Thursday, April 30, 2009

Health Agenda Hijacked by Fashion, Again

The latest health scare is swine flu and people in East African countries are right to be scared. Swine flu may not reach their countries, it may not even be a very deadly form of flu, but the ability of countries to prevent epidemics is virtually non existent in this region. In the past few months, Kenya has had outbreaks of cholera in many parts of the country; not long ago it was Rift Valley Fever that was going around. Even bird flu alerts are still in place in many areas.

Somalia has yet to respond to the threat of swine flu, as has Burundi. Other East African countries have issued directives or have plans to do so. Hopefully the flu will never get here. If it does get here, hopefully those measures will prevent it from spreading. The only practical suggestion available for members of the public so far is to wash their hands regularly. Many people may do that already, but in most places, they will wash their hands with contaminated water.

If East African has the luck or the resilience to avoid a swine flu epidemic, they probably won’t have to wait too long for the next serious threat. Besides, they don’t need to wait for threats. Their depleted health services are currently struggling to deal with a multitude of epidemic and endemic conditions. At present, the number of doctors available per 100,000 people in Kenya is 14 (compared to 250 in the UK). In Uganda the number of doctors is 8, in Tanzania, only 2. This is unsurprising, given that public expenditure on health in Kenya is a measly 1.8% of GDP; in Tanzania the figure is 1.7%, in Uganda, 2.5% (similar to each country’s military expenditure).

In East African countries, some of the biggest killer diseases are acute respiratory infections, diarrhoea, malaria, TB and Aids. Aside from Aids, all these diseases can be prevented and cured. But not enough money is spent on public health, especially reproductive and sexual health, childhood immunisation, water and sanitation, food security and nutrition, habitation and labour conditions.

If public health has been allowed to slip so far down the agenda, emergency measures to prevent swine flu will require more luck than skill. So rather than obsessing about each and every health threat as and when it arises, East African countries would be better to look at long term declines in health, education, infrastructure, social services and governance. When a country is taken by surprise, it is their existing capacity and resilience that determines how they fare.

Ironically, one thing that may reduce the threat from swine flu in East Africa is the lack of tourists and visitors they are currently receiving. Several of the countries are at war, are experiencing some kind of civil disturbance or have recently had a civil disturbance. Even Tanzania, which is very peaceful, is not seeing many tourists, partly because it’s the rainy season, partly because the global financial instability has reduced the numbers of people going on exotic holidays.

When it comes to spreading infectious diseases inside a country or region, it is often the most mobile who play the biggest part. Migrants can take diseases to their destination country, spreading them among their fellow migrants; they often have to live in close proximity to other migrants, in cramped and dangerous conditions. They also return home with transmissible diseases, such as sexually transmitted infections, HIV, meningitis and TB. So they can be responsible for spreading diseases among whole populations, both directly and indirectly.

Another irony, then, is the fact that some of the industries most associated with internal migration, mining, horticulture and raw materials production, for example, are also currently depressed. (These are also some of the industries most associated with the spread of infectious diseases and other health hazards.) Many projects are on hold and people are being laid off in huge numbers. The cut flower growing industry in Kenya and gold and precious stone mining in Tanzania are examples. Therefore, circular migration, inside countries and inside the region, is probably relatively low and declining at present.

The point is not that East African countries are in big trouble if swine flu arrives. The point is that East African countries are already in trouble and have been for a long time. If the next hazard is not swine flu it will be something else. Millions of people in East Africa (and other developing countries) are dying every day from preventable and curable diseases because of lack of access to basic things like clean water and nutritious food. East African countries need to build up their health, education and all other social services. Don’t let the threat of swine flu distract attention from everything else. Does that sound familiar?


Wednesday, April 29, 2009

The Excesses of Globalization

The top three revenue earners in Kenya are tea, horticultural products and tourism. There is little interest in tourism after the 2008 post election violence, which has still to be resolved. Sales of horticultural products are depressed due to the global economic climate. And tea is a turbulent commodity; most plantations are owned by multinationals. It's not difficult to work out who benefits from the tea industry in Kenya.

In addition, most of the big players in Kenya in these sectors are foreign. They pay little or no tax; they employ as few people as possible; they pay them as little as possible. The country will never get rich from their top revenue earners because they are in the hands of people and organisations who are allowed to exploit the country for everything they can get, and are happy to do so.

The majority of people in these sectors are not permanently employed, are often part time and have little or no protection from their employers. You might expect the International Labour Organization's (ILO) 'World of Work Report, 2008' to give considerable coverage to Kenya and other African countries. But you'd be disappointed. There are mentions of African regions but there seems to be little data about most African countries. In the light of this lack of data, one may conclude that conditions in Africa are far worse than in other continents.

The report as a whole shows that income inequalities are increasing in most countries and have been doing so for nearly two decades. The conclusion is that the economic model that led to the current financial crisis is not sustainable and that balancing economic with social and environmental goals is vital to recovery, as well as to a reverse in the trend towards higher levels of inequality.

While a few, rich people, gained from the economic expansion preceding the current crisis, the majority did not get richer. Indeed, many became poorer. But it's that poor majority that must pay for the current financial rescue package. Those on high incomes have seen huge increases in their incomes. Those on low incomes have seen small increases or even decreases. Women in all countries, especially developing countries, are less likely to be employed and more likely to be employed on an informal basis. They also receive lower wages than men.

The ILO's report shows that financial globalization has played a major part in these increases in inequality. Unemployment has increased while productivity has decreased. Globalization has resulted in a significant increase in banking crises. The report argues that there is a need for regulation to limit the excesses of financial players and protect the vulnerable, who usually suffer the most when things go wrong.

The ILO also notes the issue of 'performance pay systems' for senior employees. This has resulted in large increases in executive pay that is not reflected in company performance. In 2007 in the US, executive pay in the top 15 firms was 500 times that of the average employee, compared to 360 times higher in 2003. Other countries experienced similar patters. The report suggests that executives are in a dominant bargaining position and the result is both an increase in inequality and a decrease in economic efficiency.

In contrast, the bargaining position of employees, trade unions and other labour institutions has weakened. There have been increases in part time and non permanent employment, which means lower pay. In addition, taxation has become less progressive, shifting the burden of tax from the richer sectors of the population towards the poorer. Redistribution and social protection are thus compromised.

The 'Decent Work Agenda' proposed by the ILO includes "well-designed labour regulations and social protection, and respect for basic workers’ rights" to achieve higher levels of employment and greater equality. They argue that, along with a reform of the financial architecture, this will contribute to a more balanced and sustainable economy. At the same time, it will help to address the social consequences of the current financial crisis.

The above suggests an opportunity for 'development by omission'. It is not acceptable for tax systems to move away from progressive forms of tax, ones that shift the burden from the poor to the rich. Nor is it acceptable for the highest paid individuals in a firm to have the power to award themselves ever increasing salaries and bonuses while the lowest paid get only small increases. The move towards less formal employment with the resulting drop in income only increases vulnerability. Big, private sector, employers have seen their profits swell for many years. The increase in profits has often been a result of cutting wage costs and this cannot continue indefinitely.

It's easy for employers to blame the economic slowdown, the rising cost of fuel, the food crisis and various other trends, but these labour trends have been worsening for a long time. They are inimical to both development and equality. The dogmatic claims for the benefits of globalization have not materialised. Employment has not increased as a result, it has decreased. Conditions have disimproved and there are rising levels of inequality.

Governments need to take into account the social consequences of globalisation, in addition to the economic consequences. This is especially true for governments of developing countries, such as Kenya. The government needs to keep an eye on employers who are increasing their executive pay, cutting employee pay and increasing their levels of temporary and part time employment. So far, they seem more interested in promoting the interests of employers, regardless of the costs to employees and the country as a whole.

The government need also to rebuild the health, education, social services, infrastructure and other public goods that have been allowed to decline for so long. Many Kenyans will not benefit directly from labour reform as most do not work in the formal sector. Any efforts at redistribution and redress needs to take this into account.


Monday, April 27, 2009

Genetically Modified Leeches Pose Serious Threat

I have been subscribing to the Science and Development Network (SciDev) for a number of years because they produce very informative articles on a wide range of scientific issues that are particularly relevant to developing countries. A case in point is the issue of genetically modified organisms (GMO). SciDev is generally careful in its treatment of GMO because much of the 'literature' is either based on pseudo research or contaminated by pseudo research.

However, I was wary of a recent article on SciDev entitled 'Is GM Shedding its Frankenstein Image'. The 'Frankenstein' stories emanated from journalists and other ill informed parties. It was found to be a useful straw man argument by the GM industry because there is still a lot of uncertainty about the long term consequences of widespread GM use. So it's easier for them to rubbish stories that no careful observer of the GM industry would believe, while ignoring the important issues.

But some of the most crucial criticisms of GM are that it increases dependence, reduces biodiversity and is not sustainable. The 'Frankenstein' stories are a matter of public relations and should not be the concern of an organisation like SciDev; they are a matter for GM companies and journalists. It's time we heard how the GM industry intends to deal with the difficult issues, not just the non issues.

The article, however, fails to deal with the issue of dependency, even though it mentions the fact that food insecurity has helped to 'change attitudes' to GM. Have attitudes been changed, or are people in developing countries so desperate that they are willing to risk becoming even more dependent than they are now? Many people in Kenya were opposed to allowing GM research, though the government has now passed the GM bill. Did they resolve the issues or just force the bill through?

Climate change is mentioned as another factor in changing attitudes. However reduced biodiversity, such as that caused by GM, has serious implications for climate change. It is funny how multinationals seem to recognise climate change as a problem when it suits them. Massive development of monoculture crops for food, various raw materials and biofuels are part of the biodiversity reduction that also feeds into global climate changes. GM will make these problems worse, and irreversibly so.

At present, Kenyans are suffering food insecurity because of global speculation on food prices, government shenanigans, planting and harvesting problems, distribution problems, acute poverty and many other issues. Do GM commentators seriously think these issues will magically disappear just because a handful of GM multinationals could become the de facto owner of all the productive land in Kenya?

A more thoughtful article on SciDev argues that GM will not benefit farmers in poor countries, it will only benefit patent owners. Big patent owners with colourful corporate social responsibility records, such as Monsanto, BASF, Bayer, DuPont and Syngenta, are stockpiling hundreds of patents, ready to pounce on impoverished countries suffering from things like drought, flooding, saline soil and excessive heat and cold.

Most GM crops do well in laboratories and in very good conditions. There is no evidence that any of them do well in uncontrolled conditions, especially where they face more than one hazard, such as cold and high salinity. GM manufacturers have spent a lot on PR in the effort to spread their technology but independent scientists, ones that haven't yet been nobbled by interested parties, are still sceptical. But these worries are small compared to the more obvious problem, that GM will increase dependency and reduce sustainability.

Farmers who buy into GM will be more dependent because they will need to buy seeds, fertilizer, pesticides and herbicides from the same multinational every year and there is no guarantee that their crops will have higher yields, as the GM companies promise. For small farmers, and most farmers in developing countries are small farmers, this will not be a sustainable scenario. They will then find it hard to get out of GM as their land will be contaminated. But the seeds they used to use before GM may well no longer even be available.

If GM is of any use at all, and that's a big if, it is a technology developed with huge landowners in mind, those who use factory production methods. Big farmers are not facing starvation right now, they are not the ones struggling with natural and human disasters, poverty and disease to get by. Yet GM companies keep insisting that poor people in developing countries will benefit. They need to demonstrate how this is possible and answer the questions they are being asked. And I don't mean the red herrings about 'Frankenstein' foods, answer the real questions.

The anti-counterfeit bill, that has such important implications for those hoping to benefit from generic drugs (discussed elsewhere on this blog), protects the owners of patents. It does not protect those who need to use the products or those who once hoped to be able to afford the products but are now unable to do so. Kenya has also signed a bill that allows GM crops to be grown in the country, so it is easy to see which side the Kenyan Government takes on this one.


Friday, April 24, 2009

Homophobia and 'Morality' Driving HIV

I recently wrote that some men who have sex with men (MSM) also have sex with heterosexuals. But research shows that a majority of MSM in some countries also have sex with women (82% in Senegal). This research was carried out in three African countries and in Tamil Nadu state, India. So MSM there are not a relatively isolated group that has little relevance to heterosexually transmitted HIV. Rather, MSM are very much a part of sexual networks as a whole and their sexual health is as important as the sexual health of communities and nations.

This needs to be emphasized because MSM, along with intravenous drug users (IDU) and women who have sex with women (WSW), are often treated as separate and even completely ignored by HIV policy. The probability of HIV transmission is much higher among MSM and IDUs for several reasons. Therefore, the fact that they are also part of a sexual network that includes heterosexuals means that HIV policy cannot afford to continue to ignore these issues.

One may think that WSW are not very likely to contract HIV, but this is not so. Firstly, they may sleep with men sometimes, for various reasons. But they are also subject to discrimination, persecution and physical and sexual violence. In South Africa, there have been instances of what has been called 'corrective rape', where women are raped because they are, or are suspected of being, lesbians. The physical trauma that rape usually involves makes transmission of HIV and other sexually transmitted infections (STIs) many times more likely. The result is that rates of HIV and STIs are high among WSW.

In most African countries, male/male and female/female sex is illegal and, even where it is legal, such as in South Africa, it can still meet with stigma and violence. In Uganda, where an early and severe HIV epidemic gave rise to a lot of frank discussion of HIV at all levels of society, homosexuality is still illegal and HIV positive MSM are denied care. Organisations involved in providing information, advice and care for MSM have been intimidated and people who have male/male or female/female sex are now reluctant to seek advice.

Even the practical side of protecting yourself from HIV and other STIs is affected by such attitudes. Ugandan men who have sex with men have complained of lack of access to lubricants, for example, and resort to using common household products, such as cooking oil or margarine, instead. This can cause the condom to break but it is also an absurd indignity, especially considering that anal sex and the need for lubricants is not just confined to men having sex with men.

Likewise, lesbians are denied information about and access to things like dental dams. Oral sex is not just practised by lesbians and many others need to know about dental dams. Come to think of it, I have never been counselled about such devices, either here in East Africa or anywhere else.

Nigeria is currently debating a bill that would ban same sex marriage and make gay rights protests a crime, punishable by a five year prison sentence. The mere discussion of the bill has given rise to an increase in homophobic attacks and people suspected of being gay have been discharged from the army. Nigerians can content themselves that non-heterosexual sex is immoral and against the teachings of their religion, whether they are Muslim, Christian or probably anything else. Sodomy is already against the law and carries a long prison sentence or even a death sentence. Discussion of any form of non-heterosexual sex would be a crime if the new bill becomes law.

HIV is higher in Nigeria than in many other West African countries. Driving some of the most vulnerable people underground will not help the country tackle this problem. One of the most important things a country can do is to understand the magnitude of their HIV epidemic, how widespread it is, where it is affecting most people, how it is spreading and how it may spread in the future. This requires as much testing and monitoring as possible. People will be very reluctant to be tested if they are afraid they may be branded as immoral or criminal as a result.

Another important implication of the above research is that countries and areas which, up to now, have only had relatively low levels of HIV, may well experience increasing levels later on. Senegal and Thailand are often discussed because they are said to have been successful in containing their HIV epidemic. Senegal is one of the few African countries to have a 'concentrated' epidemic, as opposed to the 'generalised' epidemics found in many African countries.

A concentrated epidemic is one where HIV rates are low in the general population and only high in specific groups, thought to be at high risk. These groups include MSM and IDU. A generalised epidemic is one where HIV rates are significant in the population as a whole. If 82% of MSM in Senegal also have sex with women, HIV may well spread beyond high risk groups and the epidemic may become more concentrated. MSM in Senegal are particularly vulnerable right now, after 9 gay men who worked for a HIV prevention agency were imprisoned in January. They were accused of “acts against nature and the creation of a criminal organisation”. They have just been released, but it remains to be seen what will happen over time. I hope this sort attitude towards HIV prevention agencies is not widespread but I suspect it is.

Thailand has also received praise for limiting the spread of HIV, but among MSM now, the rate of spread is increasing rapidly. In Kenya, the Northern areas have low HIV prevalence, lower than those of Ukraine (about 1.6%) or Washington DC (about 3%). However, prevalence among pastoral communities, previously thought to be at less of a threat of HIV, is now rising. These communities are isolated from health and other social services. School attendance, achievement and literacy are very low. So if HIV starts to spread rapidly this area will be even less able to react than other Kenyan provinces.

HIV prevention requires a lot more research into what may happen in the future, rather than concentrating on what has happened. We need to analyse the data that is available, not just use it for good news publicity or shock media campaigns.

And those who choose to see HIV as a moral issue may like to consider the morality of the poverty, inequality, discrimination, injustice, exploitation and numerous other outrages that go on in their country. Punishing innocent people, such as MSM and WSW, will not protect others and will, sooner or later, become a threat to everyone.


Thursday, April 23, 2009

Immediate Needs Sidelined by HIV

Wildly exaggerated estimations of how many lives could be saved by mass male circumcision or universal HIV testing and treatment grab the headlines. But stories about being able to save two million children a year who are dying from diarrhoea don't seem to attract so much attention. The treatment for the acute diarrhoea that kills children, an oral rehydration solution of a pinch of salt and a handful of clean water (CLEAN water!), just doesn't jingle the way expensive programmes and drugs do.

Another thing that doesn't grab headlines is something like a nutrition programme that targets starving children. Free meals in a school in Tanzania has had the effect of increasing attendance and allowing almost all children to graduate from primary to secondary school. Before the programme started, pupils who made it to school were too tired and undernourished to concentrate and most failed to finish primary school. Mainstream media has a taste for good news sometimes, but this seems to lack the high sugar content that appeals to them.

If children just turned up at school to be fed and then left or didn't bother to do any work, this programme would be disappointing. But the fact that they were enabled to go on to secondary school means that the programme could have many benefits aside from nutritional and educational. According to the most recent figures, fewer children go to secondary school in Tanzania than in Kenya or Uganda. And only around 1% go to tertiary level education.

One of the problems with current HIV prevention programmes, the ones that are implemented in schools, anyhow, is that the general level of education in the country is low. I have met people who, at the age of 15, started having sex, usually with an older partner. That's not the surprising bit; the surprising bit is that they didn't know what sex was or if they did, they didn't know that that's what they were indulging in.

I came across a paper about reproductive awareness among adolescent girls (10-19 years) in Bangladesh and many had incorrect knowledge or misperceptions about reproduction, the fertile period, STIs and HIV. This is often connected with the educational status of girls or that of their mother. 18 out of 20 married adolescents who had recently given birth didn't understand why they had become pregnant. Most had never heard of STIs and while 40% had heard of HIV, only 20% had knowledge about how HIV is transmitted.

Many girls experience sex of some kind in their teens, whether they chose it or not. Most of them know so little about sex that they don't know how to avoid doing what someone is coercing them into doing, they don't know how to negotiate precautions, such as using a condom, they may not even know what condoms are, where to buy them or how to use them. To understand what safe sex is, children need to understand what sex is. There is no evidence that teaching children about sex encourages them to try it, all the evidence is to the contrary.

Many school based programmes have had little effect except to give people a superficial ability to answer questionnaires about sex in the required manner. Well educated young people are ones who can make decisions, negotiate, relate to other people at a level other than a reflex level, where they simply say things like 'sex is bad' or 'abstinence is the safest sex' or whatever brainless platitude is the current favourite. People need to learn to think, not just repeat what they are told to think.

Even adults are confused about the 'ABC' strategy, Abstain, Be faithful, use a Condom. The word ‘abstain’ is widely misunderstood, or ignored where it is understood (I certainly ignore it); being faithful is sometimes understood as meaning that it is ok to have other partners as long as your main partner doesn't know; and condoms are a somewhat exotic commodity that used to be really common a few years ago. You can still get condoms free of charge sometimes but, apparently, the free ones are not as common as they used to be. (A packet of three condoms made in Tanzania costs the price of a small bottle of soda. A packet of three produced in rich countries cost about four times that much. Some splash out for the local brands but others spend the money on soda.)

Children (and adults) have rights, that are enshrined in the Universal Declaration of Human Rights, to a good level of nutrition, water and sanitation, health and education. There is nothing in the declaration that says they only have the right to remain HIV negative and to other rights only insofar as they maintain a HIV negative status. HIV is just one aspect of development and underdevelopment. To many, it doesn't even matter that much compared to the urgent need for something that the lack of will kill them very quickly.

HIV has deflected attention from vital areas of development. In fact, many HIV prevention and care programmes have poor results because most areas of development, such as health, education, social services, infrastructure, governance, human rights and equality, have been ignored.


Wednesday, April 22, 2009

Low Emissions Cooking

The Science and Development Network had a couple of interesting articles on cookers, cookers that only require freely available, renewable fuels and cookers that produce less pollution. Environmental degradation and air pollution are serious threats in all countries but especially in developing countries.

Solar cookers have been mentioned on this blog in the past. Now a solar cooker made mainly of cardboard boxes and other cheap, accessible materials has won a prize that will fund the manufacture of the product for developing countries. It's called the Kyoto Box, after the Kyoto Protocol. It's very simple and the fact that it can be made from easy to obtain materials is important where people earn little or no money.

The inventor emphasizes the Kyoto Box's simplicity. We hear a lot of hot air about high technology solutions, such as diagnosing TB using satellite technology or supporting people on antiretroviral therapy using mobile phones. Not that there is anything wrong with these, but they are usually not accessible to people in developing countries and not appropriate to countries with poor infrastructure.

I have heard from several sources that solar cookers are a hard sell, partly because their use can disrupt a daily pattern that people are reluctant to change. For example, women (who usually do the cooking) go to the market in the morning and spend a good while there. They don't just buy and sell things, going to the market is an opportunity to gather with friends and neighbours and keep informed. Yet this is the time when you need to be cooking the midday meal, so cooking by sun may not appeal to everyone.

However, the solar cooker can be used for other things, drying fruit and vegetables. You can produce, for example, sun dried tomatoes, bananas, mangoes, dried mushrooms, fish, etc. Many products need to be sold or preserved and solar cookers can help speed up drying and preservation without requiring much labour. They can also be used for pasteurising water in areas where contaminated water causes much sickness and many deaths.

The Kyoto Box is estimated to save up to two tonnes of carbon emissions per family per year and may be eligible for carbon credits. I hate the thought that people in developing countries will be forced to subsidise the wasteful habits of people in rich countries, as they do that enough already. But I hope the availability of cheap solar cookers will help some people to reduce their daily costs and reap the benefits of a very clean and completely renewable source of fuel.

The other article was about a stove that produces less soot than conventional cooking methods. Soot is the second biggest contributor to climate change, so reducing soot production could have quite an impact on efforts to slow down climate change. Soot and other emissions from traditional cookers also give rise to health problems in the households that use them. Acute respiratory infections are responsible for around 20% of deaths in young children (another 20% being caused by water borne conditions).

This cooker is a problem because of its cost. They cost $20 to make, which is way beyond the means of most poor people, many of whom earn $2 a day or less. It remains to be seen whether rich countries are willing to pay for an intermediate technology that may help us out of the mess that we have created and continue to create.

Whether rich countries are willing to participate in reducing global warming or not, it is good to see intermediate technologies promoted in developing countries. Especially intermediate technologies that can be developed and produced in those countries without expensive materials and expertise that are virtually unavailable there. Far too much aid money is spent on advanced technologies, such as pharmaceutical products, genetically modified organisms and military projects. Spending aid money on these technologies only benefits the rich multinationals who produce them. Aid money should be spent on poor people, not rich people.


Tuesday, April 21, 2009

Generic Drugs are Counterfeit, Say Kenyan Government

When pharmaceutical products first became available to treat HIV, they were far too expensive for most people to afford, especially in developing countries. Yet, the majority of people in need of treatment for HIV live in developing countries. So, how could pharmaceutical companies fix a price that would allow them a staggeringly high profit margin but also a large volume of sales?

HIV treatment (antiretroviral treatment or ART) is still very expensive, and that's just the drugs. It's still unaffordable to most people, but pharmaceutical companies have successfully lobbied donor governments to pay for the drugs. That gets rid of one problem, how to maximise profits for pharmaceutical companies.

But then there was another problem. Some countries who had the capacity to do the requisite research and planning and production are now producing generic equivalents of HIV drugs. These are much more affordable but this is a terrible headache for pharmaceutical companies. Of course, they are not too worried, most aid money for HIV goes to buying the branded, expensive drugs. Very little is allowed go to generics.

In Kenya, the pharmaceutical companies don't seem to have had much problem. The government produced a piece of legislation that doesn't distinguish between counterfeit products and generic equivalents. Perhaps the Kenyan government thought it was better to buy products that are tens or even hundreds of times more expensive. After all, they are not paying for them. Or perhaps someone nobbled the Kenyan government, it's hard to know. But the legislation makes sure that generics from any country can be considered counterfeit and this is very useful to the pharmaceutical companies.

There are hundreds of thousands of Kenyans in need of ART in order to stay alive and raise their families. Many of them are not on ART because the business of rolling out the drugs is slow. And because so little money is being spent on preventing new infections, the number of people requiring ART continues to increase. In fact, most of the money being spent on HIV prevention goes to programmes that have little influence on transmission of HIV or any other sexually transmitted infection.

I agree that treatment is part of prevention; people who are on treatment are less likely to transmit HIV if the treatment is working properly. But it's not good enough to spend, say, 50% of the 15 billion dollar President's Emergency Fund for Aids Relief (PEPFAR) on treatment when only 20% is going on prevention, especially as many prevention programmes have fairly dubious benefits.

It wouldn't be so bad if some of that 50% is going on something other than drugs. People on ART need more than just drugs, they need a lot of palliative care, a lot of monitoring, good health care, economic and moral support, good levels of nutrition, etc. Perhaps if pharmaceutical companies were to provide these things, donor money would be spent on them. As it is, many people get the free drugs but little else.

Those on ART who are not taking the drugs in the prescribed way, or who are not responding to the treatment for some reason, may turn out to be like the 80% of Kenyan's who don't know they are HIV positive; they could be continuing to have sex, not knowing that they are may be as infectious as people not on ART. Even worse, they may be spreading a resistant strain of HIV.

Resistance is most worrying in Kenya because it could take some time to identify people who are carrying resistant strains. Health and social facilities are not strong enough to monitor people adequately. Many get the drugs and disappear, for some reason or other. Others struggle to get the treatment they need but they don't know if they are or are not responding to the treatment until they become ill. By this time, their life and the life of their partner may already be at risk.

Resistance is a good thing, though, if you are a pharmaceutical company. People who are resistant to 'first line' drugs are usually put on 'second line' treatment. This is far more expensive, meaning higher profits. So if people fail to take their ART drugs properly, that could help the pharmaceutical companies greatly.

The Indian government is protesting because similar legislation is planned in other African countries, one of their biggest markets. And it's not just HIV drugs that are threatened, also cholera, malaria, hepatitis and malnutrition. This is not what Kenya or any other African country needs.


Saturday, April 18, 2009

Mixed Views About Male Circumcision for HIV Prevention

Has anyone come across evidence that access to adequate food supplies reduces acute malnutrition? How about access to good health services reducing illness or good education reducing illiteracy? Should we believe that good water and sanitation reduces water borne diseases or that a clean environment can help to reduce acute respiratory infections?

The answers to the above questions are all 'yes'; there is overwhelming evidence for an affirmative answer to each one. But does Kenya or any other developing country have any of these benefits? Well, no, that is why they are called developing countries. Underdevelopment and retrogressive development are not new and these issues have been discussed in one form or other for many decades.

But just recognising their desirability doesn't give rise to development. The knowledge that these are all good things, necessary for development and for the insurance of human rights, has not given rise to their promotion. So when I see an article entitled '[Male c]ircumcision does reduce the risk of HIV, say researchers' I am pleased to hear it. But which developing country has the facilities, resources and personnel to carry out millions of circumcisions safely and to continue to circumcise all newborn males (either shortly after birth or later, when informed consent is possible)?

Kenya does not have presently have the health capacity required. Evidence has shown that the level of adverse effects relating to circumcision is nearly 20% when the operation is carried out in a clinical setting and around 35% in traditional settings. Those who presently don't go for circumcision, usually for reasons associated with the traditions of their tribe, may be more likely to choose a clinical setting. But with statistics like that they could be forgiven for opting to remain uncircumcised.

Kenya does not have the capacity required to control most of the infectious diseases that are endemic in the country, diseases that kill more people and diseases that have been around for far longer than HIV. If Kenya had good health, education and other social services, the HIV epidemic would never have got so out of control and some of the expensive prevention measures that are being carried out might have achieved some success by now.

In fact, the problem here is not the Cochrane Collaboration publication, entitled Male Circumcision for Prevention of Heterosexual Acquisition of HIV in Men, it's the newspaper article that reports on the original publication. The newspaper article only adds in the final sentence that policy makers need to consider the culture and environment in which MMC is carried out. This is crucial and the Cochrane abstract makes this clear, asking if "[a]t a local level, further research will be needed to assess whether implementing the intervention is feasible, appropriate, and cost-effective in different settings."

One might conclude from the newspaper article that because male circumcision can reduce the risk of HIV, that mass male circumcision (MMC) is a good thing, especially in countries that have high HIV prevalence. Circumcision may also protect against herpes simplex virus (HSV), which increases susceptibility to HIV, human papilloma virus (HPV) and various other sexually transmitted infections (STI). But the Cochrane review notes that incidence of adverse events was low in the trials they examined. One would expect the incidence of adverse events to be low, these were randomised controlled trials! The review concludes that circumcision "under these conditions" is a safe procedure.

The Cochrane review may have found the evidence conclusive and that could eventually be very significant. But the studies they refer to still raise many unanswered questions. I will not rehearse the various problems with the circumcision trials in question. A quick search of other sites and blogs will give you as much information as you could possibly want. (I haven't had access to the full Cochrane paper, although I am familiar with some of the literature and trials involved.)

Mass Male Circumcision (MMC) will not be carried out in ideal conditions in Kenya, not given the present state of Kenyan health services. If there were ideal conditions in Kenya it is unlikely that the country would have need to implement such a huge and costly project as MMC.

But a second objection to MMC is the problem of 'disinhibition'. Some circumcised people think they are, more or less, immune to HIV. People have told me that they don't need to use condoms because they are circumcised or even that condoms don't work because they are circumcised. There is a worry that MMC could result in a large number of people believing that they don't need condoms or that they don't need to be careful because they are circumcised. This will not be an easy problem to deal with.

There’s often a ‘eureka!’ quality to articles about MMC as a means of reducing transmission of HIV. Why not the same cry with regard to development issues where the solutions are more obvious, such food and food security for the starving, healthcare for the sick and healthy, alike, education for all, safe water and sanitation and a healthy environment? The Cochrane report also concludes with a need for further research. Let's hope policy makers are not as selective as journalists in what they glean from scientific papers.


Friday, April 17, 2009

HIV is the Problem, Except for Everything Else

The received view about men who have sex with men (MSM) and women who have sex with women (WSW) in African countries is that it is not common and certainly not as common as outside Africa. I have yet to come across any evidence that these phenomena are really less common in Africa than in other continents. However, most African countries have laws against such practices.

In Kenya, Tanzania and Uganda, for example, MSM have been persecuted. WSW are even less often talked about, but they face many dangers and often have to go to great lengths to keep their sexuality hidden. Thus, MSM and WSW often get married, to pretend they are heterosexuals. In marriage, some repress their sexuality, some don’t.

And that’s where some of the mystery about the numbers of non-heterosexuals in African countries arises. It’s not that long ago that in Western countries, non-heterosexuals would pretend to be heterosexual and behave accordingly, at least for some of the time. In East Africa numbers are a matter of speculation, really. People who choose to be frank about their sexuality face abuse, even imprisonment.

Those who choose to keep their sexuality a secret, and who could blame them, also face dangers. They may follow their sexuality and put their partner and themselves at risk; they may be exposed at any time, etc.

In countries where HIV prevalence is high, everyone needs to be careful. As an advertising campaign pointed out, if you sleep with someone, you also sleep with all that person’s partners. MSM, WSW, intravenous drug users (IDU) and other groups who face special risks are not as neatly compartmentalised as such acronyms may suggest. As to the percentage of people who are actively bisexual, either through orientation or necessity, it’s anyone’s guess.

HIV is often exceptionalised as if it were more threatening than any other health issue. This is not the case; sexual health in developing countries is a much bigger issue. HIV is only a small part of sexual and reproductive health, which itself is only a small part of the health of whole populations. And more people’s lives and welfare are threatened by the manipulation of a few rich multinationals than by HIV; the same could be said for the manipulation of a few international institutions, a few rich countries, global warming, etc.

One of the problems with exceptionalising HIV is that other important messages get lost. In some age groups in Kenya, nearly half of all sexually active people have herpes simplex virus (HSV), many others have various sexually transmitted infections (STI) and there are so many reproductive health problems, why concentrate on HIV at the expense of all others?

There’s a particularly horrifying statistic about human papilloma virus (HPV) among gay men in Asutralia; nearly 80% of them were found to have some form of HPV in a recent study. This virus causes anal cancer, although anal cancer is rare. HPV is particularly common among those already infected with HIV, standing at 94% in the Australian study. One wonders what the prevalence of HPV is among gay men in African countries. The same question could be asked about other STIs that are associated with anal sex, especially where gay men either need to or choose to sleep with women as well.

Things must be very different in Australia. Non-heterosexuals are free to express their sexuality, there are laws against discrimination and persecution, they have access to health services, legal protection and support of various kinds. This is not the case in East African countries, where men in Uganda who protested recently about the lack of HIV services for gay men were arrested. Non-heterosexuals continue to be excluded from HIV prevention and other services that are aimed at almost entirely at heterosexuals.

In addition to decriminalising commercial sex work (discussed elsewhere), those who are not heterosexual and who wish to express their sexuality need the protection of the law. They need access to health services, especially sexual health services. They are not isolated ‘groups’. They are, ultimately, an integral part of the whole network of people that make up a country. Their sexual health is everyone’s sexual health, just as the sexual health of the heterosexual community is also part of the sexual health of non-heterosexuals.

Persecuting people for their sexuality, denying them the protection of the law and access to health and social services, is as damaging as persecuting commercial sex workers and denying them some of their most basic human rights. The moral crusade against whatever target happens to present itself is doing more to spread HIV than the groups of people who are being targeted.


Wednesday, April 15, 2009

Bill Gates to Face Trial by Intestinal Worms

It has long been recognized that poor health results in people being more susceptible to anything going. That's why many people aim for good overall health by watching what they eat, taking enough exercise, getting enough sleep, etc.

It was also established some time ago that poor health and a high disease burden results in populations being more susceptible to major diseases like cholera, malaria, acute respiratory infections, TB, HIV and many other things.

The connection between high rates of intestinal parasite infestation and HIV was made more than a decade ago and soon after, it was pointed out that the search for a HIV vaccine would be hampered by the high disease burden suffered by populations most affected by HIV.

Anyone seeing a connection yet? People in areas with high rates of HIV are the same people who suffer from numerous diseases, many of which are treatable or curable, they suffer from poor water and sanitation supplies, poor nutrition, etc. Oh, and low levels of education, minimal infrastructure and many other things.

On the other hand, if water and sanitation were improved, many of the most common diseases would be prevented or seriously reduced. Cholera, for a start, also intestinal parasites, also hepatitis E, the list is long. 20% of young people in developing countries die of diarrhea alone, most of the other things that kill young and old are either preventable or curable. Many relate to water and sanitation.

So why does Bill Gates want to find a vaccine for cholera. He seems to like to find a 'big one' and hack away at that. HIV, TB and malaria are three others (the third of which is also directly related to water and sanitation). He wants to create a completely unsustainable and expensive solution to cholera when the best prevention for this is good water and sanitation.

Cholera vaccine research has come up against a problem. The vaccines work well in developed countries, where water and sanitation are not such a problem, but they work badly in countries where water and sanitation are a problem.

Have I spelled it out clearly enough for Bill and his defenders? I'm not saying he shouldn't spend his money on research that could save the lives of millions of people. I'm suggesting that he could spend his money on saving the lives of billions of people. Think of the number of diseases that would be reduced if he spent his money on water and sanitation.

But he seems to like intellectual property, drugs for cholera, drugs for malaria, drugs for HIV, drugs to prevent HIV among those who are not yet infected, pharmaceutical products for the starving, in the form of genetically modified organisms, a 'green revolution' driven by locking poor famers into an agreement to be slaves for the biggest multinationals in the world.

Because Bill knows intellectual property, he made his money out of it. What is software but intellectual property, low costs but high sale price? He has been manipulating intellectual property for most of his working life and now that he has become a philanthropist, he is depending on it still.

I'm not suggesting that he has anything personal to gain, in the sense that he has shares in all these pharmaceutical companies and all the others that will make billions. Perhaps he doesn’t have shares or any kind of interest. I'm just suggesting that there are immediate things that could be done that would obviate the need for all this research into more drugs when the solution is far more basic.

People in developing countries need, in addition to water and sanitation, good education, access to health care, good nutrition and food security, infrastructure, rights, equality. Drugs come and go, that's the problem, that's one of the reasons that they are not sustainable (also the ridiculously high prices and the corruption that keeps the prices high). And why put so much money into this technology when there are solutions that will have far greater benefits?

As many as 2 billion people in the world may have intestinal worms, this will affect their health, their welfare, their intellectual and physical growth. Bill, think of what good water and sanitation could do for people, never mind the pharmaceutical companies. Beating the worms would be a far bigger reward.


Saturday, April 11, 2009

Prediction Versus Observation

Nobody could have predicted the development and spread of HIV/AIDS in the decades leading up to the 1980s, when the disease was identified. Why would I (or anyone) say something that seems so mind-numbingly obvious? Well, predictions relate to the future, they don't relate to the present or the past. Ok, that's pretty obvious as well.

But try this: in Kenya and other African countries, it was mind-numbingly obvious in the 1980s that, if any epidemic, natural disaster, economic crisis or other highly threatening event were to occur, many people would be adversely affected. Despite post independence improvements and optimism, the majority of people were poor and vulnerable, they had limited access to health, education and other social services. Things were improving, but not fast enough.

There were economic crises, there were oil crises, there were crop failures and famines, there were high rates of disease of various kinds and, inevitably, many people suffered and died prematurely. In the 1980s, it was obvious that most people in Kenya were highly vulnerable as a result of earlier events and also because of rising poverty and disease and decreasing levels of coverage of services that would reduce exposure and mitigate the effects of exposure to disease and other processes.

In the 1980s, there was a clear need for development to reduce the spread of disease, to reduce rising levels of malnutrition and food insecurity, to increase levels of education, to develop infrastructure, especially water and sanitation. Countries like Kenya had a lot of developing to do. The country lacked resilience and would continue to suffer badly every time disaster struck.

The economic fundamentalism of wealthy countries in the 1980s, which continued into the 90s and beyond, dictated that what developing countries needed was, exclusively, economic development. Maybe at the time it seemed like a good bet, that if the economy was ok, everything else would be ok. Perhaps it wasn't clear that most people would remain poor and vulnerable, even when the economy was doing well (whatever 'doing well' happens to mean). If it wasn't immediately clear, it became clear; economies, even in poor countries, waxed and waned. But disasters, diseases, poverty, starvation, etc, and their devastating effects, continued.

But in what way were economies improving? An article I came across recently points out that African economies grew by 1.8% in the 80s and 2% in the 90s and never kept up with population growth. The goal to halve absolute poverty by 2015 is predicated on the achievement of 7% economic growth. At the same time, the percentage of people living below the poverty line increased from 42.6% in the 80s to 44.1% in the 90s and 45.7% in 2003.

Over the decades following the identification of HIV/AIDS, researchers continue to make clear that HIV is transmitted as a result of many factors. These factors relate to the economy, the environment, infrastructure, labour, legal issues, equality, especially gender equality, human behaviour, especially, sexual behaviour and many others. Additional factors and their respective significances are being discovered all the time. Those involved in work to reduce the transmission of HIV and to mitigate its effects cannot be faulted for not knowing about things that have yet to be discovered.

But rather than approach HIV as the multifaceted threat that it is, most approaches to HIV ignore the broader picture of extreme underdevelopment in which HIV transmission needs to be viewed. Most approaches treat HIV as a disease that is spread by sexual intercourse and a disease that can be fought by influencing people's sexual behaviour. There are exceptions, of course, but most of the big HIV money goes into these approaches.

It’s true, HIV is mostly spread by sexual intercourse in developing countries like Kenya and it is vital to understand sexual behaviour and to influence it to the extent that people's levels of exposure and vulnerability can be reduced. But levels of exposure and vulnerability increase during times of economic and social stress. There is an increasing number of poor and unemployed people in Kenya right now. There have been high levels of civil disturbance for some time and there may be more to come. The poor working practices found in Export Processing Zones (EPZ, a polite term for sweat shops), mines, sugar, tea and flower plantations, continue. These, and other conditions, need to be addressed as a matter of urgency.

It has proved very hard to influence people's sexual behaviour and that will probably always be the case, the dangers of sexually transmitted infections (STI) notwithstanding. But services to screen and treat people for common STIs should already be an integral part of Kenya's health services. Children and adults can receive sex education and can be given access to family planning advice and services. These benefits already relate to human rights to which people were entitled long before HIV became an issue. HIV wasn't predictable but high levels of poor health and low levels of education have long been obvious. The fact that people were vulnerable to anything that struck has long been obvious.

In addition, the success of HIV interventions, whether they relate to health, education or anything else, depends on the levels of health, education and other social services in a country. It has never been a secret that, without these services, interventions would have little impact and mitigation of the effects of disease (or any other threat) would be difficult.

The virus may be an 'act of god' but levels of vulnerability are due to decades of underdevelopment and decades of impoverishment of developing countries by developed countries. There were good times in wealthy countries but most people in developing countries never experienced any good times. Now that times are bad again in wealthy countries, no doubt, developing countries will suffer even more.

It's not as if developing countries could never have done anything to help. Oxfam have estimated that the financial bailout package currently in operation represents $1250 for every person on the planet. The same amount of money could lift 1.4 billion of the world's poorest people out of poverty for fifty years. This package is unprecedented, but large financial packages have been made available in the past for wars, following wars and for really important things like the race to the moon.

But I don’t see the global financial industry sacrificing a handful of failed financial institutions for the benefit of a few billion people. As for whether it will work, the bailout package is probably as effective as eating beetroot to protect against HIV.

There is little point in approaching HIV as it were the first infectious disease in the history of medicine to be entirely independent of people’s living conditions. The areas of underdevelopment that were involved in the spread of HIV have been more or less ignored since HIV has been identified. Yet, any measure to reduce transmission of HIV requires those areas of underdevelopment, all of them, to be addressed. Once they have been addressed, HIV transmission will reduce and efforts to reduce transmission further and mitigate the impacts of HIV have a greater probability of success.

There are serious HIV epidemics in many developing countries because they are underdeveloped; the people are vulnerable. As long as they stay underdeveloped, people will continue to be vulnerable and the HIV epidemics will remain. Future predictions are tenuous and difficult but we should all be perfectly capable of making observations about the present and the past.


Wednesday, April 8, 2009

IMF: a Sixty Year Old Limping Contradiction

I don't know if it is a coincidence but last year the Americans have finally said they would allow someone other than an American to hold the position of president of the IMF (International Monetary Fund), which they have dominated for 60 years. Will the Europeans also allow a non-European to be Managing Director? At the same time, many developing countries, recipients of IMF loans, have decided that the conditions attached to the loans cause more harm than good. So they have paid back their loans (Thailand, Brazil, Venezuela, Argentina, Indonesia). If this trend continues, the IMF could cease to exist.

Is it possible that the Americans see the IMF as an obsolescent institution? Well, perhaps not. Although the IMF appears to have been limping along for some time, the global financial crisis has prompted the G20 to add half a trillion dollars to its funds. The people who are tasked with dealing with the consequences of financial and banking liberalization are also promoting them, one of the IMF's favourite conditions being financial and banking liberalization.

Contradictions have never been a problem for the IMF or the World Bank. They give loans to countries to assist 'development' at the same time as they oversee the reduction of health, education, social services and infrastructure in the same countries. These are the very areas that are in need of development but if you've got the money, you get to decide on the ‘best’ route to development; even if that route is in the opposite direction to anything that could be described as development.

It's vaguely possible that the IMF, similar institutions and donor countries will one day start listening to their recipients. After all, many recipients have had clearer insights into what they need in order to achieve development that benefits their own people. But given their behaviour to date, it seems unlikely that these unwieldy institutions will change much for the better. One might almost think that they are not designed to benefit their recipients. (Remember the Goldenberg scandal in Kenya? Ok, it’s a bit of an easy target!)

A recent issue of Africa Focus (Africa: Global Economic Crisis 1-3) makes the point that developing countries have long been worried about the subsidies that developed countries paid to its farmers (while stipulating the removal of subsidies in developing countries as a condition of receiving loans). Now they also need to worry about subsidies being paid to financial institutions and the possible subsidies to be paid to manufacturing industries, such as the automotive industry. But those who have the money, again, get to make all the rules. Worse still, they also get to break the rules they later find they don't like.

The fiscal stimulus package is designed to favour American (and perhaps Western) interests, goods and services. The fact that Americans and Westerners own or have an interest in financial and other institutions, goods and services in developing countries does not mean that those developing countries will benefit from the package. Developing countries are not allowed to protect themselves, developed countries are.

It is almost laughable that one of the conditions the IMF and World Bank like to apply is an increase in democratic accountability and good governance. These institutions have no democratic accountability and their governance has been demonstrated to be flawed over and over again. Almost laughable, but the poorest people in the world suffer from these jokers’ repeated cock-ups.

Those responsible for the way international finance works have screwed up, badly. Yet the same people and institutions are also responsible for addressing these problems and they seem to be applying the same tired and failed solutions. The IMF is supposed to continue to give loans to developing countries with the same conditions that have been so destructive in the past. Even countries who have made some progress in reducing their indebtedness will now go back to where they were, at best.

The first and most practical thing the IMF and other donors can do is to cancel debts. Really cancel them, not just tinker around with the figures. These debts stem from loans that had impossible conditions attached to them. The recipients of these loans usually end up poorer as a result of the loans and, in reality, have paid them back many times over.

It's not developing countries that need to reform, it's institutions like the IMF. If they are to be in a position to assist developing countries, they need to face up to the reality of the mess they have made. They need to be more representative, they need good governance. Or perhaps the IMF has is finished? Perhaps the IMF now realises that is is an experiment that went on sixty years too long.


Monday, April 6, 2009

A Short History of HIV in Kenya

[UPDATE: August 10 2014 - I am completely revising this short history and posting the new version in parts, on this blog and on my other blogs, Blogtivist.and Don't Get Stuck With HIVPart I Part II Part III Part IV]

In response to a recent blog post on the history of the HIV epidemic in South Africa, I would like to provide a brief history of the HIV epidemic in Kenya.

Kenya had a very different history from South Africa. In fact, the histories of most African countries may share similarities but are also subtly different. Therefore, each country is now experiencing very different HIV epidemics and need different sets of HIV prevention interventions.

Following independence in the early 60s, Kenya under Kenyatta saw many changes, some good and some bad. Spending on education, health, infrastructure and various social services increased. The country underwent a transformation and enjoyed a level of prosperity that was unmatched, before or since.

The early independence period was not perfect, of course. Some gained, some remained in the position they had always been in. In general, many people were employed and social and economic indicators showed improvement. But at the same time, those in the Kenyatta government had already started the process of enriching themselves from the public purse.

It is important to note an advantage that Kenya had over some other African countries. They opposed the soviet regime and were well rewarded for the part they played in the cold war. Kenya continues to support the current ‘war against terror’ and appears to be generally sympathetic to US aggression. It is probably not an accident, therefore, that they currently receive the tenth highest share of US aid money.

So, while health, education and other social infrastructures were being built up during the 70s, politics and governance were taking shape to eventually undermine many of the earlier gains. Kenyatta died and was replaced by Moi in 1978. (The current president, Mwai Kibaki, held senior cabinet posts in the Kenyatta and Moi regimes, so there is a high level of continuity between the early independence years and the present decade.)

HIV probably first reached Kenya in the late 1970s, coming from the Western Equatorial region via Uganda and perhaps via Tanzania. This was still some years before it would be identified, though some health professionals working in Kenya at the time retrospectively noted an unusual health situation characterised by acute versions of relatively common conditions.

1980: retrospective tests of blood samples from Nairobi commercial sex workers (CSW) show zero HIV prevalence (the percentage found to be HIV positive), but a sexually transmitted infection (STI) programme was established. So the virus may well have already been present in other areas because in 1981, retrospective tests show a prevalence of 4%. Around this time the US Center for Disease Control (CDC) noted a new disease that affected gay men.

Kenya had been receiving loans from the International Monetary Fund (IMF) and the World Bank for some years but it was in the 1980s that these institutions started to build conditionality into its loans. ‘Structural Adjustment Policies’ (SAP), which resulted in reduced spending on education, health, infrastructure and social services, had an enormous impact on the country. When HIV prevention efforts started, belatedly, they were seriously curtailed by these SAPs.

These SAPs continue to this day, sometimes under different names. This is despite clear evidence that their effects are almost entirely destructive. They play a major part in what can only be described as retrogressive development and the sooner they are reformed the better. As long as developing countries are compelled to reduce health, education and other services, they will be unable to develop or, therefore, to reduce the spread of HIV.

1982: AIDS is named and vertical (mother to child) and heterosexual transmission are recognised. The following year a virus is identified that is suspected of causing AIDS. It is later named HIV and World Health Organisation (WHO) HIV surveillance starts. In 1984 the first case of HIV in Kenya is identified and in the following year the National AIDS Committee is established.

For the whole of the 1980s and 1990s, even into the 2000s, Kenyan leaders persisted in denying the existence of HIV. There was plenty of evidence that HIV was a serious problem in Nairobi because prevalence among CSWs there peaked at 81%. Prevalence subsequently declined, despite the fact that HIV prevention efforts were not very widespread until many years later. In fact, it remains unclear why prevalence peaked so early among CSWs and then declined.

1987: the WHO formed the Global Programme on AIDS. The following year, Kenya’s Ministry of Health issues guidelines stating that patients should be told their HIV status. In 1989, President Moi is said to have ordered the quarantining of people with HIV/AIDS but the order was quietly ignored. By 1990, there were an estimated 7.5 million people living with HIV, globally.

Without the Kenyan government substantially moving from their position of denial, HIV incidence (the number of new infections per year) peaked at 2%. Prevalence in one province, Rift Valley, peaks at 14% in the same year. At this time, Moi publicly refused to admit that the HIV epidemic had become national in scope. Prevalence peaks in Western Province at 17% in 1994 and the government as a whole recognises HIV as a critical issue.

But in 1995, the Kenyan government still seems uninterested in the epidemic. Donor funds are not distributed or go missing and, although the countries blood stocks are found to be unsafe, the government denies that this poses a major problem. At this time 17.5 million people are living with AIDS, globally. Prevalence in Nairobi peaks at 17% and national prevalence is estimated at between 10 and 14%.

1996: Highly Active Anti-Retroviral Therapy is developed (HAART). In the same year, a Kenyan cardinal condemns the use of condoms to prevent HIV infection. The following year, HIV prevalence peaks. Early prevalence figures were subsequently revised and it is now thought that HIV prevalence peaked at 9 or 10% in the late 1990s.

1997: UNAIDS (Joint United Nations Programme on HIV/AIDS) is formed. The Kenyan Parliament approves a 15 year national AIDS policy and forms the National AIDS Council. Moi bows to election year pressure from religious leaders and shelves sex education plans.

1998: incidence is thought to have peaked globally at around 3.4%. A large number of Kenyan public sector employees die as a result of AIDS. The Great Lakes Initiative on AIDS (GLIA) is established. The following year, HIV in the last of Kenya’s provinces peaks; North Western Province peaks at a relatively low rate, 6%, although this and other figures are often questioned.

In the same year, Moi declares AIDS a national disaster but is still reluctant to do anything about it. He says he feels it would be improper to encourage the use of condoms in schools and colleges. However, the National AIDS Control Council was formed and is still in operation.

2000: an estimated 27.5 million people are living with AIDS, globally. Kenya develops a five year National AIDS Strategic Plan and plans AIDS education for all schools and colleges. The Millennium Development Goals (MDG) are adopted by the international community and reducing the spread and impact of HIV are include in this initiative.

2001: the Global Fund to Fight AIDS, TB and Malaria (Global Fund) is formed by the World Bank. Moi, in the run up to another election, publicly expresses reluctance to spend public money on condoms. He recommends abstinence as protection against AIDS. Christian and Muslim leaders join him in opposing condoms.

2002: the new president, Mwai Kibaki, declares ‘Total War on AIDS’. However, the following year, Global Fund grants are withheld because of corruption allegations. Widespread corruption, misuse and disappearance of funds are discovered and, unusually, some people are held accountable.

2003: Kenya’s prevalence is found to have dropped to 6.7% and the death rate peaks at 120,000 per year. These are highly significant milestones. As HIV incidence peaked in 1993 and declined thereafter, it would follow that prevalence would peak some years later, around the end of the 90s, say. A few years after that, it follows that many people would die of AIDS and prevalence would drop dramatically. The first wave of the HIV epidemic ended in the early 2000s.

2005: globally, 37 million people are living with HIV. AIDS deaths peak at around 2.2 million. Kenyan prevalence is said to stand at around 6.1%. A new five year strategic plan, due to run up to 2010, is published. The following year, Kenyan prevalence is said to have fallen again, to around 5.1%.

2007: global prevalence is revised downwards as a result of improved reporting methods. HIV figures are confusing, but data collected in Kenya suggest that prevalence had been rising since 2004 and had reached 7.8%. This is despite the previous assumption that prevalence had been falling continuously since the late 90s and had dropped to about 5.1%

The data published in 2008 show rising prevalence and my interpretation is that this may indicate a ‘new wave’ of the HIV epidemic. On the other hand, it may indicate no such thing. Estimations are very imprecise and predictions are dangerous. Some say HIV in Kenya is declining, some say otherwise. Personally, given the apparent connections between the spread of HIV and the country’s history, I would suggest that that Kenya is in a worse state now than it was in the 1980s and is therefore experiencing another serious HIV epidemic.

Holding a pessimistic position when everyone wants something to be optimistic about is hazardous; people want you to be wrong. But, as I have said elsewhere on this blog, I too would like to be wrong. I am not an epidemiologist, I could well be ignoring many factors and exaggerating the effects of others. No doubt it will be some years before the true picture is known. It is to be hoped, in the meantime, that some effort is made to improve health, education, social services and governance. These are in serious need of attention, regardless of what the HIV epidemic is doing at present.


Saturday, April 4, 2009

Tax Havens - Thieves' Heavens

It's a while since I have revisited the them of development by omission. But the environmentalist George Monbiot recently wrote an article about tax havens and the effects they have on developing countries. Other commentators have taken up the same theme following a report by Oxfam which showed that developing countries could be losing as much as $124 billion, compared to the $103 billion they receive in foreign aid.

It is remarkable that at a time when human rights violations are being carried out on an unprecedented scale on the pretext that there is a 'war on terror', the very thing terrorists depend on, money, is nestling right under the noses of one of the countries claiming to be right behind that war.

Despite all the sanctimonius bilge that comes from British leaders and interested parties and the sycophantic toadying to the Americans, most tax havens are British. And they are doing very well, thank you for asking. The excuse for allowing rich people to keep their money where it cannot be taxed is that they will not invest in Britain if they have to pay tax. The fact is that their money stays out of Britain (and other country where they could be taxed) and only they stand to gain.

As for the difference between the leaders of developing countries, terrorists (or those presently called terrorists), multinationals, rich people and assorted criminals, I don't know. There is certainly one major similarity; where they do their banking. If Britain is so concerned about such behaviour and if they are really interested in protecting developing countries, they know what to do.

However, it seems they make too much money from the present system. They have spent decades reducing any regulation that would protect people from global level financial corruption. This simply means that they have become part of that corruption, they supply the infrastructure. And now that their deregulated system has collapsed, they are squealing like stuck pigs. Poor people have been forced to pay the bulk of countries' tax burden because rich people don't bother to pay any.

Development by omission, in this case, reform of tax havens, would do a lot more than the very expensive programmes that are presently referred to as 'aid'. Instead of pretending to build dams, irrigation and hydroelectricity installations for the benefit of people in developing countries when they are really giving fat contracts to their friends, British leaders could reform the very system that supports the impoverishment of poor people all over the world.

As is so often the case, it's not a matter of what developed countries can do for developing countries, it's a matter of what we can stop doing. Will the rich countries carry out the necessary reform? The G20 countries met recently and if they saw it as being in their interest to reform the system, they they may have discussed it. Otherwise, I don't see them giving up such a useful and profitable setup.


Thursday, April 2, 2009

Is a Woman with Obstetric Fistula Worth Less than an Uncircumcised Man?

The debate about mass male circumcision (MMC) as a solution to the HIV epidemic rages on. The evidence that, in ideal conditions, male circumcision is protective against HIV, is convincing. On the surface, it seems crazy not to implement MMC in Kenya immediately. Many new infections could be prevented and even rates of transmission of other sexually transmitted infections (STI), such as herpes simplex virus, could be cut.

But Kenyans do not live in ideal conditions. If they did, the HIV epidemic there would not be as serious as it is now. The health infrastructure that would be required for MMC does not exist. After independence in the 60s, Kenya's health infrastructure improved. But from the early 80s, global and domestic crises halted this progress.

Then the World Bank and IMF (International Monetary Fund) introduced structural adjustment policies. Countries that got loans from these institutions had to reduce their social services, reduce their public sector employment, privatise as much as possible, remove 'barriers to trade', etc. This process of impoverishment, despite overwhelming evidence of the damage it causes, continues today.

Men in Kenya would be well advised to think twice about being circumcised. The level of adverse affects is 35% for traditional circumcisions, though these have long been known to be hazardous. But the level of adverse affects for clinically performed circumcisions is 18%. I wouldn't even have a tooth extracted in a health service like this. Kenyan health infrastructure is not up to an MMC campaign. It has been systematically run down for thirty years. It will take a long time to build up. Then an MMC campaign may be more feasible.

But there are still problems. Men (all over the world) don't like using condoms. I have met men who will use any excuse to avoid using them and they jump at any 'evidence' that they don't work, such as the maunderings of some Catholic with odd taste in headgear. There is even a myth that condoms don't work for circumcised men. So, if circumcised men use condoms, circumcision may have some effect on HIV and other STI transmission rates.

There is also a phenomenon referred to as 'disinhibition'. People who have been circumcised have been found to behave as if they are protected from HIV and can do without condoms. The same process is thought to occur among people who are on antiretroviral treatment (ART). There is a danger that people who feel disinhibited are likely to have unprotected sex and thus to undermine the effects of all this expensive prevention and treatment.

It is sometimes argued that circumcision is a small and routine operation. Well, in Western countries, maybe it is. But compare it to another small and routine operation, the operation to correct obstetric fistula (OF). Women who have difficulties in labour sometimes suffer from damage to their bladder or rectum. The result is that the baby usually dies and the mother suffers from chronic incontinence.

Lifelong, chronic incontinence is bad enough in itself, but in some societies, where there is no way to reduce the effects of this condition, the person suffering OF is shunned and stigmatised. They can spend their whole life with a preventable condition that could be reversed by a simple, routine operation. OF often occurs in younger girls and it occurs where births are not attended by trained midwives or otherwise qualified people. Lack of education, as well as poor healthcare, is an important factor in maternal health.

An estimated 3000 women suffer OF every year and most don't get treatment. There is currently a backlog of hundreds of thousands. OF is preventable but Kenyan reproductive and maternal healthcare is inadequate, it is unable to prevent this and other maternal health problems. The infant deaths just add to the huge infant mortality rate, which has been growing since the 1980s. Kenyan healthcare is also unable to provide the operation to reverse the damage and allow women to live a normal life.

If the health infrastructure is not up to preventing OF, it is not up to MMC and the follow up care that would be required. And if this simple, routine operation cannot be carried out for those who continue to suffer from OF, what are the chances that the hundreds of thousands of male children born every year can be safely circumcised and cared for? If there is money available for MMC, there must be money available for OF.

But the problem with MMC is that a simple, routine operation for millions of people requires complex health infrastructure. The basic infrastructure needs to be built first. Then, MMC has a chance of working. If the basic infrastructure is there, OF will not even occur or will be as rare as it is in developed countries.

The persistence of OF bears witness to the lack of health infrastructure in Kenya and clearly indicates that MMC or any other grand programme has little chance of success.


Wednesday, April 1, 2009

Damn Your Traditional Values

People can often be heard moaning about the disintegration of traditional family values (and Christian values, etc), especially in the context of discussions about HIV transmission. In the old days, children respected their elders, they paid attention to what they said, they discussed their relationship and marriage plans with their family, they didn't have sex before marriage, etc. We've probably all heard it in some form or other.

But there's a bit of a contradiction in being told to place absolute trust in people who can sometimes become part of the problem, such as parents, teachers or employers. HIV programmes often aim to instill in young people the belief in their own self efficacy, the belief that they can decide when, where and with whom to have sex. Yet sometimes, the person who is demanding sex from them is a parent, a relative, a teacher or someone else who is supposed to be in a position of responsibility.

Also, people in positions of responsibility, religious leaders and political leaders, for example, are telling people how to behave and how to live their lives. Either people have a degree of autonomy or they do what they are told. Personally, I think respect is due to some people and not to others. Children (and adults) need the ability to judge who is entitled to respect. They need to see that respect is not always due to people just because of their position. They need to be able to decide for themselves what to do and what to avoid doing.

Politicians often abuse their position, police take the law into their own hands, parents do many things that are harmful to their children, religious leaders often lie to suit their church's dogma, adults often abuse younger people, strong people often take advantage of weak people. There is no rule of thumb about who is to be respected and who is not. Such rules of thumb lead people into dangerous positions.

I met a young Tanzanian woman recently who told me that she almost had to drop out of college because she failed four out of seven of her exams. She was sure that she had only done one exam badly but to get a recheck she had to pay a lot of money for each one. She approached each teacher and discussed it. One of them suggested that if he were to do this 'favour' for her, she would need to think about a 'favour' she could do for him. She said she would prefer to pay.

She was lucky that she works as a volunteer HIV counsellor. She was also lucky that she had the money. As it is, she cannot afford to live in student accommodation and needs to stay with relatives. So she is lucky that she has relatives that are close to her college. Many people would not be so lucky.

This is not an isolated incident. I came across an article recently about children who are coerced into having sex and even long term relationships with their (already married and sometimes HIV positive) teachers. The teachers often agree to give them money or to pay for their schooling. Girls who become pregnant are excluded from school and that's often the end of the agreement. They end up much worse off than they were before.

To make matters worse, parents and guardians sometimes encourage these relationships because they can't afford to pay school related expenses and fees. The children are let down by those closest to them, the people they are supposed to treat with respect. They are being abused emotionally, sexually and physically by people who are teaching them to be submissive towards their parents and teachers.

Children must be very confused. The people who are telling them to respect their elders are abusing them. The people who are telling them to make decisions for themselves are lying to them and undermining their ability to make decisions. The people who tell them that lying is wrong also tell them lies. I met a Catholic priest here recently who asked me if it was really true that there are tiny holes in condoms that allow the HIV virus to pass through. I told him to check with the WHO (World Health Organization), who have a lot more experience with health and reproduction that the Catholic Church.

It's very disobedient of him to refuse to follow the teachings of his church. But if there is a god, I'm sure the priest's decision will be understood.