Tuesday, February 16, 2010

Kwashiorkor takes its toll in Kibera

This series was inspired by Dr. Nelly’s experience working in Kibera as a consultant pediatrician with a research interest in malnutrition. The characters and events are fictional. All Rights reserved.

Our first week in Kibera was largely uneventful. The clinic did not get as busy as we had anticipated. We were told that word was still getting round, and that in time, people would come, “once they have learnt to trust us.” This lack of trust for “posh donor clinics,” we were told, was because people in the slum have become wary of scientists who exploit them. This was one of the messages that had leaked out of the film, “The Constant Gardner.” The movie was partly shot in Kibera, and some of the group actors had been sourced from the slum.

Another emerging concern was media reports that poor children (slum or orphanage children) in Africa were often used as “guinea pigs.” This later belief arose from the now famous ‘Nyumbani Children’s Home’ story, which was later highlighted in the press. According to the story, blood was often taken from the children and shipped overseas, without authorization.

We had not seen any child ill enough to require admission, or even challenge our competence. In fact, we were beginning to feel generally overstaffed when Akinyi was rushed in. Akinyi was brought by her father who seemed rather rattled by her serious condition: “Anahitaji usaidizi mara moja; ni mgonjwa saana,” he implored.

She looked severely dehydrated, pale with labored breath. The clinic suddenly became alive with activity. We had been through the drill: the first task was to put her on oxygen while another team prepared to get an intravenous line open for giving fluids and any injectable medicines that might be necessary. It is very easy to lose such a child if you delay, so we sent the parents out of the room so as to focus on Akinyi; another staff followed them to get the child’s history.

Next, in a warm room, we began to peel off several layers of clothes she had on, starting with a jumpsuit that had left only her face visible. Children with kwashiorkor (and the less serious form, marasmus), are often overdressed to keep them warm, shield them from prying eyes, hide their parent’s shame, or even to avoid being accused of child neglect; parents compensate by trying to draw attention away from the child.

Unclothed, Akinyi looked desperately ill: she was breathless, looked anemic, with a tinge of blue to the extremities. She was also very cold. These are signs of a collapse of the cardiovascular system. She had obvious signs of kwashiorkor- reddish thin hair, rounded cheeks (moon-face), edema of the extremities, wasted frame, enlarged parotid glands, and in spite of the dehydration, a distended abdomen, with a prominent umbilical hernia.

Akinyi had no energy and did not cry when her parents left the room. Low energy and a depressive demeanor, with a lack of interest in the sorrounding, are some of the symptoms of kwashiorkor.

Dr. Cecily Williams, a Jamaican doctor of British descent discovered kwashiorkor while working in Ghana. The disease derives its name from the Gha language of Ghana, meaning “the deposed child.” It is caused by lack of protein (and micro-nutrients, including immune boosting proteins) available in mother’s milk.

Since the 1930s, it has proved difficult to find a suitable replacement weaning diet across Africa, because protein malnutrition has become an endemic problem, which is passed from generation to generation, as milk intolerance. Many people, for example, are unable to digest a cow’s milk (and other animals’ milk in general) because of lactose (and cow’s milk protein) intolerance. This runs in families. Children borne in such families therefore cannot healthfully be weaned on a cow’s milk, leaving porridge from maize or cassava, as the only viable alternative. Both are poor sources of essential nutrients, including amino acids, the building blocks of body protein and worsens the problem. Indeed, to support this view, Akinyi’s mother had a six moth old healthy looking baby boy, who was now happily breast feeding, oblivious of the battle for life his sibling was waging.

In the meantime, Akinyi’s color and circulation seemed to be improving as the reviving fluids coursed through her veins. Her history revealed that she had arrived from Western Kenya three weeks earlier. At the time, she was not as ill as she now was. She developed a fever two weeks later, and her condition had been steadily worsening. Akinyi had gone to a dispensary, where she was treated for malaria, pneumonia and worms, among other things. The fever had improved a bit, but Akinyi kept vomiting and having diarrhea. She could not retain any fluids, or food for the past three days, and her parents returned her to the dispensary the previous day for a review. Akinyi received an injection and her medicines were changed. Although the fever had now settled, she was getting weaker and weaker. Akinyi’s hstory was typical of what happens to many weaning children across Sub-Saharan Africa, especially in communities where maize (or cassava) is the dietary staple.

Maize is a poor source of B vitamins, especially niacin (vitamin B3), and essential amino acids, (especially tryptophan), which although present, are tightly bound and not available for absorption. Cultures that have thrived better on maize such as Mexicans who subsist on tortillas, have learned to process maize in lime, prior to cooking. The alkalinization process helps break the strong bonds, making the grain easy to absorb. The Xhosa of South Africa, for example, improve the availability of micro-nutrients from a maize diet, by fermenting the flour for a couple of days before cooking it.

In Kenya, when the British entrenched maize in the diet, they went to great lengths to discourage traditional cuisines such as the fermentation of porridge as “primitive.” Maize came hand in hand with the diesel grinding mill, which facilitated milling, making maize flour readily available to boarding schools, urban dwellers, prisoners, and training colleges. The introduction of hybrid maize saw a gradual decline of other traditional crops, especially in places such as Western Kenya where it is widely grown. Hybrid maize is nutritionally inferior to its native form. For example, its pigmented varieties are richer in beta-carotene, the pro-vitamin A. Vitamin A deficiency is a common cause of prolonged diarrhea, among other serious developmental problems, including night blindness, and a weakening of the immune system.

The paradox inherent in treating kwashiorkor therefore lies in the fact even when other high quality dietary proteins are availed in the diet, the problem worsens; this is because of lack of other necessary micro-nutrients. Mothers have therefore learnt from experience not to give milk, or even eggs. But when they go to the hospital, they are often encouraged to increase proteins in the diet, without catering for the micro-nutrient needs. This is why children from maize or cassava eating regions dominate malnutrition wards all over Kenya. Akinyi therefore fits the Kenyan stereotype.
Akinyi’s nutrition history was also predictable because she kept throwing up any food we gave her, especially protein; the diarrhea seemed to increase as more protein was included in the diet. In fact, the mother was very categorical: “Tangu tutoke nyumbani, kuhara imezidi (since we came from home, the diarrhoe has increased).”

Alikuwa anakula nini nyumbani? (What did she used to eat at home?)

Uji tu. Anakataa chakula yengine. Wakati tulienda kwa clinic, sister alituambia tumpatie maziwa na mayayi. Lakini tu kimpatia ndio anahara zaidi na kutapika.”(Just porridge. She refuses other foods. When we took her to the clinic, sister (the nurse) advised us to give her milk and eggs. But when we do, the diarrhea and vomiting increase).

I have heard a variation of the above conversation so many times as a pediatrician. As a post-graduate student, I studied diarrhea extensively. The findings were stunning: of the children with persistent diarrhea admitted to the emergency ward at Kenyatta National Hospital, we observed that those with protein malnutrition kept coming back for readmission, until they succumbed.

In part, this is what inspired me to study the subject further. The realization that maize was at the heart of our endemic protein malnutrition, both in children and adults (maize causes the disease pellagra in adults) took many years of study to actualize. Although a poor source of essential nutrients, maize has many other popular uses in industry, including manufacturing of starch and feeding cattle, among others. But maize’s history, geography, politics, and economics has proven that it is also a tool of imperialism. As evident in Akinyi’s case, the grain gradually weakens people’s immune systems, making them vulnerable to many diseases and exploitation. This is why Kenya’s (and Africa’s) poverty map closely mirrors that of maize (cassava) endemicity.

A deficiency of niacin in the diet gradually weakens all the body’s systems, by blocking major physiologic reactions, because products of niacin metabolism are central to very complex energy and protein reactions. Niacin is so crucial to the body that nature allows it to be made in the body. For example, in a healthy person, dietary tryptophan is converted in the body to niacin co-enzymes NAD and NADP. These conversions are facilitated by the availability of some B vitamins, including niacin, iron, and energy. These co-enzymes are central to energy generation throughout the body, and extreme deficiency is incompatible with life. Tryptophan is also converted in the body to 5-hydroxytryptamin, also known as serotonin. Serotonin is an important nuero-transmitter both for the brain and the digestive system. It modulates many functions in the body, including appetite, sleep, mood, muscle movements and even memory and learning. In children under five years, serotonin is crucial to optimum brain development. There are many other neuro-transmitter disorders related to maize and psychological health.

Protein malnutrition in children is damaging to future learning, innovation, and even psycho-social health, among other issues. The same is true for the optimum development of the immune system, although the latter peaks during adolescent years. Nutritionally acquired immune deficiency syndrome (NAIDS) in part explains the high HIV burden among poor people; the virus is opportunistic to the weakened immune systems.

Niacin’s role in the immune system is varied and complex. Those from Western Kenya, especially child-bearing women might know somebody who was put on iron to treat anemia, but they were unable to tolerate it. There is a causal relationship between niacin deficiency, and the incapacity of the body to utilize iron, so it is deposited in the tissues instead. The syndrome of Bantu siderosis (iron is deposited in the body tissues, especially the liver), once thought to be due to excess iron imbibed by men taking alcohol from iron-containers has been documented in non-alcoholics, and even in non-alcohol drinking women.

Niacin deficiency has also been documented in the breast milk of Bantu mothers on a maize diet. This means that in maize staple areas, niacin deficiency is passed from mother to child through breast milk. A child with kwashiorkor therefore should not be given iron, before control of the malnutrition and any infections is well under way (fluids rich in iron are a good medium for germs to thrive in). Both niacin and iron deficiencies worsen the lactose intolerance that is rampant across Africa. Weaning such a child on cow’s milk or formula sets them on a path to more protein malnutrition, unless any deficient micro-nutrients are replaced concurrently.

From the above, it can be seen that endemic malnutrition is a complex problem that poor parents cannot address without assistance. If left untreated, survivors are handicapped in diverse ways as they enter adulthood. Problems like Alzheimer’s disease, and premature dementia are increasing in the community because of endemic malnutrition. In Egypt, a community study has demonstrated a link between enlargement of the parotid glands and endemic pellagra.

Diarrhea and or headache and skin rashes are some of the earliest symptoms of classic pellagra in adults: diarrhea, dermatitis, dementia and death compose the 4 Ds of classic pellagra. General malaise, vomiting, lack of energy, muscle wasting, lack of appetite, depressed mood, lack of sleep etc are also common in adults. In children, diarrhea and or vomiting, apathy, lack of energy, misery, (enlarged parotid glands occur in some cases) oedema and anemia are common. Edema often masks the extreme muscle wasting that can be quite striking (some parents have been known to mistake the rounded chicks for “health”). The edema has many causes, including electrolyte imbalance (pseudo-hyponatreamia i.e low blood sodium is common; mechanisms are discussed elsewhere), protein deficiency, hormonal imbalance, a weakened heart muscle are considered contributors. Because of a weakened immune system, these children often harbor ’silent infections;’ pneumonia is common, as is sub clinical malaria. Children from Western Kenya must be treated for malaria even if they have no fever, concurrent to the treatment of the protein malnutrition.

Since treatment of kwashiorkor appears to be complex, it would appear therefore that the most cost effective way to reduce disease in communities is to tame malnutrition at community level. If kwashiorkor and pellagra are such serious illnesses, why have Africans embraced maize as their dietary staple? More importantly, if the problem has been with us for such a long time, why hasn’t a preventive policy been put in place?
Maize was the dietary staple of African slaves during their journeys, and wherever they settled. Contemporary black Americans revere maize as “the food of their forefathers.” So what efforts have been made to address the problem? Why have the efforts failed? Who benefits from African children’s malnutrition?

Previously published on East Africa in Focus.

Tuesday, February 9, 2010

Kibera slum: A resource for rich landlords and home to the urban poor

This series was inspired by Dr. Nelly’s experience working in Kibera as a consultant pediatrician with a research interest in malnutrition. The characters and events are fictional. All rights reserved.

In 1992, I got an opportunity to work in the Kibera slum, Nairobi, as a consultant to a donor-funded project whose main aim was to assess the extent of under-five malnutrition in slum children. Nairobi is the capital city of Kenya, and Kibera is a slum approximately 7 kilometers from the city center. It has been described as the largest slum in Africa, with population estimates ranging from half a million to one million people. Not many cities in the world have such a large slum situated within walking distance of the city center. Maybe this is one reason Kibera attracts so much attention from researchers, NGOs, religious groups and tourists. Kibera also attracts many film crews, including the makers of The Constant Gardner, an Oscar-winning film adaptation of John le Carre’s similarly-named book.

The site where Kibera stands today was dense forest at the beginning of the last century. In fact Kibera is a corruption of the Kinubi word “Kibra”, which means “jungle or forest.” After the First World War, the British allowed Wanubi army recruits from the King’s African Rifles to settle at the site. Because they had originally been brought from the Sudan, they had been rendered “detribalised natives” after the war. They were awarded plots on which to build their homes but, by the 1940s, many had become landlords to the poor urban migrants who came to Nairobi in search of jobs. The Wanubi had perfected skills in distilling gin (chang’aa). It has been said that the skill was also passed to them by the British in appreciation for their war exploits. Some believe that the ready availability of chang’aa in Kibera (although criminalised) was what initially attracted tenants in large numbers to the slum. This is important because Kibera was by no means the only slum in Nairobi.

After Kenya’s independence in 1963, Kibera acquired many more landlords from other tribes, the Kikuyu being the majority. Since Kibera remained essentially government land, only temporary structures were allowed. Housing in Kibera therefore consists mainly of one or two-room shacks crowded together, with no clearly demarcated roads. Basic infrastructure is absent as are government services. Kibera therefore lacks roads, running water, a sewage system, street lights etc. Its famed features include “flying toilets,” which essentially mean that after defecating into plastic bags, slum residents wrap the contents then hurl them out, away from their own shacks. Wherever the bags land, they become part of the “normal” environment of Kibera. When it rains, the mixture of domestic garbage, raw sewage and layers of accumulated debris in what is essentially an open drainage system can truly test the senses.

Although Kibera attracts low-income earners from all of Kenya’s ethnic groups (and even from neighboring countries), a significant majority tend to come from Western Kenya. In a bid to escape rural poverty, many get employment as "house boys" (domestic employees), watchmen, "shamba boys" (gardeners) or casual construction workers for minimum wage. Therefore, the only place where they can afford to live is the Kibera slum. Kibera also attracts a large number of female-headed households. Many, trying to escape marriages gone sour or the deaths of their spouses land in Kibera. Then there are the city’s own economic migrants who, having landed on hard times, e.g. due to the loss of their jobs, or due to serious illness like HIV/ AIDS, move to Kibera. There is a growing sense that the slum is becoming home to more Nairobians as the gap between the haves and have nots continues to widen. Some researchers estimate that up to one third of Nairobi residents live in the slum.

The area occupied by Kibera is estimated to be 1% of the area occupied by Nairobi city. Yet it is estimated (by others) that the slum carries 20-25% of Nairobi’s population. Kibera is therefore highly populated, with up to 2,000 people per hectare. Because of poor hygiene and crowding, poverty-related communicable diseases are rampant in the slum. It has been estimated that 1/5 of Kenya’s AIDS burden is borne by 15% of the Kibera population. Kibera is divided into 12 contiguous villages, each headed by a village elder. They are administered by government-seconded chiefs who keep law and order. They also decide who can get plots to build rental shacks. Oral rather than written contracts prevail. Usually, rich people bribe the chiefs and are allocated land on which they are allowed to build shacks for rent.

Apart from the Wanubi landlords, therefore, the majority of the latter-day landlords do not reside in Kibera; they simply come to collect their rents, or pay agents to collect them on their behalf. The shacks are therefore a very good investment because they are cheap to put up, rents are largely unregulated, and no maintenance is expected. Many well-connected landlords put up a large number of these structures, and I have heard that some politicians with clout easily collect huge sums of money in monthly rents. Kibera is therefore a valuable resource to the well-connected landlords. It is also a resource for the government because it houses cheap laborers, without any input from the government. The residents pay taxes to the local authorities, buy goods and services, and are even good targets for bribes. It is, therefore, not surprising that a slum-upgrading program, initiated by the government and donors, has been challenged in a court of law. The case is yet to be determined.

Kibera is very close (about 3 kilometers) to Kenyatta National Hospital (KNH), the nation’s referral hospital. Because of its proximity, many children from the slum are brought there during emergencies, especially at night when the outlying dispensaries are closed. One has only to work in the emergency ward for a few months to realize that mothers with malnourished children tend to bring their children at night. The reasons are twofold: first, the women are ashamed that their children are malnourished, and, second, if they came during the day, they would be referred back to the nearest dispensary by the duty nurse.

In my experience, the nurses tended to be very harsh with the mothers of malnourished children because they assumed the women were the source of the problem. Many of the mothers had previously been admitted with their children for the same problem, but even after health education on the ward, they always came back. In many cases, the children’s malnutrition would be worse. Many of the children were severely dehydrated from constant diarrhea; others simply refused to eat, or kept vomiting when force-fed. The large number of affected children and the recurrence of the problem convinced the hospital administration to secure funding for a community study in order to identify the factors that had contributed to the problem, and to intervene at the community level. I was seconded to the project as the Consultant Pediatrician. That is how the medical team and I found ourselves surveying the slum to identify suitable premises for our project one chilly morning. We needed an office space large enough to accommodate an observation clinic for the mothers and their children, including consultation facilities for those who were ill and needed attention. The intention was to lighten the burden of care at KNH by intervening at the community level. Only very ill children would be referred to KNH for hospitalization and further treatment.

It was hoped that, after initiating community interventions for these slum mothers, the team would use the insights it had gained in Kibera to intervene in other areas of the country where child malnutrition was endemic. In the meantime, having identified suitable premises for our needs (we had rented a permanent structure on the outskirts of the slum), we embarked on our project. We mainly spent the first week familiarizing ourselves with the slum residents and passed around fliers announcing the launch of the project. The village headmen were very helpful, taking us around and generally assisting with logistics. The health outlets that dot the slum were also mobilized to refer any under-fives to our clinic. By the end of the first week, we had determined that we needed to lump the villages into 4 groups in order to cope with the caseload. Mothers from the first group would bring their children on Monday, those from the second group would bring their children on Tuesday, those from the third group would bring their children on Wednesday, and those from the fourth group would bring their children on Thursday. Friday was left open for administrative functions like data entry, project monitoring and the harmonization of activities.

A Kenyan doctor working with malnourished children in any part of the country soon learns to recognize the common features of this communal problem: Poverty and ethnicity are among them. It was not common, for example, to see malnourished Maasai children, unless the situation was one of famine. By contrast, children from historically-marginalized communities tended to form the majority of malnourished children. It did not take long for us to confirm that, while some of these malnourished children had been born and raised in the slum, a majority had come from upcountry in this weakened state. In fact, the majority came from Nyanza and Western provinces, with a smaller number coming from Ukambani, especially Kitui district. These were all politically-marginalized areas dating from independence. Diets in such areas were typically monotonous and deficient in essential nutrients. Most of the people in the most affected areas subsisted on maize as their main dietary staple. Maize is a poor source of important nutrients that would typically have contributed to the proper utilization of dietary proteins.

A familiar pattern soon emerged among our clients: The mothers and their children lived in the rural areas, where they endured poverty. When the children got ill, their mothers would bring them to their migrant-worker husbands in the city slum. Many migrant workers tend to forge new relationships with new women in the city. Therefore, they usually demand that their wives remain in the village until they are invited to visit. Alternatively, they insist that their wives inform them of such visits in advance. Thus, the rural mothers would use the children's illnesses to justify their visits. After the children received treatment, they would go back to the same environment that had created the initial problem. In a few months, the children would get worse again, thus creating a vicious circle. This helped to explain why KNH continued to receive a large burden of malnourished children from Kibera slum.

Previously published on East Africa in Focus.