Malnutrition research in urban Africa: issues and opportunities

By Kelsey DJ Jones

Screening for acute malnutrition in a Kenyan slum

KEMRI-Wellcome Trust Research Programme, Wellcome Trust Centre for Global Health Research, Imperial College London

Kelsey Jones is a paediatrician doing clinical research on acute malnutrition between the KEMRI-Wellcome Trust Research Programme’s laboratories in rural Kilifi and an outpatient therapeutic feeding programme run by the non-governmental organisation ‘German Doctors’ in Mathare Valley, Nairobi. He shares some of his observations on the challenges of conducting operational research amongst vulnerable urban populations.

There is increasing recognition that addressing health and social problems faced by those living in urban slums will require adaptation rather than wholesale import of approaches developed in rural areas. For malnutrition, it is likely that the determinants and risk factors are completely different in an environment that is entirely cash-based, where even water is a daily expense, compared to places in which subsistence farming is the norm. Treatment or preventative strategies may need to be directed towards overcrowding, poor sanitation and stress just as much as acute or long-term food insecurity. Up to now, in Africa at least, urban settings have received nothing like the levels of research interest and investment as are directed towards rural areas. But for the work of a few pioneering groups like the African Population and Health Research Centre (APHRC), our current conception of the scale and types of problem that exist in urban slums is almost entirely at the anecdotal level: a situation that will need to change in order to reflect an Africa that is urbanising at a tremendous rate.

In Mathare, the process of establishing a research presence has been made easier by the fact that the ‘German Doctors’ clinic already has excellent community relations and outreach. Getting started is never totally straightforward, though, and has presented a number of themes and issues - opportunities as well as problems - that may be common to many urban areas. Perhaps the greatest challenge relates to the interconnected issues of frequent short-term migration, access and security. Stable communities grow and are bound together by a shared sense of belonging, but very few people live in Mathare by choice. ‘Home’ is often outside of the city, and trips back and forth as either is more able to meet immediate needs, are a fundamental part of many people’s urban existence. Research often requires a constancy of setting and population that is difficult to reconcile with this. Whether it is being prepared to deal with an unstable population structure or having contingencies in place to trace participants who travel, factoring this in is essential. Personal mobility in and out of urban areas is not matched by freedom of movement with the slum. Well-justified fear of crime and the maintenance of traditional village socio-political structures means that those who are considered ‘outsiders’ are spotted quickly and can be objects of suspicion. Working within existing local frameworks is critical to gaining community trust and consent. Community Health Workers (CHWs) are frequently underutilized and resourced, but the very fact of working in such a role, often unpaid, demonstrates vocation and commands the respect of the community. In Mathare, working with a group of committed CHWs has allowed us privileged access to a marginalised community, and has greatly increased the depth of my own understanding of the environment. The potential for engendering emotional conflict, by virtue of the fact that these are people who often live in the slum and so are to some extent both object and agent of the research, means that such relationships should be handled sensitively.

Ethical aspects of working with vulnerable populations will be familiar to all who work in areas where malnutrition is prevalent. In Mathare, I have found that balancing and establishing appropriate frameworks for fair compensation for research participants to be a particular challenge. When most mothers have to go out in the mornings to look for paid work (often washing clothes, for example) to pay for food/water/toileting for that day, the opportunity costs of attending research visits can seem enormous. The idea of ‘paying’ for involvement is not acceptable, because it generates disincentives to health and jeopardises community support, but providing fair expenses is very challenging, when participants live within walking distance. If most days’ search for casual work is in vain, receiving expenses for a research visit might be very attractive - but isn’t that the same as paying for involvement? Our approach has been to carefully think through how to maximize potential productive working hours via use of home and out-of-hours visits, streamlining less-essential research activities, and relying on provision of ancillary benefits to the whole community. As interest in urban research increases, synchronising approaches to these issues is critical. Different research groups doing different things will cause huge problems, and I feel that this would be a productive area for further work and understanding.

Working in the city affords easy access to sophisticated laboratory facilities, to greater numbers of participants, and to the political decision-makers that turn research into policy. But though these are extremely important benefits, for me the most important difference to rural areas is the ubiquitous transparency of inequality. Nairobi houses many very poor people and a few very rich, and the distribution of health and wellbeing is intensely geographically defined. The parents I work with in Mathare want to work hard, and have a drive to improve their family’s situation that I think is partly a consequence of the immense disparity in living standards in the city. Perhaps such feelings lie behind the great enthusiasm and generosity of spirit that I have encountered when initiating research - where aiming to improve on the current situation is also the guiding principal. It is certainly a great source of motivation for me. In fact, the immediacy of this inequality formed part of the inspiration for my current main project. The same child with a mid-upper arm circumference of 11cm, stunted, chronic diarrhoea and raised inflammatory indices is defined as suffering from ‘severe acute malnutrition’ in Mathare, but might be labelled inflammatory bowel disease (IBD) in one of the big private clinics over the road. Who is right?

There is a pressing need for more research in urban settings, great opportunities for partnership with communities and individuals, and no shortage of inspiration. We are performing a pilot randomised controlled trial to see whether simple, cheap medications that aid growth in paediatric IBD might be safe and useful in malnourished children (NCT01841099). I hope this article will help to encourage more people to think about getting involved.

For more information, contact: Kelsey Jones, email: KJones@kemri-wellcome.org