Morbidity and Mortality

As I experience more of life in Kenya, I begin to understand the realities that lie behind the words “morbidity” and “mortality” that we so often use to describe the effects of disease.

Mortality – death – is the most definitive and the most sobering way to measure the effects of a disease. Simply put, how many people die because of it? 1.8 million children die from diarrhea worldwide each year. In 2010, malaria killed about 655,000 people – mostly children in Africa. These numbers are large and sobering, but in reality the simple number on a page doesn’t elicit much of a reaction, especially if you happen to spend a lot of time reading about such horrible things for your job (as I do).

But living in the midst of it is quite different. The town mortuary is right across the street from our lab and next to our apartment, and is regularly surrounded by crowds and buses and parades of mourners. Families bring a coffin to bury their loved one, usually strapped to the top of a car or sometimes the back of a motorbike. Sometimes I can’t walk to work without tearing up as I witness the ebb and flow of loud singing, at first seeming celebratory, and softer mournful hymns. But the thing that gives me goosebumps is the regularity with which the family is bringing in a small, child sized coffin.

Over the next few days Tim is going to be in Kisumu doing some training on verbal autopsy – an interview with the family of the deceased so that if a child who is part of our study dies, we can try to understand the causes. It is so devastating to consider that we have to prepare for these children who are not yet even born to die. I am glad that we will be able to look at the causes of mortality in this study to help prevent other children from dying in the future, but I hope that Tim has no use for this training.

As awful as it is to dig into mortality, morbidity is a more silent but still insidious force. Mortality is very clear cut and easy to measure, and we tend to assume that as long as someone recovers from their illness everything will be fine. But in reality even a complete recovery from illness can leave detrimental effects, and all too often there is lasting damage that has been done to a person’s body or mind by the trial they have suffered. Over the past few days I have been so struck by what an impact illness makes on work and productivity. Today it seems like half our staff is sick at the doctor or are taking a child to the doctor. Malaria and GI illness are the biggest culprits. Last week one of our staff was out with “a little malaria and a little typhoid.” He returned to work the next day because he said he was bored at home, and it is a regular occurance for staff to come into work with malaria. Despite this generally strong work ethic, 7 out of about 70 employees are out sick today. The cost to organizations and families of this lost work and productivity is enormous, and the loss of income due to illness can be devastating here as it is anywhere.

I don’t mean to be depressing, but I think it’s important to recognize the stark realities and upsetting facts behind the numbers. Understanding the sobering reality gives a purpose to what we do, and make me grateful to be a part of a group of people that are trying to change that reality. The numbers are impressive and maybe that should be enough to galvanize a response, but the reality is that there is nothing like living next to the mortuary in Kakamega to show you the true impact of preventable disease.

Volunteering with IPA

Well it has certainly been a busy two weeks! After staying at home and running errands for the first several weeks that I was here I was ready to get involved with something. Looking at the organizations around Kakamega I decided that volunteering at IPA on the water, sanitation, and hygiene project was the best fit for me. So for the past two weeks I have been helping with the survey team. This team is responsible for actually administering the survey to all of the individuals in the study. For the past two years the study has been doing paper surveys and then manually entering the paper information onto computers for data analysis. While this is ok for the pilot that was being run, it would be much more unmanageable for the main study which is covering 10,000 households. My role so far has been to facilitate the transition to using net books to collect data rather than paper.

I’ve been working with the field officers, the Kenyan staff that actually visits the villages, to train them how to use the net books and data collection software and to collect their feedback on how it could be improved. They have been quick learners so far and have provided all kinds of helpful feedback. I have also been the person communicating with the programmer and helping him implement the feedback. He is a very well educated Kenyan and has been great to work with and get to know. Today we are just finishing a small survey during which we have piloted the net books and it has been a great success!

I’ve begun my focus towards the main study now so that we can ensure the programming and training is on schedule. Before the actual survey is conducted in each village we will be running a census to determine the number of eligible study participants in each village. This is a much shorter survey just to get basic information and I have been helping them develop a version that can be used on Android phones. Using phones allows easy recording of GPS coordinates and basic information for each participant without generating a lot of paper data that needs to be entered. I’ve been working on programming the census myself using Open Data Kit, an open source program for mobile phone data collection.

I’m also doing a lot of planning for training of the main study and have been in meetings the last couple days all over Western Kenya. I was in Bungoma yesterday and I’m currently in the car on my way to Busia. I’m really starting to find my place in the organization and I’ll keep you updated on what I’m up to!

Tim

Field Work

Right now I am sitting in mud hut in a small village supervising the field work that is happening today.  We are collecting urine and stool, which is quite a strange procedure. The baby that I’m with today is only 7 months old.  How can you collect urine from a child that small, you ask?  Well, we have a bag with adhesive on it that sticks around the child’s genitals. The bag hangs and collects any urine the child excretes for 5 hours, while a field officer periodically uses a tube from the bag to siphon off the urine into a jar.  Stool is scooped from a diaper and then taken to the lab, where it is processed for Kato-Katz. One problem has been that most of the mothers have never seen a disposable diaper, and need to be taught to attach it properly. Part of my never ending battle as lab manager is to ensure that everything is very sterile and that we don’t have stool or urine contaminating all of our surfaces when the samples are processed in the lab.  There is a very real risk of contracting worms from these samples, and I do not want any inside of me! While the young babies that we are looking at now usually do not have so many worms, the school aged children sometimes have awful infections.  Don’t worry, every child that we take a stool sample from receives a deworming pill.

The problem of parasites is so persistent here! I was having a conversation with Wekesa, a lab technician who is very knowledgeable about parasites, and he was asking me which parasitic diseases we have in the United States.  He was actually very surprised by how few we have – the main diseases that exist in both places are giardia and pinworm (probably the most benign of the wide range of parasitic infections available here). For many diseases, such as malaria and hookworm, I explained that we used to have it, but do not anymore. Wekesa was encouraged by this, and vowed that Kenya would also eliminate these diseases.  I hope so!  Because we experience so few of these infections in the United States it is very easy to underestimate the damage that they do.  Sometimes it seems like a waste to pour money into these “neglected tropical diseases” that only exist in secluded corners of the world that most of us rarely consider.  But when you visit a community and see the distended bellies on malnourished children everywhere and you realize the enormous impact that intestinal parasites have had on so many people in that place, you cannot deny that this is truly neglect.  Malaria is not a neglected disease – it is one of the “big three” tropical diseases that receive large numbers of donor dollars along with AIDS and TB. However I feel more and more surrounded by the hopelessness that people feel facing malaria, and wonder what the solution is. What I do know is that we cannot think that what we are doing is enough for malaria or the wide range of neglected tropical diseases that exist here.  Not only does malaria have a high mortality rate (especially in young children), Tim and I have met mothers who have miscarried at 8 months and children and adults who have suffered brain damage from acute malaria.  Just last week one of my lab techs was less talkative than usual, and I asked him what was wrong.  He pulled some pills out of his pocket to show me, and simply said “malaria.”  When Tim and I worked in Tanzania one of our workers also had malaria, so this was unfortunately familiar to me.  The costs of malaria are so high – the mortality, the morbidity, the productive time lost for families that are already scraping to get by. And despite everyone’s efforts, just today I saw – not for the first time – a mosquito net being used as a chicken coop.

As I sit in this boma monitoring the child’s urine bag, I feel face to face with these problems in a very real way.  I’m reading a report from the WHO that says 46% of deaths in the African region are children under 15 years old.  In high-income countries, that number is just 1%. The child in this house has a fever and horrendous cough, and when we suggested to the mother that she should take the child to the doctor she shrugged, saying that she doesn’t have the resources. She seems like a caring mother, but she kisses her baby and sits holding her, waiting to see what happens. At another home I was in recently, a pregnant mother holding her firstborn told us that she had given birth in the hospital.  After some further questioning we realized that she had clearly given birth at home, and the baby had never seen a doctor or received any vaccinations because the mother couldn’t afford the 100 shillings ($1.20) that it cost to see a doctor.  At a year old, she looked clearly underweight and we couldn’t even coax a smile.

Sometimes it feels discouraging to “just” do research when there are so many challenges facing the people around you.  However I am also confident that this is a good place to be and good work to be doing.  Water, Sanitation, and Hygiene have long been shown to have an impact on diarrheal disease and health of children, but there is currently a lack of studies evaluating interventions in these areas.  This study is an enormous undertaking that will hopefully provide information to help governments and organizations evaluate which interventions are most beneficial and cost effective, so that the projects that are implemented can have a real impact.  I am excited to be a part of this and I think that this work is very important – but still sometimes I want to throw in the towel and give all the money, all the interventions to the one sweet family that I meet with the adorable child with diarrhea.