Tuesday, August 18, 2020

With Responses Like These, Who Needs a Pandemic?

The Open Society Initiative has announced a Covid19 Emergency Response Fund. Great to hear, but first key area on their list is health system strengthening. Health systems have been in need of funding for decades.  

Second on the list is mitigating the economic impact of Covid19, but that is far more a matter of the devastating effects of lockdowns, people unable to work, purchase food, tend to food production, sell produce, etc. 

A few headlines highlight some of the emergencies faced by African countries and they seem to be either: 1) caused by the response to Covid19, not the virus itself, or 2) emergencies that go back many decades, and increase the harm that kneejerk lockdowns, curfews and the like can cause. 

Unemployment, nothing new, but exacerbated by global lockdowns: Nigeria Records 21.8 Million Jobless People After Covid-19 Effects 

Female Genital Mutilation, nothing to do with the pandemic, but NGOs need to follow the money: No Christmas for West Pokot Girls 

Economic inclusiveness, again, every cause needs to mention the current focus of the media: Covid-19 - Where to From Here for Efforts to Support Youth Economic Inclusion? 

The number of confirmed deaths from Covid19 in Africa is about a third of the number of people who die of rabies every year: Lessons From a Community-Driven Rabies Vaccination Campaign in Kenya 

Diabetes, a recognized risk factor for many conditions long before Covid19: Covid-19 - Understanding the Increased Risk in People With Diabetes 

Foot and Mouth, like all other health conditions, put on the back burner. If there’s an outbreak of this disease now, countries that have closed their economic and administrative functions down will be able to do little to protect themselves: Mozambique: Foot-and-Mouth Outbreak in Maputo Province 

Tourism, conservation, environmental and other projects, all threatened by lockdowns: In Kenya, Maasai Entrepreneur Moves Conservancy Beyond Tourism Hit By Pandemic 

Hardly surprising that food prices have rocketed. They are unlikely to drop anytime soon. Unlike most articles on the pandemic/response, this one identifies other pressures driving up food prices, all of which were there before Covid19, but are made a lot worse by the response: Food Prices in Nigeria Have Shot Through the Roof 

If countries can’t get food locally, or import it from other countries because they can’t get around restrictions on movement and trade, they may end up depending on illicit trading, black markets and other threats to economic and political stability. The above list is from today’s AllAfrica.com newsletter, not at all exhaustive, unfortunately. 

Many are now questioning the wisdom of rigid Covid19 responses urged on them by international institutions, NGOs, donors and foreign leaders. Tanzania is one of the only one to impose a modest lockdown with a viable exit plan. Other countries could soon follow their example. None can afford the millions shelled out by rich countries. 


allvoices

Saturday, July 18, 2020

Covid-19 in Tanzania: Pursuit of Health Sovereignty?

What’s the difference between Kenya’s response to Covid-19 and Tanzania’s? It’s difficult to know about Tanzania because journalistic practice dictates that if an African leader stands up to western leaders, experts or even mere bureaucrats or journalists, they must be slapped down, ridiculed and hounded for the remainder of their office for their temerity.

It’s not so difficult to find out about Kenya’s response: a curfew was imposed and violently enforced, many people were held (effectively, interned) in insanitary conditions, some were beaten and some died, children will remain out of school until next January, hospitals are said to be overwhelmed (aren’t they always?), there are restrictions on movement, shortages of food, etc.

In Tanzania, children were sent home for a few months, but people were encouraged to go to work, feed their families, take care of themselves so that they could take care of people who were not able to. Magufuli refused to go running to the international community for handouts earmarked for (well-behaved) African leaders.

Consequences from Kenya's response to Covid-19 are far more severe than those from the virus itself. Of course, Tanzania is going to have to face the consequences of the responses of countries around them, and the consequences of their trading partners’ respective responses; for example, there is already a massive drop in tourism, globally, something a lot of poor countries disproportionately depend on.

But perhaps the difference between Kenya’s and Tanzania’s response to the virus runs deeper than the daily struggle for basic things, such as food, habitation, education, healthcare and the rest. The BBC, in that sneering tone specially honed for Africans, have coupled Magufuli’s approach to Covid-19 with his objections to ‘imperialism’.

In fact, Magufuli objects to the likes of mining operators from rich countries granting his country a paltry 3%, quaintly referred to as ‘royalties’, of anything declared as a profit. He advises people to balance rich countries' 'giving' against what they take, which is not unreasonable. Or perhaps the BBC doesn't recognise imperialism that hasn't been branded as such by them?

While the Constitution of the World Health Organization states that “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”, their response to the virus appears to view health as the avoidance of certain pathogens deemed more catastrophic than others, pretty much at all costs. Tanzania, and all poor countries, have a lot more to worry about than Covid-19. (Don't we all?)

In their anxiety to depict Magufuli as an unworthy opponent of imperialism, an incapable leader of Tanzania and a generally uninformed person whose tenure verges on dictatorial (and I’m certainly not saying he’s faultless), many commentators have missed something important. Africa and Africans won’t be ‘rising’ when, or because the English Guardian or the BBC plasters it up in banner headlines.

Perhaps it will happen when leaders like Magufuli, human as he is, stand up to the sanctimony of the western media, the neo-imperialism of wealthy countries, and the complicity of the ‘international’ institutions they fund. But the difference between Kenya’s and Tanzania’s response? Tanzania refused to be cowed into overseeing a complete breakdown of the economy, of law and order; they even refused to take money to do what Kenya and other countries happily did.

It could be argued that Magufuli is striving for health sovereignty, which is, by definition, autonomous, unlike the top-down, one-size-fits-all ‘solutions’ that rich countries and their institutions are so keen for poor countries to adopt. At least, he seems to be highlighting a tension between the WHO’s definition of health and their approach to health emergencies, especially in poor countries (but not exclusively).


Much remains to be seen, but what Magufuli has done so far has resulted in a lot less harm than what Kenyatta has done, which is just more of the same. In contrast, Magufuli has stood up, with his people; he has refused to be goaded, and to be induced into handing over everything to rich countries and institutions. He refused to betray the Tanzanian people, refused the readies. How many other leaders, in Africa and elsewhere, can claim the same? 

allvoices

Tuesday, June 2, 2020

Tanzania and Covid-19: Some Accidental Truths?

A British journalist based in Tanzania claims in The Spectator that the WHO is ‘concerned’ about the government’s lack of transparency during the Covid-19 pandemic. Writing under the pen name ‘Tom James’, the journalist gives the impression that there is an extremely serious Covid-19 outbreak in the country, one that the government is refusing to address.

However, the story is undermined by the journalist’s description of how things are in Dar es Salaam, the country’s biggest city, during this outbreak. For a start, he admits that there is little or no evidence for any deepening crisis, but he continues to write as if the absence of evidence means things must be worse than the government says.

The journalist could return to Britain, although he chooses not to do so (because he wants to look after his dogs). But clearly, things are not so bad that he must leave; he’s got a job and a home; he has a car that he is still able to run, so no fuel shortages; he can go to the market to buy supplies, so no panic buying, hoarding or sudden spikes in prices of staples.

It sounds, if the journalist is to be believed, as if everyone there is just getting on with it. We get a description of normal, everyday life in Tanzania: the police are patrolling the highways, fining people for anything and nothing; a motorbike taxi with three passengers is on the road; only the driver has a mask, but no helmet; again, nothing unusual. What, I’d like to know, would ‘Tom James’ prefer?

The English Guardian claims that Tanzania’s president is undercounting cases and deaths. But the US is overcounting, something the Guardian seems oblivious of; so is the UK, and they are collecting records that cannot be reanalyzed, should anyone ever wish to know the true numbers of cases, deaths and excess deaths.

If President Magufuli is 'playing down' the threat of Covid-19, the US and the UK are talking it up (Norway is considering the possibility that their own lockdown was unnecessary).

The media frequently uses the word ‘authoritarian’ when referring to the Tanzanian president. So, what if Magufuli did impose a lockdown? Wouldn’t that be even more authoritarian than not doing so? In most African countries, people can’t just stop working, self-isolate at home, work from home, get their food delivered or hop in their car, unlike the more fortunate ‘Tom James’.

I doubt if he and others criticizing Magufuli would like to see Tanzania follow the example set by Kenya. Human Rights Watch describes a country completely unprepared to ‘isolate’ thousands of possible Covid-19 cases, as unprepared as all poor countries are.

In Kenya, people have been rounded up and held with numerous other people who may or may not have the virus. Even in the UK one doctor writes: "many patients acquired the infection while already hospitalised for other causes". Infection control in East African hospitals is not great; how much worse will it be in these temporary holding facilities in Kenya?

Kenya imposed a curfew early on in the pandemic and police have been beating people who break the curfew. But, as the Human Rights Watch article shows, conditions in the country don’t allow everyone to drop their normal routines and get home before 7. People can’t easily ‘socially distance’ in overcrowded slums, cramped public transport and other overstretched services.

An article in African Arguments describes just how authoritarian, and how destructive, the lockdown is in Kenya (although the same publication in April called for a lockdown in Tanzania).

Al Jazeera point out that opposition leaders in Tanzania accuse the government of lying about Covid-19 and of failing to address the crisis. But what country’s opposition doesn’t accuse their government of lying and of making unwise decisions? It’s an election year, and Magufuli wants to win, as does the opposition, and these phenomena are not peculiar to Tanzania, nor even to African countries.

Usually the first to shout ‘fire’ in a crowded building (and they have done plenty of shouting about Covid-19 in Tanzania), the BBC has a short piece entitled “Tanzanian doctors 'not overwhelmed by pandemic'.” (You need to page down a long way to find it. It's worth noting that the BBC’s content about Tanzania seems to depend heavily on contributions from the public, social media and other questionable sources.)


One of the worst things that can happen to poor countries during a pandemic is that people panic, as it can bring about the very conditions that will only deepen the crisis. 'Tom James' appears to want someone to shout 'fire', although he doesn't quite do it himself. But, however inadvertently, his article suggests that no one in Tanzania is listening to him or his media colleagues. Let’s hope that continues.

allvoices

Tuesday, December 17, 2019

Why are the Majority of HIV Positive People African & Female?

Could women's higher rates of access to healthcare account for higher rates of HIV in African countries, where unsafe healthcare is very common? Sex, unsafe or otherwise, is no more common in African countries than elsewhere.

The full sized version of this dashboard is here.

allvoices

Thursday, April 11, 2019

Antimicrobial Resistance and PrEP: Medical Disasters

Here are two antimicrobial resistance (AMR) scenarios, one rapidly spiraling out of control, and the other (arguably) incipient:

The AMR scenario that is spiraling out of control is described in an article in The New York Times. The development of AMR is blamed on overuse and misuse of cheap antibiotics, usually without prescription. Ever-increasing use and misuse of antibiotics results in ever-increasing development of resistant strains of pathogens.

The NYT article describes the appalling conditions that an estimated one billion people live in; slums where waterborne, foodborne and airborne pathogens thrive. Unable to escape the risks, people try to treat the symptoms with antibiotics, inevitably leading to resistance to most or all available treatments.

The scenario described is a loop: widespread disease leads to overuse of antimicrobials; this leads to development of resistance; people with resistant conditions, if they survive, are taken to healthcare facilities, which also overuse antimicrobials, amplifying resistance and transmission of resistant strains; this loops back to the slum, resulting in an even higher disease burden, and greater levels of resistance.

The loop could be broken by: 1) improving the environment, including water, sanitation, habitation, food, etc and 2) improving conditions in healthcare facilities, infection control, safety, hygiene, etc. This will reduce antimicrobial use and, therefore, resistance.

The approach suggested by the Global AMR R&D Hub, on the other hand, risks speeding up the loop leading to AMR. They aim to “tackle the threat of resistant pathogens” by developing “new antibiotics and treatments against infections.” Producing antimicrobials of ever-increasing power, without addressing 1 and 2, above, only continues the cycle of ever-increasing resistance.

The other scenario is described on websites such as iwantprepnow.co.uk (and prepster.info and others). They advise on the use of PrEP (pre-exposure prophylaxis), antiretrovirals taken by HIV negative people to reduce the risk of HIV infection. For example, if "you have sex in a variety of situations where condoms are not easily used or not always used", PrEP, if properly used, can reduce risk of infection with HIV by more than 90%.

There are (at least) two problems with this. Firstly, overuse or incorrect use of antiretrovirals can give rise to a resistant strain of HIV developing in an infected person, and that resistant strain can also be transmitted to others.

Secondly, the advice from iwantprepnow.co.uk (and other similar sites, such as PrEPster.info) is aimed at people who frequently have sex without protection from other sexually transmitted infections (STIs). Exposing yourself repeatedly to infection with STIs increases the development of resistant strains of, for example, gonorrhea, shigella and Mycoplasma genitalium.

Use of PrEP without condoms also increases transmission of hepatitis C virus: “Incidence of acute hepatitis C virus (HCV) among men who have sex with men who use PrEP in Lyon increased tenfold between 2016 and 2017”. HCV has doubled among HIV positive people.

The Center for Strategic and International Studies spectacularly fail to notice the positive feedback mechanism, whereby improper use of PrEP could increase transmission of STIs and the development of resistance in countries where HIV prevalence is highest, sub-Saharan African countries:

"In areas where there is so much HIV circulating, every sexual encounter is high risk, and widespread PrEP could be a prevention lynchpin." The same article even acknowledges that "High rates of sexually transmitted infections (STIs) increase the risk of HIV acquisition", without noticing how PrEP will increase STIs and resistance!

According to The WHO, health is a "State of complete physical, mental, and social well being, and not merely the absence of disease or infirmity." In the two AMR scenarios described above, producing stronger antimicrobials and PrEP are examples of medicalization of health, viewing it as merely the absence of disease or infirmity. These kinds of medicalization will radically increase AMR.

allvoices

Tuesday, April 9, 2019

Cherie Blair and ‘Rape in Africa’ Stereotypes

Cherie Blair was accused of perpetuating and reinforcing stereotypes and usurping African voices with her comment that “most African ladies’ first sexual experience is rape”. The English Guardian and NPR both weigh in, with a number of reasons why Blair’s remarks were met with outrage.

Critics of Blair are not wrong in calling her out on these comments. But they don’t go far enough. Yes, Blair should have acknowledged, for example, that rape and gender based violence are faced by women everywhere, not just in African countries. But Blair is only repeating stereotypes she would find throughout the mainstream media, and in a lot of specialized published sources.

Blair is far from being alone in perpetuating and reinforcing stereotypes, such as those of the ‘promiscuous African’, ‘the violent African male’, ‘the widespread exchange of sex for money’, ‘the disempowered African female’, etc. Most of these stereotypes are a lot older than Blair, and date back to colonial times, at least.

Nor have the long-held stereotypes mellowed with age. The bulk of HIV programming (and spending) is based on the very assumption that “sexual transmission [is] the major mode of spread of HIV-1 in Africa”, with some estimates suggesting that sex accounts for 80-90% of all transmissions in high prevalence countries (which are all in sub-Saharan Africa).

On the subject of rape, the Center for Strategic and International Studies (CSIS) claims that: “Girls and women [in South Africa] also face an epidemic of rape and gender-based violence; many young women express more concerns about getting raped or getting pregnant than getting HIV. At one site we visited, the girls stated that getting raped was their number one fear.”

CSIS was commenting on the fact that in some parts of South Africa, 60% of women are HIV positive. Many new infections are among girls 15-24 years old. However, the entire CSIS article assumes, without ever arguing for it, that all HIV transmission is sexual. This assumption may suggest that stereotypes such as those above are based on empirical findings, rather than being rank prejudice.

Far from being based on research, stereotypes about ‘African’ sexual behavior are flatly contradicted by vast quantities of data collected by Demographic and Health Surveys, every five years, about sexual behavior in African countries. Just select any sub-Saharan country; rates of ‘unsafe’ sexual behavior are low, and there is little or no correlation with HIV prevalence.

Cherie Blair is unlikely to have come across views that diverge from the mainstream prejudices about HIV in SSA, and that challenge those prejudices. But many of those challenges can be found, for example, in a paper by John Potterat, and in the bibliography for that paper. One of the main suspects in high rates of HIV transmission is unsafe healthcare; others are unsafe cosmetic and traditional practices.

If Blair would like to reconsider the sort of stereotypes about sexual behavior and violence also expressed in the CSIS article, this is a good time to do so. Those outraged by her comments about ‘Africans’ and their alleged sexual behavior may wish to avail of the same research. Otherwise they all risk reinforcing and perpetuating stereotypes.

allvoices

Thursday, April 4, 2019

Ebola: A Strategy of Misinformation?

In an article in The New England Journal of Medicine entitled ‘An Epidemic of Suspicion — Ebola and Violence in the DRC’ Vinh-Kim Nguyen writes about violent attacks on Ebola treatment units and other health facilities. Nguyen argues that: "Epidemics thrive on fear — when they are frightened, patients flee hospitals, sick people stay away to begin with, and affected communities distrust groups trying to respond to the epidemic."

But there's an important sense in which the opposite may be true. When people fear something that has proven dangerous in the past, avoiding that something may be the only rational response, the only way to avoid the danger. After all, several well-documented epidemics have been shown to thrive on unsafe healthcare. Examples are Ebola Virus Disease (EVD), hepatitis C (HCV), extensively drug resistant tuberculosis (XDR TB) and MRSA (Methicillin-resistant Staphylococcus aureus).

The second ever outbreak of EBV, which occurred in Yambuku (in Zaire) in 1976, was a result of unsafe healthcare: "Peter Piot...concluded that it was inadvertently caused by the Sisters of Yambuku Mission Hospital, who had given unnecessary vitamin injections to pregnant women in their prenatal clinic without sterilizing the needles and syringes."

WHO has recently announced that "The outbreak [of EBD] in Katwa and Butembo health zones [in DRC] is partly being driven by nosocomial [=originating in a hospital] transmission events in private and public health centres. Since 1 December 2018, 86% (125/145) of cases in these areas had visited or worked in a health care facility before or after their onset of illness. Of those, 21% (30/145) reported contact with a health care facility before their onset of illness, suggesting possible nosocomial transmission."

Globally, hepatitis C virus (HCV) has infected an estimated 130 million people.... [T]he wave of increased HCV-related morbidity and mortality that we are now facing is the result of an unprecedented increase in the spread of HCV during the 20th century. Two 20th century events appear to be responsible for this increase; the widespread availability of injectable therapies and the illicit use of injectable drugs. A significant healthcare associated outbreak occurred in  Egypt in the 1970s.

Associated with poor infection control in health facilities, one of the first outbreaks of XDR-TB was discovered in Tugela Ferry Hospital, KZN, South Africa, in 2005. And a significant proportion of healthcare associated infections are resistant to methicillin (ie, MRSA).

Nguyen goes on: “In areas where the epidemic response has not involved security forces...people ask to be vaccinated.”

But rolling out vaccinations in environments where infection control is inadequate (for example, healthcare facilities) might increase the risk of viral strains developing resistance (for example, among healthcare practitioners). Going to a healthcare facility during an outbreak of Ebola may be the worst thing a person can do. When people didn’t go to health facilities during earlier outbreaks, case numbers were limited, and the outbreak didn’t last long.

Nguyen has also highlighted the importance of trust, and the consequences of mistrust of authority, experts and science. But if people are right to question the safety of healthcare facilities, as it would appear from above considerations, how can the trust of people at risk of exposure to ebola and other pathogens be regained?

As long as continued Ebola transmission is blamed on what is depicted as an irrational fear of healthcare and vaccinations, people will stay away from healthcare. Because their fear is far from irrational, it is supported by scholarly research, expert opinion and even communications from the WHO. XDR TB, MRSA, HCV and other outbreaks have been shown to be healthcare associated outbreaks. Healthcare facilities also contribute the lion’s share to anti-microbial resistance (AMR).

Modern healthcare facilities are potentially dangerous places. If patients were informed about the dangers, they would know better how to avoid them, and healthcare facilities would be compelled to address those dangers. Some of the earliest EBV outbreaks occurred when people came together around healthcare facilities, and died out when healthcare facilities closed, often because healthcare staff had been wiped out by Ebola.

Trust in healthcare in developing countries may be regained, slowly, if people are adequately informed about the greatest risks they face, such as poor infection control, lack of hygiene, AMR, etc. Trust will not be regained by dreaming up new misinformation, nor by reinforcing old misinformation.

allvoices