Dr. Nelly’s journal: Kibera

BY DR. NELLY M’MBOGA
Published February 23, 2010

This series was inspired by Dr. Nelly’s experience working in Kibera slum as a consultant pediatrician with a research interest in malnutrition. The characters and events are fictional. Dr. Nelly’s work can be viewed at www.nutritionafrica.com. All Rights reserved.

Ugly politics behind spread of Kwashiorkor

After stabilizing Akinyi with fluids and oxygen, we put her in an ambulance, which rushed her to the hospital for admission. She stayed in the emergency ward for about three days, where she was put on IV (intravenous) fluids. Blood tests confirmed that she had anaemia and malaria, but her chest X-ray was normal. She was put on antibiotics in addition to the malaria treatment, because children like her with weakened immune systems tend to have ’silent’ infections. This means that the body does not react to infections the way it is supposed to.

Three days after admission, her condition became stable, and she was transferred to the malnutrition ward, which caters for special needs of children with malnutrition like her. While in the ward, such children are usually put on a special high-protein or high-calorie diet prepared by the hospital nutritionist. Micronutrients (vitamins, minerals and other trace elements) are usually added to this mixture. These help improve appetite and the processing of protein in the body. The children tend to stay in the ward until the diarrhoea and vomiting stops; usually, it takes an average of two to three weeks. We normally know that a child is ready to go home when she starts showing an interest in food and can smile. Akinyi was not there yet, according to the daily nurse’s report.

We had asked Akinyi’s mom to pass by the clinic and update us on how Akinyi was doing (from her own perspective), but also so that we could give her family extra attention. This was because by then we knew that kwashiorkor was because of more than just “lack of protein” in the diet. We wanted to be sure she got the right counselling. Akinyi’s 6-month-old brother, whom we had come to know as Dennis, was our main concern. Dennis was an at-risk child for two reasons. First, if the mother got pregnant, he would lose the goodness of breast milk too soon, and fall victim to kwashiokor.

Secondly, the family came from a community where maize was the staple food. This meant that his mother’s breast milk was most probably deficient in niacin. This posed a health risk to him. He could develop diarrhoea, which would set him on a path to kwashiorkor like his sister. The mother’s health status could also decline fast because of her low niacin status. Pellagra is part of the reason maternal mortality is increasing rather than decreasing with ‘development.’

The late Dr. Nelson K’Okul, working among the Samia of Western Kenya, reported in his book,  ”Maternal and Child Health in Kenya”  that some babies refused breast milk and some even developed diarrhoea on breast milk. This development should have alerted policy makers to intercede because loss of the ‘health giving qualities of breast milk’ surely means certain death for a majority of Africa’s children!

Indeed, the most affected areas showed grim statistics: infant mortality was higher than 195 per 1000 live births in Busia, Siaya, South Nyanza, Kilifi, Kwale and Lamu; in Nyeri, it was 49, according to K’Okul, quoting the 1979 census. The national figure, which was about 70, could therefore have been quite misleading. Note that these census figures were from 1979, before the AIDS era. When under five deaths (from kwashiorkor) are added, the crisis becomes apparent.

In 1931, Dr. Cecily Williams first described kwashiorkor as a lethal protein deficiency disease while working in Ghana. She had observed children with a similar problem in her home area of Westmoreland, England. In fact, this type of malnutrition was already recognized by European paediatricians, although each community tended to have its local name.

These children, had “swollen bellies, diarrhoea and vomiting,” just like our children. There was a time when maize used to be a dietary staple for poor Europeans, especially in the South (e.g Italy’s polenta), so this is no cause for surprise. Once Europe realized the hazards of maize, it stopped being central to their diets. Research, much of it done here in Africa informs today’s nutrition culture. In Dr. Williams’ home, just like across sub-Saharan Africa, kwashiorkor was viewed with suspicion; the children were said to be suffering from “marasmus, an incurable disease.” The locals often alleged that “ghosts were sucking their blood.”

When she was posted to Ghana by the Foreign Office, Dr. Williams observed a similar problem among local children. The locals called it “kwashiorkor,” meaning “the sickness the older child gets when the next one is born,” or simply, “the disease of the deposed child.” She later published on kwashiorkor as a “protein deficiency disease” linked to the dietary staple of maize. However, the linkage to a maize diet got lost along the way, and kwashiorkor came to be commonly known to many (even in textbooks) simply as “the disease of the deposed child.” The fact that lakeside communities that subsist on fish protein are significantly affected by kwashiorkor supports the view that simple lack of protein is not the main problem.

In Kenya, kwashiorkor is well recognized in many communities where malnutrition is endemic. In Western Kenya, for example, the Luhyas and Luos sometimes share names and explanations for disease causation. The local name for kwashiorkor in Samia is akuodi, while marasmus is known as chira. Akuodi is said to be because of ”bewitchment,” while chira is said to result from “breaking of cultural taboos.” While Dr. William was documenting kwashiorkor in Ghana, the British were busy promoting maize in Kenya (and elsewhere on the continent). They misrepresented maize as a superior food, when compared to traditional staples such as sorghum and the millets. Thanks to British persuasion and even coercion, maize became central to the diet in Western Kenya.

In the meantime, the British studied the disease, now well entrenched among communities. The skin rashes that became common were attributed to “poor hygiene” (the same characterization happened to Black Americans). Dispensaries to dress the many wounds that became common started sprouting all over although this problem eased when antibiotics became readily available. One of the contentious issues that came out of their studies was that the African brain was smaller and primitive in structure, when compared to the Caucasian brain. Such controversial findings (examinations were done on adults postmortem) when pellagra was well entrenched in the community) were used to promote the now discredited ‘black inferiority dogma.’

Just before independence, hybrid maize was introduced in Western Kenya even though nutritionally inferior to the local varieties. By the 1960’s, therefore, affected communities had developed significant malnutrition. A documentary done on the Maragoli during this period showed revealed signs of malnutrition among participants (stunted children, wasted adults with very dark skin). It was during this same period that the UN formed a Protein Advisory Group (PAG), to treat protein malnutrition in children, while promoting bottle feeding using dry skimmed milk (DSM). Lysine, a non essential amino acid readily available in beans (as opposed to tryptophan) was also tried. This was done despite the fact that DSM is especially dangerous in malnourished populations. Other interventions were also introduced, including various immunizations. Kwashiorkor can therefore be viewed as an industry that supports Western technologies.

By the 1980s, when HIV/AIDS was first documented in Kenya, akuodi  and chira  (in both adults and children) were well recognized entities in affected communities. Now that HIV/AIDS has entrenched itself in the community, any ‘wasting disease’ is automatically called HIV/AIDS. The song, “Lumbe”, by Bernard Lukose, set in Western Kenya highlights this dilemma. The musician dramatize an illness which causes abdominal pain before the index girl dies of what they are told is AIDS (ukimwi). The soloist concludes that people are being cheated that chira is the disease ukimwi.  Malnutrition makes people more vulnerable to HIV/AIDS; pellagra causes wasting, just like HIV/AIDS.

HIV/AIDS is a global billion dollar industry that supports many individuals and industries. Cutting edge research goes on all over the continent and globally. Some very ill HIV orphans now depend on imported breast milk from the West to keep them alive. Our mothers’ milk is undernourishing our babies, and underdeveloping tomorrow’s generations; animal milk makes the malnutrition worse. Weak immune systems automatically create a market for drugs, because of the high disease burden. A high infant mortality controls populations. Dependent people provide a ready market for other people’s manufactured goods, including alcoholic spirits. Western Kenyan youth (like youth all over Africa) are notorious for over-indulgence in alcohol. A link exists between malnutrition and addictions.

Some time during President Mwai Kibaki’s first term in office, he inaugurated the first millennium village in Africa: Sauri. Now these villages dot the African landscape. Sauri in Western Kenya is heavily funded. The villagers are even given money to buy meat, and their health care is taken care of, although the clinic is kept very busy. Among the foods being promoted are new varieties of maize. Many however now wonder what will happen to the villagers when the project folds. In part, maize is the reason Africans have become “the diseased race” as kwashiorkor continues being passed from one generation to the next.

Dr. Nelly’s Journal continues next week.

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