Tuesday, June 9, 2009

It Doesn’t Need to be Related to HIV to be Important

Nairobi, perhaps in common with other cities in developing countries, is a curious sort of place. Many economic, health, education, infrastructure and other social indicators are the best in the country. You would think that the majority of people there lived well, at least when compared with rural Kenyans or Kenyans living in other cities. Out of eight Kenyan provinces, only Central is anywhere near as prosperous as Nairobi.

However, an estimated three quarters of people living in Nairobi live in slums. People in cities are often better off, or are seen as being better off, than those in rural areas. Perhaps, like Nairobi, those in slums simply don't count. The government barely recognises the existence of slums except when they send in the police to shoot people, almost at random, in the name of anti-terrorism. They consider slum dwellings to be illegal and therefore not entitled to resources.

As a result, slum dwellers in Nairobi, the majority of the capital's citizens, suffer from terrible poverty. But when the country experiences food shortages, as it is doing at present, the aid tends to go to other areas and to pass over Nairobi. As a result, there are serious levels of malnutrition in this city that tries to be so Western and cosmopolitan.

Cities like Nairobi, Mombasa, Eldoret, Nakuru and Kisumu have been growing rapidly for several decades. Public services, far from growing, have stagnated or been reduced because of poor governance, internal and external. Right now, poverty, food insecurity, unemployment and other factors are driving people to cities in greater numbers. Therefore, the problems are becoming more acute.

It's very hard to demonstrate any causal connection between poverty and HIV. Rather than attempting to do so, I would argue that poverty itself is abhorrent. HIV is a terrible disease but it is just one of many. I would not argue that poverty needs to be alleviated because it causes HIV. Poverty needs to be alleviated because it denies people many of their rights. As a result of poverty people suffer numerous health problems, they often receive little or no education, they have reduced life expectancy and they live in poor and degrading conditions.

It's clear enough that some people are exposed to HIV because they are poor. But others are more vulnerable because they have not had enough education. Others still are vulnerable because of their lifestyle, their gender, their sexuality or their working conditions, etc. In Kenya, most cases of HIV are sexually transmitted, but the conditions under which people have sex, when, how often and with whom, are another matter. The things that make people more vulnerable to HIV are often not related to sexual behaviour. People who are in bad overall health, for example, are more susceptible to diseases, including HIV.

Since the 1980s, education, health and other social services have been reduced and continue to be reduced nearly thirty years later. HIV probably arrived in Kenya in the late 1970s and spread rapidly throughout the 1980s and 90s. It took a long time for the world to realise what sort of disease HIV is and to work out how to react to it. But in Kenya and many other countries, health, education and other social services were inadequate. They are still inadequate and most efforts to reduce the spread of HIV to date have failed.

HIV is still spreading in many parts of Kenya. True, prevalence has dropped in some places where it was once very high. But this is to a large extent because many people have died. In other areas, where HIV has been low for a long time, it is now increasing. And some places have had high HIV prevalence for a long time and it remains high. The figures have fluctuated over the years but the backslapping that has gone on in Kenya, Tanzania and even Uganda is premature.

The vast majority of Kenyans don't know their status. The vast majority of people who are HIV positive don't know their status. The county's health service does not have the capacity to test everyone. The country's education sector is in no condition to give even a basic education to many people, let alone sex and health education. When people become ill, many will suffer unnecessarily and die unnecessarily because of the inadequacies of the health services. Billions of dollars of aid money is going to treating and caring for people already infected with HIV but much of this, too, is being wasted.

The health of many Kenyans is bad. The determinants of health are many and various but include things like water and sanitation, food and nutrition, housing and environment, health services, education and infrastructure. Dealing with these determinants of health, may or may not directly reduce HIV transmission but people have a right to health.

Similar arguments apply to poverty. Poverty alleviation may not directly reduce HIV transmission but it will help give people access to clean water, adequate nutrition, better housing, etc. These are all rights and they don't need to be related to HIV to deserve attention.


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