- Rickets is commonly caused by a lack of vitamin D, which is plentiful by way of sunlight.
- Yet in areas like the Mukuru slum in Eastlands, sunlight is a rare commodity as urban congestion and buildings erected so closely together block the sun.
- The closure of schools and religious worship facilities, the only other places with sufficient outdoor spaces, has worsened the situation.
Deep inside Nairobi’s Mukuru slum, Doreen Atieno walks home, occasionally dodging mounds of garbage and hopping across pools of wastewater with her sickly daughter firmly strapped on her back.
But the torturous trek to a windowless apartment does not seem a big concern to the mother of two. She is more concerned about her daughter, Esther Awino, who at nearly three years old, has neither walked nor talked as the result of a disease that is nearly eradicated in developed countries.
Awino suffers from rickets, a crippling disorder that also kills. The illness has bent her spine, bowed her legs and retarded her growth.
And despite Kenya being an equatorial nation for which sunlight is blindingly abundant, Awino, and an increasing number of impoverished children like her is being stricken by a disease literally fed by darkness. Rickets is commonly caused by a lack of vitamin D, which is plentiful by way of sunlight.
Yet in areas like the Mukuru slum in Eastlands, where Atieno and her family live, sunlight is a rare commodity as urban congestion and buildings erected so closely together block the sun. Moreover, health officials fear that this year’s Covid-19 related stay-at-home directives are likely worsening the prevalence of rickets in such areas.
“My daughter needs sunlight to grow up like a normal child, but it is almost impossible in this neighbourhood to get a place where she can bask,” Atieno said.
“We live in darkness!”
Rickets is slowly spreading through Nairobi’s slums and congested lower-middle-class habitations, like Pipeline, Umoja and Mlango Kubwa estates as a silent endemic. The childhood disease leads to the softening of bones, making casualties susceptible to fractures. In its acute form, victims present with flat feet, a widened forehead, curved back, enlarged wrists, knocked knees and bow legs.
Severe rickets, if left untreated, can lead to permanent bone deformities, retarded growth and chest infections that easily result in death, according to Fredrick Mitieng, an occupational therapist at Mukuru’s Ruben Health Centre.
“Mild rickets can be averted within months using supplements, strict diets and sunlight exposure, but severely affected patients have to be on therapy for about two years,” he says.
Samira Nassir, an epidemiologist and nutritionist at the Baraka Medical Centre in Mathare Constituency — also in Eastlands — says the trigger for the disease continues to be the limited access to sunlight by residents. Poor urban planning, she says, has people living in neighbourhoods that often have windowless buildings, crammed so closely together that midday routinely plays like midnight there.
The closure of schools and religious worship facilities, the only other places with sufficient outdoor spaces, has worsened the situation.
“Children are stuck indoors — some parents have been overly careful, requiring their children not to go outside for fear of contracting the coronavirus,” says Nassir.
“I anticipate that we will have more new rickets cases, as existing ones become severe.”
Covid-19 containment measures in Kenya took effect in March and data suggests a firm corollary between the shutdown measures and increases in rickets morbidity rate, according to records from multiple health facilities.
In one instance, at Kenyatta National Hospital, Kenya’s largest referral facility, records show a 23.5 per cent increase in the rickets morbidity rate between March and September, compared to a similar period last year.
At the Ruben Health Centre, where Atieno takes her daughter for treatment, admission records show an increase in the monthly frequency of patients undergoing physiotherapy to treat deformities caused by severe rickets infection. An average 20 cases are recorded at the facility every month since January, with the number reaching 25 in September, according to the centre’s records.
The situation, says Caroline Munyi, a paediatric nurse, has been especially exacerbated by the congestion in the Eastlands where 2.5 million people occupy 206 square kilometres of land.
In comparison, 1.9 million people live in the rest of Nairobi’s 498 square kilometres, according to the 2019 Kenya Population and Housing Census report.
“Most houses in the region are built in such a way that doors are the only ventilations,” says Munyi, who is stationed at the Baraka Health Facility, in Mathare, another slum in the Eastlands.
And where windows are available, they are often blocked from opening by neighbouring buildings.”
Experts blame crowding in informal daycare centres that serve the slums for fuelling rickets cases in the city slums. In these unregistered facilities, it is not rare to have babies less than three months old holed up in the tight cubicles, with little to no sunlight exposure.
This corroborates findings of a 2013 research by Doctors Without Borders in a Nairobi slum, which found that children living in slums had less than the recommended three hours minimum of sunlight exposure per week.
Regina Ndunge, whose three-year-old son Januaris Muuo is recovering from rickets, takes a two-kilometre walk each day from Mukuru to the Embakasi Secondary School.
Once there, she begs the guards to sneak her and her son into the school playground.
“I do not have an option,” says Ndunge.
“I have to chase the sun every morning and sometimes in the evening too. Sunlight is the only guarantee my son will get better. I have to ensure he gets it.”
Januaris legs are feeble. Anytime he tries to stand up, he immediately falls back to the ground. Weighing nine kilogrammes, he is five kilogrammes lower than he should be his age. His lungs, too, are severely damaged by the disease, making his breathing laboured and wheezy. Like Awino, Atieno’s daughter, he cannot walk or speak.
Ms Ndunge says he suffered recurrent bouts of pneumonia before he was finally diagnosed mid last year with rickets.
This sort of misdiagnosis is common in health facilities across Nairobi as medical officers are largely unaware of its prevalence.
Ms Munyi, the paediatric nurse, fears that the extent of the disease’s commonness is likely worse than is currently diagnosed in hospitals.
“We get numerous patients who have been on antibiotics for so long because of chest infections but have not recovered, says Ms Munyi, citing her experience at the Baraka Health Centre.
“Usually, it is because the root problem, which is rickets, has not been addressed.”
The non-communicable disease is often misdiagnosed as a respiratory illness, especially where deformities are not present or visible, according to Dr Edwin Walong, a paediatric pathologist and researcher.
Dr Walong, in an unpublished investigation on causes of paediatric deaths at the Kenyatta National Hospital, found rickets to be a common occurrence.
The study indicates that 12.5 per cent of the investigated paediatric deaths had rickets in 2015. The investigation also found that the disease was not initially diagnosed or recorded as the primary cause of death — pointing to the extent of how neglected it remains.
In all the cases where rickets was found, patients had severe pneumonia.
He says given the findings from the study and the paediatric autopsies he has conducted over the years, it is highly likely that a majority of rickets cases in Nairobi are determined upon death.
Recently, a child who lived in an Eastlands neighbourhood died from Covid-19. He was posthumously found to have rickets as an underlying condition. In response, the Ministry of Health urged parents to ensure that their children received enough daily exposure to sunlight.
In Mukuru, Awino’s mother said her daughter’s health is improving. Consequently, Awino will soon no longer need rickets therapy.
“She can finally hold a cup, feed herself, sit, roll on the bed and can stand and make some steps when supported,” said Atieno of her daughter’s progress after two years of therapy.
“My husband used to blame me for Esther’s sickness,” she said.
“He used to say that I had hereditary defects that I had passed on to the girl, which is not the case.
“However, that is in the past now,” she said excitedly.
Ms Atieno plans to take Awino to school as soon as she begins to talk and run. She makes only one demand for the new school.
“It has to be a proper school with a big playing ground.”