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Sunday, May 20, 2012

Tackling the Burden of Non-Communicable Diseases in Kenya

Africa is witnessing a monumental triumph in development. According to a World Bank report released early this month, child mortality has plummeted more rapidly than hitherto anticipated. The average decline in child mortality in Africa today is faster than it was in China in the early 1980s.

12 of the 20 African countries which have detailed demographic and household surveys since 2005 reported falls child mortality of over 4% per year; a rate of decline that is required to meet the millennium development goal of cutting child mortality by two-thirds by 2015.

Kenya's infant mortality rate has fallen by 7.6 percent per year, the fastest rate of decline among the 20 African countries. The World Bank report attributes half of the overall drop in Kenya’s child mortality to the huge increase in the use of insecticide-treated bednets in areas where malaria is endemic. Targeted public policy works!

But as Kenya reins in child mortality, the grim reaper has forged a new scythe for adults. According Prof. Anyang Nyongo, Kenya’s Minister for Medical Services, non-communicable diseases (NCDs) account for almost half of hospital deaths.

In September 2011, the United Nations declared that for the first time in history, NCDs such as diabetes, heart disease and cancer pose a greater health burden globally. Today nearly 80% of deaths from NCDs occur in developing countries. By some estimates, 9 out of 10 deaths from NCDs, before the age of 60, occur in developing countries.

NCDs deliver a triple whammy of morbidity, early mortality and poverty. Medical expenses are often covered through family resources, leading to catastrophic erosion of family assets.  At the national level NCDs cost millions of dollars in care and hospitalization.
Like in the developing world, the epidemic of NCDs in the developing world is attributed largely to four behavioral risk factors that are associated with increase in per capita GDP, rapid urbanization “modern” lifestyles: tobacco use, unhealthy diet, insufficient physical activity and excessive consumption of alcohol.

Three of the most important and prevalent NCDs; heart disease, diabetes and cancer are linked to increased intake of sugar. In his book, Pure, White and Deadly, British physiologist John Yudkin illustrates that sugar and not fat is a more probable cause of heart disease. Yudkin showed that heart disease is uncommon among pastoral communities, like the Maasai and the Samburu, who live on a high fat diet mostly meat and milk but no sugar.

Nature made sugar hard to obtain. Sugar as fruit was available to our ancestors for only seasonally, or as honey fiercely guarded by bees. Today sugar is ubiquitous, added to virtually every processed food.

In a paper published early this year in the journal Nature, pediatric endocrinologist Robert Lustig and colleagues at the University of California, San Francisco School of Medicine argue that sugar in all forms is harmful to public health and must be regulated like alcohol.

Here is what you need to know about sugar. Table sugar is made up of glucose, bonded to fructose – a fifty-fifty mixture of the two. Insulin is produced when sugar is ingested. The more sugar you ingest, the more insulin your pancreas will produce, and the higher your triglyceride levels are likely to be. Triglyceride is a mechanism for storing unused calories.

High levels of triglycerides in the bloodstream is linked to atherosclerosis and the risk of heart disease and stroke. Atherosclerosis is a condition in which an artery wall thickens due to accumulation of fatty materials such as cholesterol.

Sugar is a major contributing factor to adult – onset of diabetes, also known as type II diabetes. Type II diabetes is associated with the inability of cells to respond adequately to insulin and excess release of glucose into the blood by the liver, leading to high blood sugar.

Sugar can be abused. Like any drug, sugar acts on the brain to induce subsequent consumption. Specifically, sugar interferes with the suppression of the ghrelin, a hormone produced in the stomach that regulates food intake. Sugar also interferes with the hormone leptin, which regulates appetite by signaling to your brain that you are full.

The processing of fructose by the liver leads to accumulation of body fat. So over time the cumulative consumption of small amounts of fructose in soda and fruit juices adds up and adds pounds, leading to obesity.

National Health Policy apparatus must focus on NCDs. Last month Prime Minister Odinga announced that the government was reviewing the National Health Policy to address NCDs. The new policy should introduce taxes on processed foods and drinks (e.g. sodas, juices and cereals). The new policy should also regulate location processed food outlets and impose age restrictions on who can make purchases. A ban on television commercials and outdoor advertising for processed sugared food could further protect public health.

Saturday, May 12, 2012

Smallholder Farmers Key to Africa’s Economic Growth

A couple of years ago I visited a feisty grandmother in village near Lake Victoria in Kisumu County. Ann is 75 years old and barely ekes out a living on her family farm. She happily volunteered to give me a tour of her half-acre estate. We stopped at a vantage point, a little mound on the edge of the farm, for a picturesque view of her field and the village beyond.

Like all her neighbors, Ann’s field was planted with corn. Grass-thatched and iron-roofed homes looked like islands in a sea of pale corn. In the middle of the growing season, the corn was thin with spindly stalks, barely one meter tall.

Ann recounted memories of three-quarters of a century spent on the shores of Lake Victoria in western Kenya. She talked about poor yields and barren soils, scarlet rivers and dusty fields, denuded hills and flash floods. She remembered her youthful years five decades ago as a fish trader, when the water was clear, fish were abundant, the hilltops were green and lush, and harvests plentiful.

“There are just too many of us,” Ann remarked. “All of us scrambling for space to live, land to grow food and pasture for our livestock. We work a lot harder for much less to eat and nothing to save. The large trees, the colorful birds and animals of my grandmother’s stories are no longer here. It is a very different world.”

My gaze rested on a bare patch, which exposed what could be the root cause of the withered corn. The Earth’s fragile skin, the soil, was wounded and pale, drained of all vital minerals. Gulleys scarred the landscape, evidence of sustained hemorrhaging of fertile soils.

Most farmers in rural Kenya and indeed sub Saharan Africa are like Ann, mostly women, hardworking but poor and malnourished. On a per-capita basis, they produce roughly 30 percent less than they did in the 1970s.

Ann is one of about 15 million of Kenya’s 31.5 million rural folk live on less than $2 a day. It is therefore not surprising that Kenya and a majority of sub Saharan Africa are unequivocally off track for halving extreme poverty by 2015.

Urban growth and rural stagnation is opening a dangerous chasm of inequality in Kenya. The broader point here is that extreme inequality can constrain poverty reduction in low-income countries. The smaller the poor’s share of any increment to income the less efficient growth is as a mechanism for poverty reduction.

Africa’s quest to free herself from hunger and poverty is inextricable bound with the productivity and profitability of hundreds of millions smallholder farmers. But there is an enduring existential question: How can the hundreds of millions of smallholder farmers increase land productivity, profitability and human well-being outcomes without causing irreparable damage to the soil and water resources on which they depend?

In his book “Starved for Science: How Biotechnology is Being Kept out of Africa”, Robert Paarlberg observes that while modern agricultural science was the key to reducing rural poverty in Asia, modern farm science, including biotechnology, is yet to take hold in Africa.

Significant global financial resources are currently flowing to sub-Saharan Africa, where the international community has set ambitious goals for ending poverty, hunger and malnutrition through increasing agricultural productivity.

On May 18, 2012, President Barack Obama, with G8 and African leaders, businesses, international organizations and civil society will convene to discuss new activities to advance global agricultural development, food and nutrition security in Africa.

The focus of the Camp David meeting must be on improving productivity and profitability for Ann and millions of smallholder farmers like her, through investment in science, technology, input and output markets, and financial services.

To be productive and profitable, smallholder production systems need an enabling environment: plant, soil and animal health extension services; timely and accurate climate forecast; quality inputs (seeds, animal breeds and fertilizer); reliable water supply; stable land tenure rights; access to affordable financial services, including insurance; appropriate mechanization; access stable markets; value addition through cottage processing.

The creation of such enabling environment, public leadership is crucial as is public funding.  The private sector must step up to the plate by creating new and divers value chains and in ensuring that the benefits flow to smallholder producers like Ann.

Ethiopia’s approach is both illuminating and inspiring. Ethiopia has created an Agricultural Transformation Agency, with support of Bill & Melinda Gates Foundation and chaired by the Prime Minister Meles Zenawi.

The objective of the agency is to strengthen extant structures of government, private sector and other non-governmental partners to surmount systemic logjams in the delivery of agricultural productivity and food security. It is a model that could be replicated in Kenya and other sub-Saharan countries.

Thursday, May 10, 2012

The Right of Gays to Marry

Obama's endorsement of the right of gays to marry is a consequential watershed in the discourse that shapes our moral conceptions. The narrow framing of human agency and free choice by religion is authoritarian and certainly old fashioned.

We must all learn to let go and recognize that we cannot define and police morality, especially sexual preferences of other adults. The same arguments that are so often peddled against gays are similar to those that we privileged to criminalize black and white heterosexual marriages in the 19th and 20th century.

As they say we learn from history that we learn nothing from history.

Tuesday, May 8, 2012

To The Tight-assed Educators

Education at all levels faces enormous pressure. Lots of people, teachers, parents, students and politicians who have opinions and love to express them have declared education broken. The language of change is often expressed in knowledge and competency terms (world class universities and the urgent need for graduates who are creative, innovative problem solvers).

But this is the best age to live in. And we are only at the beginning. The current generation of students and professors will witness the remaking of education in ways that were completely unimaginable a decade ago.

Change is happening on many fronts: economic, technological, paradigmatic, social, and the natural cycles of change that occur in complex social/technical systems.

There are multiple fronts of disruptive innovation and creative destruction of bad habits in: open education resources; internationalization; partnerships with universities in developing economies; adoption of new technology; and, new pedagogical models.

Early this month, Harvard University and the Massachusetts Institute of Technology today announced a partnership that will host online courses from both institutions free of charge. The platform dubbed edX has the potential to improve face-to-face classes on the home campuses while giving students around the world access to a blue-ribbon education.

John Boyer teaches a megaclass at Virginia Tech. He delivers a class, Introduction to the Planet to 2,670 students. He is exploring how technology can help engage students in face-to-face courses that enroll from 600 to 3000 students.

Mr. Boyer's "show"  (class) begins on a Monday at 7:58 p.m., when his technical assistant, Katie Pritchard, blasts alerts to 9,000 Facebook and Twitter friends: Live online office hours are starting in 5 minutes! Join the fun.

Mr. Boyer hosts the sessions from his bottom-floor office. Some participants attend in person, some online; some are current students, others former ones who like to check in. The few students in the office follow on laptops and iPads as the instructor interacts with a much larger crowd online. But much of the fun is virtual.

Boyer’s approach? Decentralize the rigid class format by recreating assessment as a game like system in which students earn points for completing assignments of their choosing from many options (1,050 points earns an A, and no tasks, not even exams, are required). Saturate students with Facebook and Twitter updates (some online pop quizzes are announced only on social media). Keep the conversation going with online office hours.

Then there's the pushback from other professors. Can students learn in such a big class? How interactive can it be? Can Mr. Boyer meet all their needs—especially less prepared kids who could fall through the cracks? He thinks the whole notion about smaller classes being superior is poppycock.

Peter E. Doolittle, director of Virginia Tech's Center for Instructional Development and Educational Research. "We're better off learning how to teach well in large classes, rather than trying to avoid them."

Mr. Boyer's students are indeed learning. Midway through the semester, Virginia Tech's Center for Instructional Development and Educational Research tested a sampling of 582 students on the ideas, concepts, and people to be covered in the second half of the "World Regions" course. Students took the test again at the end of the term. Average performance improved from 43.4 percent to 74.3 percent.

At the end of the day, much of Mr. Boyer's effect on students seems beyond quantification. But students make it clear that he has inspired them. Like one who joined the Peace Corps because of the class. Or another who went on to work for an NGO in South Africa.

Adopted from “Supersizing the College Classroom: How one Instructor Teaches Students” By Marc Parry. Published in The Chronicle April 29, 2012

Monday, May 7, 2012

We Must Rethink Conservation to Save Biodiversity

Contemporary policies and practices of conservation in Africa through isolated national parks and reserves is a relic of the colonial romanticism. With the rapid population growth and the concomitant land use change, the paradox at the heart of contemporary conservation is unraveling.

The chickens are coming home to roost. Long-term data for 69 large mammal species from 78 protected areas in Africa revealed a 59% decline in large mammal population between 1970 and 2005. Closer home, large mammal populations in Masai Mara National reserve have declined by over one third between 1977 and 2009.

Agriculture, settlement, roads and urbanization have chocked migration corridors that hitherto enabled seasonal dispersal of wildlife across contiguous requisite habitats. Today wildlife is sequestered and trapped in parks and reserves, which lack the requisite habitat resources to support viable populations, especially of large mammals and associated predators.

In the face of irrevocable anthropogenic landscape transformation and inexorable wildlife extinctions, conservation based on the purist pre-human wilderness model is antiquated. Conservationists must renounce romantic notions of nature as separate from humans – notions that have no basis in ecosystems science – and embrace a whole landscape based approach in which diverse species and natural habitats co-exist with modern human landscapes.

The dualism of conservation – development or biodiversity – has estranged it in a crowded world where livelihood resources are scarce and dwindling. In Kenya where over 20 million people live on less than two dollars a day, efforts to prohibit compatible subsistence use of parks and reserves and privilege tourism seem unfair, if not immoral.

The notion that nature without people is more valuable than nature with people is an untenable colonial absurdity. People are a part of nature. One does not need to be a postmodern ecologist to understand that the concept of “Nature” has always been an idyllic human construct, shaped and contrived for human needs. 

A curious contradiction of nature untrammeled is the logic of using parks and reserves for some things and not others. By excluding long-established human use such as livestock grazing to build hotels and resorts, excavating dams 
to water wildlife, and imposing fire to manage vegetation quality, we create parks that are no less human constructions than glorified zoos.

Perfunctory arguments around the intrinsic essence of biodiversity and economic benefits of tourism receipts are not enough when the vast majority of poor rural folk who underwrite the enormous credit of conservation enjoyed by the wealthy global urban class are mostly poor.

Any justification for conservation in the 21st century, locally or globally, must stringently demonstrate how the fates of nature and of people are inextricably bound together.

 Conservationist cannot promise a return to pristine, pre-human landscapes. The real challenge for 21st century conservation is maintaining and enhancing biodiversity and ecosystem service value of functional landscapes; urban areas, forest plantations, agricultural monocultures, wetlands and marginal drylands. 

A new vision of conservation must embrace marginalized and demonized cultivators and herders, and to embrace benefit sharing, an imperative which conservationists find repugnant. To succeed, conservation must be a broad-based coalition supported in corporate boardrooms and corridors of political power, as well as the village council.

When recent declines in wildlife populations are examined in the context of patterns of human settlement, the natural dynamics of ecosystems and climate change, it becomes imperative that we must rethink the design and management of existing parks and reserves.

Parks and reserves need not be isolated, stand alone of biodiversity storehouses. There is a need for a paradigm shift toward spatially connected, interdependent parks and reserves if they are to hold viable wildlife populations and resilient habitats.

Connectivity will enable dynamic interactions among species and utilization of ecological resources across space and time. The bigger challenge lies in negotiating access to or acquiring portions of wildlife migration corridors currently under private ownership.

However, there is a great opportunity here to create the largest and most lucrative ecosystem service markets in Africa. For instance landowners in Kenya and Tanzania could be persuaded using financial incentives such as ecosystem service payments to lease their land for use as wildlife migration corridors. The ecosystem service market could be developed further to enable trading of such leases in the region's stock markets.

Implementing trans-boundary management of wildlife resources will require novel policy, legal and institutional regimes to co-ordinate multiple stakeholders, including national governments, local authorities, and private/community interests such as pastoralists, agriculturalists and game ranchers.

The East African integration process through the Arusha Secretariat provides a legitimate platform for an earnest negotiation of a protocol for joint management of trans-boundary wildlife corridors.

The future of wildlife conservation will remain tenuous as long as it is narrowly focused on the creation of parks and protected areas, and assumes often without evidence, that local people cannot be entrusted with the stewardship of nature.


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