“You really should do your research because this is a very unique and special case in which people do not have to die,” Mr. Russell said.
“We put a man on the moon. That’s what we did as human beings. People maybe should have died doing that but we figured it out.”
The key to capturing Mr. Kony is to outsmart him, Mr. Russell said in the interview.
“We have to use our technology and resources and human power to ask him to surrender because we don’t want this to end bloody,” he said, calling Mr. Kony “the world’s worst criminal.”
“We don’t want bombs being dropped. We don’t want a bullet through his head. We want him alive. That’s the win.”
Mr. Russell said he sees a “beautiful ending” to the manhunt that ends with Mr. Kony surrendering peacefully, boarding a helicopter and being tried in the International Criminal Court.
Driving through the countryside or city streets in Uganda or Rwanda, one is greeted by the same sight over and again – children. Youngsters in colourful uniforms fill the sidewalks and paths every morning and afternoon as they trek to and from school.
Jogging in the early morning down Kigali streets I have more than once been embarrassingly out-run by little girls in dress shoes and backpacks, screeching gleefully as they dash past. Meanwhile, the smaller children toddle curiously around the home, and babies find themselves securely strapped to the backs of their busy moms. You don’t have to look up demographic figures to know that one word characterizes the population: young.
In a region long defined by civil war, violence and dictatorship, youth is the new and hopeful quality permeating society. The wars that wracked the region for the past several decades have drawn to a close, one by one – the Ugandan civil wars of the 1970s and 1980s, the 20-year terror of the Lord’s Resistance Army in Northern Uganda, the Rwanda genocide of 1994, and the Congo wars that followed. As the worst episodes of violence recede, how will newfound security affect the political, social, and economic opportunities and beliefs of the new generation? How will the youth relate to the decisions of leaders whose lived experiences are increasingly distant from their own?
The children and young adults of today will live profoundly different lives than those of their parents and grandparents. While conflict continues in eastern Congo, a peace and cautious hope has come to most of the region. Nearly half of Rwanda’s population today was born after 1994. 52% of Rwandans and 61% of Ugandans are less than 20 years old. Nearly three quarters of all Ugandans have lived under President Yoweri Museveni for their entire lives.
Most Ugandans and Rwandans, therefore, know only stories of the terrible wars that once ravaged society. The scars, visible or not, are everywhere, but the memory is increasingly derived from history passed down by those who lived through it. As these children come of age, they face very different challenges than their parents before them. The vast majority will attended primary school, and will read and write in English. Many will graduate from secondary school, and an increasing number will obtain a university degree. Unlike their parents, most will not fear for their lives, but for their livelihoods.
Yet for now, those who govern the countries in which these children grow up – individuals who were intimately involved in the conflicts of the past several decades – continue to make calculations, judgments, and risk assessments based on the experiences through which they have survived, as have done leaders before them. National security is at the top of the agenda for every government, but the price one is willing to pay for security is shaped by experience. For the older generation, there may be no price too high. For the younger generation, the choices may not be so clear-cut.
It is difficult to assess the extent of the divide between today’s youngsters and the generation that preceded them. Often votes are a good indication of political and policy preferences, but the post-conflict generation is only just coming of age. Surveys too can help, but ultimately we are left to some speculation.
Recent surveys in Rwanda show that both the young and old continue to place a high value on national security. Overall, 44% of Rwandans said that “strong defence forces” should be the top national priority, with a similar percentage across all age groups, according to the World Values Survey. In the U.S., by contrast, while 38% of all Americans surveyed believe strong defence forces is the most important national priority, only 20% of those under 30 list national defence as the top priority. The vastly different security challenges facing each country have surely shaped these preferences.
In Rwanda, an extraordinarily large percentage of people not only support strong defence forces as the top national priority but would also contribute to this goal – 95% of all Rwandans and 96% of 15-29 year-olds surveyed said they would be willing to fight for their country. In the U.S., only 41% of 15-29 year-olds were willing to do so. 91% of Rwandans also expressed a preference for greater respect for authority in the country. All this suggests that so far, there is little evidence of a generational difference in security preferences. Nevertheless, it is important to keep in mind that most of the peacetime generation is still too young to be included in any survey. We are likely still observing the preferences of an adult population for whom the remnants of conflict may still be too fresh, and continued violence in eastern Congo too close.
In Uganda, evidence is mixed regarding whether the old and young have different preferences when it comes to national priorities, but there appear to be greater differences than in Rwanda. There are obviously serious economic challenges facing Ugandans, which may trump security concerns for the ordinary citizen — 64% of 18-29 year-olds were unemployed in 2008, according to an Afrobarometer survey. For most Ugandans, “improving economic conditions for the poor” is the most important national priority. Only 17% of 18-29 year olds listed maintaining order in the nation as the highest priority. Interestingly, young people expressed greater fear of political intimidation or violence than the very old in Uganda – 36% of young people said they had “a lot” of fear of political violence. And worryingly, the majority of Ugandans believe political competition often or always leads to conflict.
Uganda and Rwanda are both societies in transition — transition away from conflict, transition toward greater political participation, transition out of poverty. How today’s children will view the behaviour and policies of leaders whose life experiences are increasingly distant from their own is yet to be seen. It may be too soon to detect generational differences in any scientific way, but ready or not, the youth bulge is coming into its own. Young people already make up the lion’s share of the population in the region. In just a few years they will be the king and queen-makers, or breakers. Watch this space.
A problem of supply in services is limiting further improvements in maternal health
Fertility rates in Rwanda have been falling steadily over the past several years, but this year close to 400,000 Rwandan women will become pregnant and give birth. Next door in Uganda, four times as many women will become pregnant, approximately 1.5 million. If recent trends hold, nearly 10,000 of these women will lose their lives during or shortly after their pregnancy. Many of them will suffer from bleeding and infections that can be treated or prevented.
Surveys show that pregnant women in both Rwanda and Uganda seek antenatal care at very high rates. Nearly 98% of women in Rwanda and 95% in Uganda have at least one antenatal visit during their pregnancy. These women want information about their pregnancy, and seek out health services that they believe will help them have healthy babies. But often the health system fails to provide these women with the information they need to take care of themselves, and far too many mothers lose their lives because they do not receive emergency care in time. Rwanda has been showing steady progress in improving maternal health, but Uganda has faired poorly.
Both Uganda and Rwanda continue to have high levels of maternal mortality, defined as the death of a woman while pregnant, or within 42 days after the termination of pregnancy (excluding accidents). Between 1985 and 1995 in Uganda, maternal mortality was estimated at 527 deaths per 100,000 live births. The following decade, from 1996 to 2006, maternal mortality was estimated at 435 deaths.Although these figures suggest a slight decrease over the past twenty years, the margin of error around these estimates are such that we cannot say with any confidence that maternal mortality rates have changed at all between 1985 and today. Thus, it appears pregnant women in Uganda today are equally likely to die in childbirth as they were 25 years ago, when the National Resistance Movement came to power.
Meanwhile, maternal mortality in Rwanda has fallen significantly, although rates in Rwanda have for some time been higher than those in Uganda. Between 1995 and 1999, maternal mortality in Rwanda was estimated at 1071 deaths per 100,000 live births, one of the highest rates of maternal death in the world. Between 2000 and 2004, however, it had dropped to 750. The most recent estimates should be available in the next year or so, and are likely to show even further decline.
Rwanda may have made greater strides than Uganda in reducing maternal mortality in the past decade or so, but both countries face significant challenges in improving maternal health. There is a long way to go. The good news is that unlike many types of preventive health behaviors, such as getting immunizations or sleeping under a bednet, seeking help during pregnancy has become very common, even natural. In other words, the demand for health care during pregnancy appears higher than for many other health issues. Unfortunately, while demand is high, supply of care during pregnancy is weak.
Although nearly all pregnant women seek antenatal services at least once during their pregnancy, not all clinics and health facilities are equipped and ready to meet their needs. In fact, most health facilities are lacking the basics when it comes to antenatal care. The Service Provision Assessment Survey 2007 found that only 31% of health facilities in Rwanda had all the items required for infection control, including running water, soap, latex gloves, and disinfectant, and only 28% had all the essential supplies for basic antenatal care, including iron and folic acid tablets, tetanus vaccines, and equipment to measure blood pressure. A mere 11% had all the medicines required to treat pregnancy complications, including antibiotics, antimalarial drugs, and medication to treat common sexually transmitted infections.
To make matters worse, very few women were given sufficient information so that they could take good care of themselves at home during their pregnancy. Only 8% of women in Rwanda were told about signs of pregnancy complications, while only 35% of women in Uganda were informed. It is perhaps not surprising that only 35% of Rwandan women and 47% of Ugandan women attend the recommended four antenatal visits. When women arrive in clinics, often without power or water, which do not provide the necessary equipment and information to help them with their pregnancy, there may be little incentive to keep going back.
Of course, the news is not all bad. On the contrary, the improvements that have been made in maternal health, particularly in Rwanda, are extraordinarily impressive. In just five years, between 2005 and 2010, the percentage of mothers whose delivery was assisted by a trained and skilled provider increased from 39% to 69%. The percentage of mothers who delivered in a health facility jumped an equally miraculous 28% to 69%. The increase in births under the watch of a skilled provider has likely played a large role in the reduction of maternal mortality. An estimated 15% of all pregnant women will encounter life-threatening complications, and trained nurses, midwifes, and physicians can help make sure these complications do not become fatal.
The fact that pregnant women appear to seek out services and information at high rates is a great opportunity for public health, but this opportunity is squandered if health facilities are poorly equipped to provide care. While Rwanda has made strides in improving the supply of care, there is less evidence of improvement in Uganda. The results speak for themselves.
Why small increases in price can lead to a steep decline in demand for essential products
A piece of nylon netting is a useful thing. It can be cast as a fishing net, hung as a curtain, or draped over a seedbed as protective covering. Netting can make a stunningly white wedding dress, or even a make-shift chicken coop.
One can also sleep under it, of course, to keep mosquitos from biting at night. Though insecticide treated nets (ITNs) are routinely distributed in malaria endemic regions, often subsidized by major donors such as the Global Fund, many worry that such campaigns are frequently futile. Anecdotal evidence from the Kenyan shores of Lake Victoria to the alters of Ugandan churches suggest that these bednets are sometimes quite literally cast aside or otherwise misused.
While misuse is certainly problematic from the perspective of those funding mosquito net campaigns, it also raises a broader question, and one with serious implications for public policy in malaria prevention and beyond: Do people value and use things that are given to them for free?
There are two competing arguments used to answer this question. The first argument says that people value more that on which they spend their own money or resources. Furthermore, people will spend some money, when they can afford it, on those objects that they perceive to be useful. A second argument says that if an object is perceived to be useful or of value, people will use that object regardless of whether they purchased it or whether it was given to them for free. The ubiquity of incumbent presidents’ campaign t-shirts in both opposition and stronghold areas is supporting evidence for those in the latter camp.
The mosquito net-cum-wedding dress is a classic illustration of the dilemma of freebies. The protective power of mosquito nets against mosquito bites and thus, malaria, is rather less effective when the net becomes a nuptial adornment or is tossed into a river, much less left in its packaging and stashed in a corner. The creative use of nets is thus often the go-to anecdote for those in the first camp of the freebie question.
Anecdotal evidence, unfortunately, can only get us so far in adjudicating between these two perspectives. Fortunately, a number of development economists have been systematically evaluating the extent to which people use services or tools given to them for free and those provided at a cost. While there is still no definitive answer, and while context matters, much of the evidence seems to suggest that people use many free goods at high rates, and often will not purchase the same products when provided even at very low prices.
A group of researchers at the Abdul Latif Jameel Poverty Action Lab, based at the Massachusetts Institute for Technology (MIT), recently wrote a report summarizing ten studies examining the question of whether user fees and cost-sharing increase or decrease the use of health and education services and products. The majority of the studies were conducted in Kenya, although some were also conducted in Uganda, Zambia, and India. Their findings are striking, and the title of the report says it all: “The price is wrong.”
Time and again, small increases in price lead to a massive decline in demand for products including water disinfectant, deworming medicine, mosquito nets, and soap. For example, one study in Kenya found that while over 80% of people used a mosquito net if they received it for free in a prenatal clinic, only 20% would purchase the net for $.60 (approximately 50 Kenyan shillings or 360 Rwanda Francs). Similarly, another study in Kenya found that while nearly 60% of people used water disinfectant when it was given to them for free, less than 10% would use disinfectant if charged $.30 for the same product. This general pattern appears to repeat itself in different locations and with different products.
Two things are thus evident. First, people are often unwilling to purchase a number of goods and services that promote health and education even at highly subsidized rates. Second, people often use those same goods and services at high rates if they are provided for free. Clearly, receiving something for free does not preclude its use. If we think back to the wedding veil problem however, it is also clear that some products may not be used as prescribed, fee or no fee.
Why are people so sensitive to price when it comes to potentially life-saving goods and services? Individuals and families weigh the costs, monetary or otherwise, of procuring and using goods and services against the expected benefits from using those goods. Bednet wedding veils notwithstanding, in most cases it appears that families perceive some benefit from using goods like mosquito nets and soap, since rates of usage are quite high when the product is free. Some speculate that people may not physically have the cash on hand to buy even very inexpensive products, or that other inconveniences, such as the time it takes to procure a product, may affect their decision. But these are only partial explanations. It is also possible that people do not believe products will be as efficacious as researchers and policymakers think they will be in promoting their health.
Available evidence suggests that people who receive goods and services for free often do use them, although the extent to which they will use them and how they will use them is subject to some debate. Even if there are large benefits to providing free bednets, water disinfectant, soap and the like, products that often provide benefits that extend beyond the individual recipient, the question of sustainability comes to the fore. In the short term, the provision of free goods and services, particularly those that promote preventive health behaviors (like hand-washing) may have large and positive effects on the health of families and communities. But ultimately, we need to better understand why people are often so unwilling to spend even small amounts on products that have the potential to keep their families much healthier.
A study by Mishra et al (2008) using data from the 2004-5 Uganda HIV/AIDS Sero-Behavioral Survey (UHSBS) suggests medical injections are positively associated with HIV status among Ugandan adults, even after taking into account other HIV risk factors and reverse causality (i.e. HIV positive individuals seek more medical care). Even if iatrogenic transmission is not the primary mode of transmission of HIV today (though Pepin argues it played a pivotal role in the early spread of HIV), this finding is worrisome. The authors conclude:
Our analysis showed a strong positive association between number of medical injections and HIV infection. Receiving frequent medical injections was significantly positively associated with HIV positive serostatus among Ugandan adults. Even after controlling for several potential confounders, and accounting for possible reverse causality from HIV infection to increased use of medical injections, men who received five or more medical injections in the previous 12 months were 2.3 times more likely to be HIV infected, and women 1.5 times more likely to be infected, compared with men and women who received no medical injections.
Our results are consistent with the literature showing a positive association between medical injections and HIV infection (Mann et al. 1986; Deuchert and Brody 2006; Barongo et al. 1992), and provide further evidence that medical injections may increase the risk of HIV infection.
…our finding of consistent and strong positive association between multiple medical injections and HIV infection reinforces the need to strengthen programs to promote injection safety and reduce non-sexual modes of HIV transmission. Medical injection as a potential mode of HIV transmission deserves continued research and programmatic attention. Program priorities for Uganda may include focus on rational use of injections, implementation of the national injection safety guidelines, and further scale up of medical injection safety programs.
There was quite a kerfuffle following President Kagame’s last visit to Uganda in December 2011. The hoo-ha that played out over the airwaves, news pages and Twitter had nothing to do with the trip per se – relations between Presidents Kagame and Museveni have been warming over the past six months and such visits are becoming the norm – but rather with repeated questions about presidential term limits in Rwanda. Amending the constitution to lift term limits is a relatively new trick in the handbook of institutional manipulations. President Museveni, together with the Ugandan parliament, steamrolled right through term limits in 2005, paving the way for a 30-plus-year reign for the former rebel leader. By the time Uganda marks its Jubilee in October of this year, just a few months after Rwanda’s 50-year celebration, Yoweri Museveni and the National Resistance Movement will have held power for over half of the post-independence period.
Whether or not Kagame will attempt to follow in the footsteps of Museveni and lift term limits in advance of the next presidential elections in 2017 is a tired argument. Personally, I doubt that he will do so, but neither do I think it would be at all a difficult task. But that is neither here nor there. Just as there will be a South Africa without Nelson Mandela, there will be a Uganda without Museveni and a Rwanda without Kagame. Though there will undoubtedly continue to be discussion regarding Kagame’s candidacy up until 2017, ultimately the more productive debate is the extent to which promising and talented individuals have opportunities today to become tomorrow’s leaders.
I’m not going speculate who the next president will be, but I’d like to float the idea that Rwanda’s next head of state will be a woman. Rwanda has led the way in bringing women into politics and positions of power, and women around the world are making inroads every day into politics, business, academia, and beyond. As in Uganda’s National Resistance Army and Movement (NRA/M), women have held key positions in the government and party of the Rwanda Patriotic Front (RPF). The presence of women in politics has been steadily increasing since 1994, and in 2003 Rwanda joined Uganda, Namibia, Mozambique, South Africa, and several other countries in implementing a gender-based quota for legislative seats. In the 2003 election, women won nearly half of all seats in the legislature.
Women have also been well represented in other areas of government and civil society in Rwanda, and have played key roles in rebuilding society in the aftermath of the genocide. Many women have been elected gacaca judges, and women groups have worked to address a wide array of issues, from health to microfinance. As of 2008, Rwanda is home to the only majority female parliament in the world. Women today hold several key ministries, including the Ministry of Foreign Affairs (Louise Mushikiwabo) and the Ministry of Health (Agnes Binagwaho), as well as senior management positions in institutions such as the Rwanda Development Board (RDB). And regardless of your view of her, Victoire Ingabire has emerged as the figurehead of the official opposition in Rwanda.
In addition to the possibility of affecting policy outcomes, some research shows that the presence of women in politics helps to alter perceptions and prejudices about women’s ability to lead and govern. A group of researchers from the US and India found that where women in India held elected positions in local government, initially with the help of gender quotas for these positions, men tended to hold less negative stereotypes about the efficacy of women in positions of authority.
Additionally, exposure to female leaders tended to increase people’s perceptions of women’s abilities over time. Although community members may rate poorly the first woman elected to a position, her successor would generally be rated more favorably. Exposure to women in politics, at least in some settings, appears to reduce negative stereotypes about women’s abilities to govern, and will likely encourage more women to enter the ring.
In Rwanda, many women have had opportunities to develop the skills and experience to lead. While the debate on term limits rages on, it is important to think beyond personalities—however formative or influential—and focus on the processes through which leadership is reproduced. Rwanda’s political system, its many flaws notwithstanding, has allowed women to participate in government and policymaking to a greater extent than in many other countries. These opportunities for leadership will help shape the next generation and next era of Rwanda’s history. It would not be surprising, therefore, if Rwanda’s next president comes out of this network of powerful and promising women leaders.
Women’s leadership in Rwanda has evolved alongside the innovative approaches the country has tested in its recovery from conflict. Like other challenges Rwanda faces, both general and gender-specific, from poverty to maternal mortality, it is to processes and not individuals that attention should be paid. Despite urgent challenges, real opportunities exist for ordinary citizens, men and women alike, to grow up in good health with a good education. The impact of public health and education policies on Rwanda’s political development may not be obvious now, but will eventually become evident. The democratic space in Rwanda is still being tested and shaped, discussed and critiqued, pushed and pulled. Ultimately the future lies not with an individual, but with a system that allows the next generation of leaders to emerge.
In August 1854 a terrible illness tore through a London neighborhood, killing hundreds in a matter of days. The terrifying disease emptied the body of fluid until vital organs shut down, after which point the petrified soul would succumb to the illness. Death often arrived less than twelve hours after the first signs of an upset stomach. Londoners of the day had a name for this illness, but did not understand its cause. They called it cholera.
Though cholera outbreaks had hit London before the mid-1800s, the Broad Street Pump outbreak of 1854 is now perhaps the best known. It was during this scourge that physician John Snow was able to demonstrate that cholera was not an airborne disease, as was the popular and professional opinion at the time, but rather a waterborne disease. This insight proved critical to improving public health in London and beyond. Londoners had been emptying their waste into the Thames, often just upstream of intake pipes for water companies. Their water and city stunk. But because disease was thought to be airborne, they doused smelly sidewalks in chloride of lime in attempt to purify the air. They made few attempts to purify the water so obviously contaminated with their own waste.
When cholera inevitably struck, they applied all manner of remedies, most of them useless at best. Castor oil, opium, and leeches were all espoused to treat cholera, not just by ordinary folks, but also by doctors. Worse still were treatments such as laxatives or bleeding. The extreme dehydration facilitated by cholera was often “treated” by attempts to further remove fluids from the body.
In hindsight, both the cause and the treatments for cholera are straightforward, if not obvious. Cholera is a waterborne illness that spreads when one person ingests the cholera-infected waste of another person. The treatment for the extreme dehydration that ensues is most fundamentally rehydration – consuming copious amounts of fluid to replace those that are lost. Yet at its emergence, a series of facts and observations did not at first fit together in a single theory about the cause of cholera. When cholera struck a household, sometimes it struck everyone, sometimes just a single person. In a neighborhood, some homes would be hard hit, while others escaped untouched. Whether you survived or not seemed random.
So it is with another illness in our midst – nodding disease. Nodding disease sounds like a folksy and tabloid-inspired syndrome. Its name describes the telltale symptoms of the disease, a rhythmic head nodding in children. The fact that unlike many diseases its name does not betray anything about its likely causes demonstrates just how little we know about its transmission. For example, HIV (human immunodeficiency virus) is named for the virus that causes AIDS. The name malaria comes from the Italian mala aria, meaning “bad air”, so named because the illness we now know is caused by a parasite was originally thought to be airborne.
But despite its odd name, nodding disease is far from folksy or fake. It is often fatal. First reported in Tanzania in 1962, nodding disease has since spread throughout what is now South Sudan, and has been rapidly spreading in northern Uganda as well.
The pattern of incidence of nodding disease and its symptoms are puzzling, as were those of cholera in the early nineteenth century. First, the onset of nodding disease appears to occur almost exclusively in children between the ages of 5 and 15.
Second, nodding is reportedly often triggered by the presence or eating of familiar foods, or when a child becomes cold. Unfamiliar foods, such as chocolate candy bars, do not induce nodding. Third, when untreated, those with nodding syndrome cease developing both physically and mentally. They are often stunted and experience mental retardation. Fourth, most children affected come from very poor families. There are now thousands of children in South Sudan and northern Uganda who experience symptoms of nodding disease, and the incidence of the syndrome appears to be increasing.
Several theories regarding the cause of the syndrome have been mooted, but none proven. For the past several years, teams of experts from the U.S. Centers for Disease Control (CDC) and World Health Organization (WHO) have travelled to South Sudan and northern Uganda in an attempt to better understand the causes of nodding disease, and possible treatments. Their work suggests that nodding disease is a new epilepsy syndrome, and that the characteristic head nodding is caused by seizures that lead to temporary lapses in neck muscle tone.
A vast majority of children experiencing symptoms of nodding disease are also infected with a parasite called Onchocerca volvulus, which causes river blindness. The high prevalence of this parasite in victims of nodding disease means that the most plausible (published) theory about the cause of nodding disease links the syndrome to O. volvulus, but how and why remain unclear. Moreover, there are a number of children both in and outside the region who are infected with the parasite and do not acquire nodding disease, so the link between the two is not straightforward.
So far, therefore, we have accumulated a series of facts about the mysterious syndrome, which have yet to be pieced together in a coherent theory. We have many more tools at our disposal than did the Londoners of the 1800s, but answers to pressing medical and public health questions do not usually come without time and resources. Nodding disease is a terrifying prospect for those living in South Sudan and northern Uganda not only because of the debilitating effect it has on children, but also because families and communities do not understand why their children are falling ill in the first place. A confusing array of facts, theories, and observations are unnerving both to those in the midst of the outbreak, but also those who see its spread as a very serious health issue for the region.
Misunderstanding the causes of nodding disease can have disastrous consequences, as was the case with cholera some 150 years ago. So far, anti-epilepsy treatments appear to be helping children experiencing nodding disease, but supplies of these treatments are often scarce, and determining the ultimate cause of epilepsy in these children should be a high priority for health officials. Cases of epilepsy are often documented at high rates in hospitals in the region, and there is thought to be a link between epilepsy and cerebral malaria as well. In Arua Regional Referral Hospital, in northwestern Uganda at the border with Sudan and DRC, 7 percent of all outpatient children over age 5 in April 2009 were diagnosed with epilepsy. In 2004/05, 74 percent (nearly 4500) of all cases in the Mental Ward were diagnosed as epilepsy.
Clearly, epilepsy, whether nodding disease or otherwise, is a condition that deserves the utmost attention from public health and medical professionals. The sooner we understand the causes of this new breed of epileptic seizures, the sooner we can take steps to both treat it and prevent its spread. In the absence of a compelling theory about its cause, however, fear and futile treatments are likely to ensue.
Nodding disease is a syndrome that was first reported in Tanzania in 1962, has been spreading in South Sudan and Uganda more recently. The number of cases in northern Uganda appear to have increased at a particularly fast clip in the last year. Nodding disease sounds made-up, but it is very real and often fatal, and is becoming a growing problem in the region. Most problematic is that the causes of nodding disease are still unclear, although there appears to be a connection with a parasitic infection from Onchocerca Volvulus, which causes river blindness.
Adult Onchocerca volvulus worms (WHO)
The Daily Monitor ran a story on December 23, 2011, quoting director of health services in Uganda, Dr. Jane Achieng, as saying that there are around 2,200 reported cases of nodding disease in Uganda (most in Acholi sub-region) and that the first case in the area had been reported in 2009.
Nodding disease appears to afflict children between the ages of 5 and 15 and is usually diagnosed by the characteristic nodding it produces in children. The head nodding (HN) is often triggered by eating or seeing familiar foods, or when a child becomes cold. Winkler et al. (2008) write:
HN represents a repetitive short loss of neck muscle tone resulting in a nodding of the head, sometimes associated with a short loss of muscle tone of the upper extremities. Loss or impairment of consciousness may be present, but not always. To date HN is not mentioned in any classification and it remains unclear whether it represents a seizure disorder and if so, whether it belongs to the group of generalized or partial seizures.
Nodding disease appears to be a growing problem that warrants serious attention from the government. The CDC and WHO have been involved in investigating its causes, but there has been relatively little information available to the public about this illness. I’ll be posting information on the published medical literature on nodding disease, as well as news updates and commentary as they become available.
Accessing people’s thoughts and interests from Asia to Africa is just a click away
It used to be that education primarily took place in a classroom. These days, the chalk and blackboard are fading away and steadily being replaced, or at least complemented, by new technology. Even in some of the world’s hardest-to-reach places, cell towers and solar-charging stations are re-inventing the learning and communication experience. Alongside the traditional classroom teacher are laptops and cell phones, paving the way toward a whole new way of seeing the world.
A world of data is at your fingertips, quite literally. The advent of personal computers and increasing interest in making information open and accessible to all means that we now have the ability to answer many questions faster and more accurately than we ever thought possible. Information on everything from economic growth to weather patterns to flu outbreaks is just a Google search away. Data and data sources are not without their flaws, but we can often see broad patterns much more clearly across and within countries than we once could. The question is, how can we take advantage of new and ever increasing sources of information? Perhaps one of the most novel uses of data pieces together the wisdom of the crowd. In particular, Internet search terms are an amazing guide to all sorts of phenomena we care about, including public opinion on politics and policies, investment interests, and even trends in infectious disease.
What kind of information are people searching for? What are the questions to which they seek answers? One can of course look at broad trends in search engine search terms across countries, something similar to looking at words and topics that are “trending” on Twitter, but one can also look for more specific information. How many people in the U.S., Europe, or Asia look for information about Rwanda, for example? What kind of information do they look for? Google Insights for Search can help answer these kinds of questions, and reveal interests from potential investors, tourists, and others that can be useful to the local business community, government, civil society, and individuals.
If you look at the most frequent search terms related to “Rwanda” used by those living in the United States, France, or even China, you’ll find that most are related to the genocide or the movie, Hotel Rwanda. Within the U.S., searches for “Rwanda genocide” spike every April and May, although the spikes are becoming smaller over time. This is some indication that while the world still heavily associates Rwanda with genocide, this association is becoming weaker with time. Searches for “Rwanda safari” or “Rwanda gorillas” increased greatly in 2005 and 2007 respectively, and most of these searches came from individuals living in the United States or the UK.
Meanwhile, searches about Rwanda in the East African region show a very different pattern. The top three search terms about Rwanda from those living in Uganda and Kenya are all related to jobs, and primarily come from three cities, Kampala, Nairobi, and Mombasa. Meanwhile, searches from within Rwanda about Uganda focused on news outlets, such as the Daily Monitor, New Vision, and “news Uganda” more generally. The most common searches in Rwanda about Kenya include Kenya Airways, the Daily Nation, and Kenyan universities.
Understanding search trends can be useful for businesses and entrepreneurs, but they are also a cheap and easy way to do public opinion polling. In the U.S., search trends of the past couple of months have tended to mirror official polling trends for presidential candidates in the Republican party, for example. If you look over time, you can see the rollercoaster levels of support for candidates such as Rick Perry, Mitt Romney, Herman Cain, and Newt Gingrich. In the U.S., regular and nationally representative polls are conducted throughout the campaign period, but the more informal “search” polling can be very informative as well, and far less expensive.
One challenge for using this type of data in countries like Rwanda and Uganda is that relatively few people are online, although the number of internet users is growing by the day. In Rwanda, approximately 13 percent of people accessed the Internet in 2010, up from 7.7 percent in 2009, according to the International Telecommunication Union. More and more people are using their mobile phones, rather than computers, to access the Internet, which makes it easier to get online. Although there may not be enough people using Google to get a good measure of public opinion in Rwanda, this will very likely be possible in the not-too-distant future.
Already, one can observe trends in public interest in politicians among those living in capital cities. Searches for “Besigye”, Ugandan President Yoweri Museveni’s archrival, spiked within Kampala in November 2005, a few months prior to the heated 2006 presidential election, and spiked again to a lesser degree in February 2011, during the most recent election. It appears there was much more interest in Kizza Besigye leading up to the 2006 election (even with considerably fewer people online) than during the time leading up to the most recent elections, a trend which was reflected in Besigye’s support on election day as well. Online searches for Besigye spiked again in April, during the Walk-to-Work protests, but unfortunately for the repeat presidential candidate, by then the election had already passed. Despite the limited connectivity of the population living in Uganda, general election trends were evident in people’s online behavior.
Searches for "besigye" in Uganda, 2004-2011
Finally, search terms can be useful for tracking trends in infectious disease. When people fall sick, they often turn to the Internet for information about their symptoms or illness. Tracking search terms can thus identify and follow outbreaks of particular types of illnesses. Google Flu, for example, uses data on search terms to estimate trends in the spread of the flu virus. Again, their data is best for countries in which the majority of the population has access to the Internet, but as Internet connectivity increases in countries like Rwanda and Uganda, crowd-sourced data on infectious disease may help health officials identify and address outbreaks.
The wisdom of the crowd has for long eluded policymakers, investors, and even public health experts because it is costly to collect information from a large number of people, and people often have incentives to misrepresent their interests and beliefs. Using search trends, however, as one measure of people’s interests, opinions, and concerns, is one way to crowd-source information gathering in a relatively inexpensive and expedient manner.
History suggests that women and water are essential in conquering the developing world’s health challenges
World Toilet Day came and went without much fanfare. In between using the toilet yourself, you probably missed it. Talking about toilets is not sexy, and discussing water and sanitation is probably not at the top of your list, but it should be. Women and water, specifically clean water, have been responsible for major improvements in health in the developed world and hold enormous potential for tackling its health challenges.
At the turn of the 20th century, some of the top killers in the United States included tuberculosis, pneumonia, typhoid, meningitis, influenza, and diarrhea (for children under two years of age). In 1900, approximately one in six American babies would not live to see their first birthday, according to one recent estimate. In just thirty years, however, infant deaths in the U.S. had fallen by more than half, to an estimated 70 deaths per 1000, approximately equivalent to infant mortality rates in Rwanda today. What accounts for this tremendous improvement in child health in America?
It is tempting to suggest that new medical technologies led to massive improvements in health, and particularly child health. In the course of the 20th century we saw an unprecedented period of medical innovation, which ultimately led to the widespread availability of life-saving vaccines, antibiotics, and other medical technologies we take for granted today. But what is remarkable is that the decline in mortality, particularly due to infectious disease, occurred before the spread, and often before the invention, of these technologies.
Deaths due to scarlet fever had fallen to nearly zero by the time penicillin, a common antibiotic today, was invented in 1946. Similarly, deaths from typhoid and tuberculosis fell dramatically before the introduction of antibiotics to treat these bacterial infections were invented in 1948 and 1950, respectively. It was not until 1963 that a vaccine to prevent measles was invented, by which point very few people died of measles in the U.S. Most of the decline in mortality from infectious diseases in the U.S. occurred before the introduction of medical technology used to prevent or treat them.
So what accounts for the decline in mortality due to infectious disease? To a large extent, women and water. Recent research by Grant Miller of Stanford University finds that women’s suffrage in the U.S. directly contributed to increases in public health spending in the 1920s. Much of this health spending went toward public campaigns to improve hygiene. Around 20,000 child deaths were averted as better hygiene prevented the spread of deadly infectious diseases. Miller argues that legislators anticipated women support of public funding for health, and voted for more progressive public reforms as soon as they won the right to vote.
In related work, Miller and economist David Cutler find that improvements in water systems in the U.S. between 1900 and 1940, specifically filtration and chlorination, contributed to three quarters of the decline in infant mortality and two thirds of the decline in child mortality during this period. Waterborne diseases were responsible for a large proportion of deaths during this time, particularly in U.S. cities, and water treatment and filtration led to a major decline in these waterborne illnesses.
Today, over one billion people around the world do not have access to clean water, and over two billion to not have access to sanitation facilities. In Rwanda, only an estimated 23 percent of the population had access to adequate sanitation in 2006, and in Uganda only 33 percent. In Uganda’s capital city, Kampala, only eight percent of homes are connected to a sewage line. A greater proportion of the population have access to clean water—64 percent in Uganda and 65 percent in Rwanda—but nearly one third of the population continues to consume unsafe water on a daily basis.
Much of the emphasis on public health today focuses on supply-side factors – on health care rather than health, on curative rather than preventive treatments, on hospitals rather than homes. But history suggests that the greatest improvements in health have taken place within the home, with a focus on preventing infectious disease rather than treating it. Women play a key role in this process. Women are more likely to be in charge of feeding children and ensuring their homes have clean water and adequate sanitation, and some research suggests women tend to place greater value on child welfare (this is why cash transfers programs often target women in the household, rather than men). As we have seen in the U.S., women voters can have a profound impact on legislator behavior and consequently, public policy.
Survey evidence from the Afrobarometer suggests that health is a major concern for ordinary Ugandans, and populations throughout sub-Saharan Africa. In 2011, 26 percent of Ugandans said that “improving public services such as education and health” was their top concern, and 50 percent said that health was among the “most important problems facing this country that the forthcoming 2011 elections should address,” and ranked health higher than any of the thirty-odd other policy issues. Whether legislators act on the policy preferences of their constituents is another matter altogether. Nevertheless, the potential of the electorate, and women in particular, to influence public policy should be taken seriously, especially with regard to health.
A focus on hygiene may be as efficacious, if not more so, than the antibiotics and antimalarial drugs that are ubiquitous in public health today. The difference between 1920s America and the developing world in 2011 is that we are not forced today to rely on prevention of disease, because the momentous gains in medical technology allow us to treat the most common causes of death and disability. But this new technology should not become a crutch, and we should not forget the tremendous gains in population health that can be made by focusing on hygiene rather than a vaccine. Toilets may not be sexy, but life without adequate sanitation just stinks.
Melina Raquel Platas 