists. The idea is that everything that came after we were kicked out of Eden, in this case East Africa, the birthplace of humanity, is an abomination. Whatever health or social problems we suffer is payback for violating the terms of our initially assigned roles as living beings.
For example, arguments (incorrect ones, by the way) are often made that humans are “meant to be” vegetarians since we don’t have developed canines, an argument of course made preposterous when one runs through the list of mammalian omnivores which also do not have canines. Worse yet, the argument fails to recognize one of humanities greatest adaptations, which is that we can eat just about anything and survive on little for extended periods of time, a skill that allowed us to rapidly move out of East Africa into every corner of the globe.
More salient, however, is that humans were not “meant to be” anything. Like all living beings, we move in response to environment pressures and then adapt while suffering the devastating loss of infants who will not live to pass on traits unsuited to the current environment. Those babies better suited to make it to reproductive age pass on whatever it is that got them there to their children, who then pass it on to their own and mix with others in a sort of genetic democracy.
Babies of my ancestors in northern Europe were more likely to survive with lighter skin, while light skinned babies in Kenya were more likely to not. Neither is “better” than another, but both are suited to their respective environments as they are at that time and neither represent a terminus of genetics.
I take issue with a static view of the world, be it from fundamentalist Christians, who claim that humanity was created fully whole in God’s image or from well meaning secularists, who claim that the world was a biologically static place before the Egyptians, the Romans, the Europeans, the Capitalists and whoever else came in and fucked it all up. Really, it’s interesting how the Biblical creation story persists, even in secular debates.
In my own field, a great failing of research has been to ignore the dynamic nature or disease and human health, assuming that each cross sectionally measured point in time represents a final culmination of set of repeatable events akin to billiard balls on a table. Diseases aren’t that simple. They change in response to the challenges we present to them, which in turn feed back into our own behaviors.
I certainly don’t defend environmental degradation or would I ever minimize calls for developing more sustainable energy and food production systems. However, I would offer that the world, like human genetics is not static, but rather, incredibly dynamic and that a static (and somewhat falsely nostalgic) view of the world is destructive in itself because it keeps us from recognizing the challenges of the present day. Only by thoughtfully examining current conditions and recognizing that things can change can we develop solutions to present and potential future problems.
Alright, I’m done.