Saturday, February 28, 2009

Universal HIV Testing and Treatment, the Latest Fashion

The philosopher Ludwig Wittgenstein spent much of his early years as a philosopher solving all the major problems of Western philosophy. So he thought, anyhow. He spent his later years trying to answer some of the questions that his earlier philosophy raised. Since his death, philosophers have moved from trying to understand Wittgenstein’s work to trying to dismiss it or trying to explain it (or explain it away). But there are still philosophical problems, and there probably always will be. I certainly hope so.

Similar claims have been made about the end of science, as if all the major scientific problems have just about been answered or soon will be. There’s also the end of history, whatever that could mean. And then there was the long held assertion that capitalism was the only way for global economics to proceed. That was until all the major capitalist economies answered the question as to what would come next: an absurd form of communism, it seems. And after that, who knows?

Well, maybe it’s just journalists and writers of a journalistic bent who still feel the need to raise such possibilities as the end of various intractable problems, for example, of development. Thus, a recent article in the New Scientist entitled “Are we about to eliminate AIDS?” This article was motivated by a much publicised article suggesting that if universal testing were carried out in all countries with endemic HIV and all those found positive were to be put on antiretroviral treatment (ART), HIV transmission would plummet and prevalence could be maintained at a very low level by 2050.

I have discussed this latter article on several occasions and I’m sure I’ll return to it, but for now, I’d like to have a look at the claims made in the New Scientist article. Right at the beginning the article claims that it would only take existing medical technology to eliminate AIDS. This highlights a major flaw in current thinking on HIV: that it is a medical problem and will, eventually, have a medical solution.

There are medical ‘solutions’ to many of today’s health problems. The biggest killer of children in developing countries is pneumonia and other lung infections. There are solutions to many economic problems. There needn’t be hunger or malnutrition in developing countries because there is plenty of food. Quite a number of medical problems don’t require medicine, they need clean water and good food. Why is a technical fix so often seen as the only way out of a problem?

The history of HIV in Kenya is just a small part of a history of processes of ‘negative development’ carried out by the Kenyan government, various business interests, foreign governments, international financial institutions and other parties. These processes are still being carried out. Members of the government are still trying to amass wealth and power as are the business interests. Foreign governments are keen on wealth as well but power is especially important to them. It’s hard to work out what international financial institutions are interested in. Their habit of screwing up the economies of developing countries is inexplicable unless they are doing it to benefit some of the wealthier countries, but I’ll have to leave that for someone else to explain.

So bringing in a technical fix, universal testing and treatment (UTT), will not reverse the effects of what has been happening in the country since independence. The technical fix will be very successful if health, education, food security, the environment, infrastructure and all other underdeveloped sectors of Kenya are also improved. But those are very big ifs. UTT will have a chance of working if Kenya is allowed to develop.

The cost of UTT is vast. The article promoting the idea is a mathematical model and it points out that the cost of not rolling out UTT is even greater, if a long term view is taken. If the cost is vast, I would suggest that those enamoured with the idea should check on conditions in Kenya that would need to be met in order to achieve universal testing alone, when in the last 15 years they haven’t even achieved 25% testing. And UTT requires testing every sexually every adult frequently, perhaps every year.

As for the millions of people who will be on ART, what about the support services they will require? Perhaps around 35% of the people who are known to require ART are receiving it. These figures are vague, but the health services are struggling to get the numbers up as it is. And all that’s needed is a crisis like the one that occurred after the elections last year and many people are back to square one.

But crises don’t come singly in Kenya. The post election crisis was followed by water, fuel, food and financial crises. Each of them affects the ability of the country to care for its sick, not just those with HIV. The country is underdeveloped, many development indicators are going in the wrong direction. This is why Kenya has endemic HIV in the first place and it is why efforts to reduce transmission have failed so far.

UTT will not fail because the idea is a bad one, it will fail because it is a solution that requires many years of development work to occur first. And if that development work is carried out, the cost of UTT will come down, too. The cost of UTT is nothing to the cost of allowing Kenya to develop in ways that have been blocked for so many decades.

But to return to the article in question, the New Scientist one, the author claims that people on ART almost never transmit HIV, even during unprotected sex. That is a very contentious claim, many would consider it a rash one to make. But if there is any truth in it, it is only true of those responding to ART who have a low enough viral load. In Kenya there are those who don’t have access to the drugs, for whatever reason, those without access to adequate nutrition, those suffering from other serious medical conditions and those who don’t take the drugs in the recommended manner, etc. They probably can still transmit HIV or will be able to soon enough.

And what is this about HIV being the only or the biggest risk from unprotected sex? Condoms can also be used to protect against unwanted pregnancy, or hasn’t the author heard of that? There are also other sexually transmitted infections, do they not count? Herpes simplex virus (HSV) is sexually transmitted, incurable and endemic in Kenya. It also increases transmission of HIV.

I applaud the people who have worked to find a cure for HIV and those who have come up with treatments. I also applaud those who put the mathematical model together showing the promise that UTT holds. I just wish they would look a bit wider than their own profession, whether they are doctors, epidemiologists, virologists or whatever. There is the whole of health, health services, development and many other things to consider if such ambitious projects are to work.

I’m glad the issue is being discussed by huge numbers of people but HIV is not just a medical or scientific problem and medicine and science do not operate in isolation from histories, cultures, societies, economies and especially, from people, their lives their ways of behaving, their circumstances and many other constraints.


Thursday, February 26, 2009

Another Country Falls For Lies About Genetically Modified Crops

Kenya has just become the fourth African country to give in to the pressure to produce and use genetically modified (GM) crops. If the GM evangelists are right, in a few short years Kenya will be entirely self-sufficient and food secure and will no longer need the vast quantities of food and aid money for food that they currently receive.

This decision follows the signing of the long discussed biosafety legislation. A National Biosafety Authority will be formed to oversee the implementation of the legislation. So everything should be fine because if there is safety legislation, nothing can go wrong, everyone will behave as they should and Kenyans will all live happily ever after, right?

GM evangelists have been using food shortages and famine to leverage their arguments for the need for GM. It's a bit like producers of a well known brand of baby milk formula distributing their produce free of charge in hospitals. The recipients return home to find that they have to pay for the product and infants subsequently die of water born diseases. Some die later because they haven't acquired resistance that they would have acquired from being breast fed.

It could be objected that the baby milk formula producers don't do that any longer. However, their tricks continue, albeit more subtly. And they can afford to spend a lot on publicity to convince people that they are really nice companies. Besides, people get tired of particular issues, so they have probably tired of that one by now.

Well, GM evangelists also pay out a lot for publicity, lobbying and downright lies. There is no evidence that GM crops produce greater yields, reduce the need for pesticides, herbicides and fertilizers, grow well in poor conditions or are in some way better for the environment. They have no advantages that cannot also be found in non-GM agricultural techniques.

There are also serious disadvantages associated with accepting GM. GM increases dependency. The last thing Kenya needs now is to increase its dependency on donors to whom they are already in debt for the foreseeable future. When farmers buy GM seeds, they also need to buy GM fertilizers, herbicides and pesticides. These are very expensive and need to be bought every year. So do the seeds. It is not possible to put by seeds for the following year, they must be purchased every year.

GM also poses a serious risk to the environment. At present, much of Kenya's arable land is committed to some form of monoculture, such as tea, sugar, sisal, cashews, rice, etc. This has been the situation for many decades, so biodiversity is already very low in many areas. But GM has a trick to reduce biodiversity even further.

If Kenya buys a particular 'variety' of GM maize, for example, that will become the only variety in many areas, if not throughout the whole country. Coupled with that, GM pesticides and herbicides kill everything except the GM crop. That's what they are designed to do. Everything in a GM field except the GM crop dies. This is not even counting the flora and fauna that are affected by run-off from the field.

Even the oldest of the GM evangalists must have learned about ecological balance when they were at school. They must have learned about how the smallestand seemingly insignificant organisms are part of the same system as human beings, how wiping out everything in an area leads to total and probably irreversible destruction.

GM evangelists even have the cheek to claim that there are substantial economic, environmental and welfare benefits offered by GM and this is why use of the technology has increased. They claim that "biotech crops can contribute to some of the major challenges facing global society, including: food security, high price of food, sustainability, alleviation of poverty and hunger, and help mitigate some of the challenges associated with climate change." What they don't say is that GM will increase these problems.

Using the current food shortages in Kenya and other developing countries to push the argument for GM is cynical beyond belief. GM multinationals are deliberately rolling out a technology that they know will make poor countries poorer and will also destroy the environment. They are doing it, not just because it makes them very rich, but because it also puts them in control of food producers. And the dependency associated with GM is far more serious than that associated with baby milk formulas. It will affect everyone, for their whole lives.

In addition, most Kenyan farmers are small farmers. They produce for their own needs and sell their surplus locally. GM is designed for mass production. Mass producers in Kenya do not, on the whole, benefit the majority of people. They employ few labourers, mainly on a casual basis and pay them very little.

What makes the Kenyan government think that this would be good for the country? Is it sheer desperation because of the food shortage and the global food price explosion? Or have they been nobbled by the GM evangalists? Well, the consequenses will be the same, whatever the reasons for the decision.

The government, it seems, has seen enough evidence to be convinced that GM crops are safe for human consumption. Well, that evidence took many years and a lot of money to manufacture. However, there is absolutely no evidence that GM will solve any of the countries problems and plenty of evidence that it will cause immense social, economic, environmental and other problems.


Tuesday, February 24, 2009

Can Kenya Treat Its Way Out of the HIV Epidemic?

There is a question that is frequently being asked these days: 'Is it possible for a country to treat its way out of the HIV epidemic?' That is to say, given the treatment options available now, is it possible to reduce the rate of new infections to a very low level? The hope is that, although HIV may not be eradicated, it could change from being a pandemic to being a chronic but manageable disease that affects relatively few people.

It has been claimed, for example, that universal HIV testing and subsequent treatment (UTT) for everyone found to be HIV positive could reduce HIV prevalence to less than 1% within 50 years (using data from South Africa as a test case).

So in Kenya, there were 1.4 million HIV positive people in 2007 in Kenya. 190,000 (14%) of them were on ART by mid 2008. Proponents of UTT want all 1.4 million to be on antiretroviral treatment (ART) as soon as possible.

One of the problems is that, after independence Kenya experienced many improvements in social conditions. But these were partly reversed as a result of internal and external crises in following decades. A combination of poor governance and structural adjustment policies resulted in a reduction in health, education and other social services.

I don't believe the issues surrounding UTT have yet become polarised, as so many other issues relating to HIV have become. There are persuasive arguments that much can be done to reduce rates of transmission and that UTT could play a big part in this. There are equally persuasive arguments that very little of the prevention work that has been carried out so far appears to have been unambiguously successful.

That's not to say nothing has been done or that what is being done should stop. People need sex education, they need to protect themselves from dangers such as physical and emotional injury, diseases such as HIV and other sexually transmitted infections, unwanted pregnancy, social stigma and even imprisonment. But such education and awareness pertain to basic human rights. It is not necessary that there be a serious pandemic before these basic rights are recognised.

Similarly, people need access to nutritious food and clean water, they need assured food security to avoid shortages and famine, they need the means to provide for themselves, access to health services, infrastructure, power, transport, commerce and many other things. These too pertain to basic human rights. People are entitled to these rights whether there is a HIV pandemic or any other kind of pandemic.

Yet it is such basic rights that are being denied to people in Kenya and other developing countries. They also need medicines for malaria, malnutrition, cholera, meningitis and intestinal parasites. In fact, countries could do more than treat their way out of the HIV epidemic. They could treat their way out of almost all endemic diseases.

The reason that people do not have access to medicines is more often because they are too expensive than because they have yet to be developed. And most don’t have access to health care in Kenya because there are very few health facilities and personnel.

The reason people don't have enough food is because they have been marginalised to the extent that they cannot access basic goods, not because there is not enough food.

But what if available medicines were to be provided to all those who need them? For a start, what level of health service provision would be required to provide all HIV positive people with ART? At present, after nearly three decades of HIV, countries like Kenya are struggling to provide HIV testing for everyone. Until people know their status, they continue to do as they have always done. Once they know their status, some, perhaps most, will seek medical care of some form. As to whether they will receive the care they need, that's another matter.

Far from increasing health structures in Kenya, health spending has not even improved to keep pace with population increases and increases in the need for health care. In general, spending has been and continues to be curtailed by loan conditions imposed by international financial institutions. The Kenyan government appears to have little interest in health and even less interest in HIV. People from outside Kenya are more interested in resources, land and cheap labour than in improving conditions in the country.

For many people willing to be tested for HIV, the services are not reaching them. There are HIV positive people who could be on ART, which would improve their health and reduce their risk of their transmitting HIV. But they are not always able to get the medication they need, for example, because they live in an isolated area. Or they are lacking some of the things they need for the drugs to be effective, such as clean water and a reasonable level of nutrition.

So is the answer to the question 'yes, it is possible for a country to treat its way out of the HIV epidemic'? I think this would be the answer if all the relevant conditions for such an undertaking were met. Then questions arise as to whether Kenya is on the right track to be in a position to roll out ART to all who need it, whether people will be fully supported in this treatment, whether they and those indirectly affected will be allowed to enjoy their rights to education, health and other benefits.

For me, the question really boils down to this: many developing countries are not much better off and some are worse off than previously, despite high levels of development aid over a long period of time. If 'treating their way out of the HIV epidemic' in Kenya means allowing the country to develop in the areas that allowed HIV to spread rapidly since the 1980s, then the project should have a lot of success. And not just with HIV but with most development issues.

But if the intention behind the question is to continue with various development programmes and tack on another one that involves mass testing and drug distribution, this will not be very successful.

It’s true that many people now on ART are doing very well, there is little evidence that they are responsible for transmitting HIV, more people are receiving sex education and HIV positive people are less stigmatised than they were in the past; many things are changing.

But despite this, HIV transmission is still high, too high for HIV prevalence to reach the very low levels envisaged by proponents of mass HIV treatment campaigns.

For UTT to be feasible, HIV needs to be seen as one of many symptoms of serious, long term underdevelopment. It is not merely a health crisis, a disease that needs to be eliminated. There are numerous factors in the transmission of HIV. They will not just go away. These factors include inequality, poverty, unemployment, poor health, education and infrastructure.

Only after all relevant factors have been dealt with will adequate HIV treatment and care succeed in reducing transmission to a level where it will be a chronic, treatable disease.


Thursday, February 19, 2009

Sex, Christians and Abstinence

Christians are unique in the animal kingdom in that they only experience the desire and even gain the ability to have sex once they are in a relationship of a sort that is approved by their church. If you don't believe me, just read a copy of a Christian bible. Ok, you have to interpret it a bit, but you'll find it there if you want to, and many people want to.

Or perhaps you would not take advice about sex from people who claim to only indulge in sexual intercourse for purposes of procreation? They are the last people I would ask for such advice. It is not supposed to be enjoyable and it is not even supposed to occur at all until approved by the church through marriage vows. Oh, and if you do 'transgress' you must feel terribly guilty and confess to someone who is probably exactly the same as you.

It's been a long time since (my last confession?) I have blogged as I have been travelling a relatively short distance very slowly. That's public transport in East Africa. And since I have reached my destination, Kigoma, Western Tanzania, there has been no electricity. The internet cafe I am writing from is supplied by a diesel generator that shudders and threatens to cut out at regular intervals. So I'll have to keep this posting short.

Several papers I have read on HIV transmission mention lack of diversion or entertainment and boredom as one of the factors in transmission. The man I am staying with mentioned the boring evenings several times and we killed some time by working late, by candle light, taking a long walk, stopping in a pub for a soda and chatting. But we would both have preferred to do something more entertaining or even just read with real electric lights.

Reading is not a big thing in Tanzania. It's very hard to get books and many people have difficulty with reading large amounts of text. So I don't even expect a big demand for books to develop any time soon. TV is popular but those who can afford TV may not be able to afford a generator to run it. Radio is a possibility, but evening with so few things to do and so little money to spend inevitably leads people to pursue cheaper and more readily available activities.

But there doesn't need to be a power cut or lack of things to do for sex to be an option, it's not just a way of filling in time. People don't need to list sex as a hobby no more than they need to list eating. They won't die if they don't have sex but nor will sexual desire go away. In fact, the desire for sex will not go away even if a load of Christians shout very often and very loudly about how you will die if you have sex of a sort they don't approve of.

One of the most extraordinary consequences of the HIV pandemic is the reaction of the Christian churches. They have been preaching abstinence, restraint, poverty and whatever else while practicing the opposite for two thousand years. They manage to attract the poorest people to give away a large chunk of their pittance to a church that lives in splendour. And they are supposed to abstain from their natural desires because of the dogma of people who, very often, know little about abstinence.

Even ostensibly secular states, such as the US, have spent millions of dollars at home and in developing countries on 'abstinence only' sex education. The word 'abstinence' is not just the absence of sex, a run of bad luck, perhaps. It refers to a decision to not have sex until marriage. The word has inherent religious and moral connotations. The policy has been a failure in the sense that most pledgers have sex as much as non-pledgers. In fact, many pledgers soon deny that they took a pledge. Worse still, the pledgers are less likely to use condoms or any form of birth control.

Here in East Africa, I have come across many interpretations of 'sex education', 'abstinence', moral issues, etc. There are those who teach 'abstinence' without even telling people what sex is. Of course, they know, vaguely, what sex is. But they are supposed to be teaching sex education. The word 'abstinence' is not clearly understood by people but even if plain English was used (without the religious and moral baggage), it seems difficult to comprehend the imperative to avoid doing something when you don't know what that something is.

Sex education programmes need to be mindful of what sex is, especially for those who claim not to indulge in sex. HIV is spread, to a large extent, by sex between heterosexuals. But people can be taught what sex is, what sexually transmitted infections are, how to ensure that you don't take risks that might result in unwanted pregnancy or sexually transmitted infection, etc. And the conditions of people's lives, the conditions that determine when, where and how sexual intercourse takes place, these have little to do with sex.

So if people are too squeamish or moral or religious or whatever to talk about sex, and I really think they should avoid the subject, they could better spend their time and money on infrastructure, poverty, gender inequality, poor health and education and many other areas of people's lives. It could be claimed, by the way, that many orphanages, schools and hospitals are run by religious institutions. But the money they spend represents a fraction of the money extracted from church followers. In areas like Kigoma, perhaps some of the churches could consider 'tax exemptions' or monetary rebates from the very poor.


Saturday, February 14, 2009

Alms for the Rich

Every year, pneumonia kills more under fives than HIV/AIDS, TB and malaria. But huge amounts of money are poured into these three diseases, much of it going towards HIV/AIDS alone. Pharmaceutical companies are speculating on these three diseases, which could make them enormously rich. Well, they are already rich but what they have now will be nothing compared with what they could make if they develop a cure for any of these.

Billions of dollars of aid money goes into disease research but only a fraction of it goes into dealing with treatable and curable conditions, such as acute respiratory infections and diarrhoea. Pharmaceutical companies are not betting on these because there are generic products available for them, products that don’t represent enough of a profit for them.

The number of people who suffer from intestinal parasites of some kind is estimated to be in the billions. This is closely related to malnutrition and nutritional deficiencies, something that may also affect billions of people. But cures for these have been around for a long time. And as no big institutions are interested in speculating in them, they receive very little money.

Don’t we in the development community look like fools, spending most donor money on a few diseases while ignoring the ones we could really have an impact on? There are people on antiretrovirals who are dying because they don’t have enough food or clean water. Are pharmaceutical companies willing to distribute pills without ensuring that there people have access to clean water? That’s how it appears, anyhow.

Some of the biggest sources of donor funding ever, the World Bank’s Global Fund, the President’s Emergency Fund for Aids Relief (PEPFAR) and the Bill and Melinda Gates Foundation, concentrate on more or less the same areas. The work done by each fund overlaps with other well funded concerns. There is very little money left for diseases and social problems that have existed for a long time.

I am not suggesting a conspiracy by big business to make sure that most donor money is spent on them. This is no secret. The money may be called donor money but it is being used as a de facto subsidy for pharmaceutical and other products. Industry lobbyists make sure that national and international laws favour their products and interests, often blocking moves by generic producers to launch far cheaper products.

Those who stand to gain from generous donor funding want all the money to be spent on them. The fact that more and more people are becoming infected with preventable diseases is irrelevant, except when this fact can be used to help squeeze out a bit more donor funding. If donor money ever becomes available in large amounts for presently neglected diseases, you can be sure that there will be companies soaking it up.

If you visit towns and schools in Kenya and Tanzania you will meet people who know more about avoiding HIV than they do about diarrhoea and colds. Some people can get hold of expensive drugs and condoms free of charge, but they can’t feed themselves or their families. There are children here who could tell you more about safe sex than many Western adults.

HIV in Kenya spread among people who had poor health, education, infrastructure and social services. Public spending was reduced in response to structural adjustment policies, starting in the 1980s. These policies are still in effect and many social indicators have been disimproving constantly for the last three decades.

Despite the concentration on HIV, large numbers of people in Kenya work without any security, for very low wages. Men often spend much of their time away from their families. Many people are reduced to exchanging sex for money, food or other commodities. These circumstances can all result in transmission of HIV and other diseases, in addition to their being social problems in themselves.

If donor money is used to chase after a few current obsessions, conditions for people will continue to decline. HIV is only one problem and whether infection rates go up or down, Kenyan people will face more and more problems as the years pass. This is because all but the most fashionable issues have been the recipients of donor funding and the ultimate recipients have been wealthy companies, not poor people.


Tuesday, February 10, 2009

Unrequited Sexual Desire

In 1942 the Irish poet, Patrick Kavanagh, published a long (and very beautiful) poem entitled "The Great Hunger". Despite sounding as if it refers to famine in Ireland, it is about sexual hunger. It was written in a social context where the eldest male member of the family would stay at home to inherit the land. He would not be able to marry until his mother died. Because his father would have gone through the same process, a woman would often be a lot younger than her husband. So the one who stayed at home would sometimes have to wait in vain because, by the time his mother had died, he would be too old to marry.

Kavanagh himself didn't go through exactly the same process as the protagonist of The Great Hunger, Patrick Maguire. But because of various circumstances, he didn't have the opportunity to get married until late in life. Very shortly after, he died. However, there is little doubt that he went through the same sort of anguish brought about by unrequited sexual frustration that Maguire goes through. Catholic taboos surrounding expressions of sexuality that existed at the time would leave someone like Patrick Maguire with few options that were not both illegal and highly immoral.

Things have changed in Ireland, though it took some time. Perhaps taboos are like that. The Catholic faith as practiced in Ireland is milder than it used to be, but the sort of Christianity propounded by a recent American president and many of his associates is anything but mild. Thus, distribution of money intended to prevent HIV and to support those infected with and affected by HIV is closely influenced by a rather narrow, fundamentalist interpretation of what it is to be a Christian.

In developing countries, an estimated 75% of HIV transmission is through heterosexual sex. This results in some donors assuming that all they have to do is make sure that fewer people have sex and that they have sex less often. Well, they may not put it like that, but that's the sort of assumption that underpins their prevention programmes. Sex that is not intended to result in conception is effectively ignored, because it just shouldn't happen. There is certainly no room for sex that is pleasurable. That, as far as such programmes are concerned, doesn't happen.

Even in academic literature on HIV transmission, you will rarely come across even brief mention of sexual desire as something that results in people having sex that may be unprotected or somehow involving risks. These risks could include transmission of HIV, some other sexually transmitted infection (STI), unwanted pregnancy or some other physical or emotional injury. Drivers of HIV transmission that are mentioned often include things like alcohol and illegal drugs, commercial sex work, ignorance about sex and sexuality, etc. Only occasionally is the lack of alternative pleasurable pursuits cited as a factor in HIV transmission. But at least that implies that sex is pleasurable.

So huge amounts of money are spent on the ABC (Abstain, Be faithful, use a Condom) 'strategy' of HIV prevention. The emphasis, especially for younger people, is on abstinence. This is despite confusion in native and second language speakers of English about why this particular term is used (aside from the fact that you end up with an acronym like ABC). In the unlikely event that a person has a (potentially sexual) partner to whom they are not married, the advice is to be faithful to that one partner. Again, confusion arises because people in Kenya, for example, associate 'faith' with religion.

Finally, if things have reached such a level of moral depravity that sexual intercourse is to take place and procreation is not on the menu, condoms can be used. Much of the money that goes to HIV prevention is earmarked for abstinence, some to being faithful but not very much to condoms. Condoms are distributed but they are not destined for younger people or even unmarried people, those who have most to gain from using them. They are mainly recommended for people who work in commercial sex, their clients and people whose regular partner is already HIV positive.

So you are faced with a group of people who want to know how to protect themselves from HIV and you rattle off ABC and the nitty gritty about each element. Sooner or later, the recipients of these nuggets of wisdom begin to ask questions, if there is still time and opportunity for that. You can field some questions without shocking the sensibilities of the affirmed Christians but sooner or later you have to face the big one: what about sexual desire?

Most people feel sexual desire at some time in their life, some do so very often, perhaps even most people. Which lofty precept is recommended first? I'm not suggesting that the imperative to abstain always falls on deaf ears. I am just suggesting that it may be trumped by the imperative to find some way of resolving sexual desire, because that won't just go away. It may be enough for some people to read their bible or think lofty thoughts but I suspect others will find this unsatisfactory. I've never found those to be helpful strategies, anyhow.

Well, you may be in the lucky position of having one faithful partner and to be with them at the time that desire strikes. Great, I hope you take all the precautions necessary, that you know about condoms and other matters and that anything you need is available to you. May it be a pleasurable experience for both of you. There may even be Christians who will not condemn what you do, or they may suspend their condemnation, somehow.

As for using condoms, there are many circumstances where this will not be an option. You may not have them, you may not know where to get them, your partner may refuse to use them. Worse, you may not have heard of them, you may not know how to use them or you may have bought the myth propagated by some religious leaders that there are holes in condoms or that they often don't work.

In countries where so called 'abstinence only' policies have been implemented, STI rates and unwanted pregnancy rates are among the highest in the world. An example of such a country is America, yet such policies are still supported by large amounts of public money. Evidence shows that these policies have little or no influence on the age at which people start having sex, the number of partners they have, or anything like that. Worse, recipients of such 'education' are far less likely to use condoms and therefore are at far higher risk of contracting an STI or getting pregnant.

Lack of evidence notwithstanding, similar approaches to sex 'education' were implemented in countries where people are unlikely to have any access to alternative sources of information about sex or sexuality. The result has been predictable, people continue to behave much as people have behaved since the beginning of time. At least to the extent that they have had sex. Well, they were still subject to sexual desire, weren't they? Which part of ABC has any influence on sexual desire?

After I started writing today, a friend sent me an article that found that some sex education programmes had limited influence on people's behaviour. But one found that participants reported increased sexual enjoyment. Later, I received a list of articles on sex and sexuality from the Institute of Development Studies in the UK. It's time for sexual desire and sexual enjoyment to be addressed in sex education programmes. Telling people about what could happen to them if they have unprotected sex doesn't give them any way of resolving their desire to do something pleasurable. It never worked for smoking, obesity, driving too fast, taking drugs, alcoholism or anything else seen as dangerous.

It's not sex that is dangerous; without it, the human race would have a bleak future. Disease is dangerous but there are ways of avoiding disease. Unwanted pregnancy is not desirable but there are ways of avoiding that, too. Pretending that sexual desire doesn't exist is not the way to make sure that people take precautions against contracting diseases and the costs of getting it wrong are too high. People have always had sexual desires and I assume they always will. They certainly don't deserve to be punished for this. In order to influence people's behaviour to the extent that they are not exposed to danger, it needs to be accepted that there are some things that can't be changed and some that can.

Kavanagh's conclusion, reached by bitter experience rather than analysis, was that there is nothing to be gained from self-denial but suffering and death. HIV and sex education policy cannot be allowed to conclude that what amounts to irrational self-denial is the only way to prevent HIV when there are many other, more feasible approaches to avoiding risky sex. Why try to plug up a sieve to hold water when you've got plenty of pots?


Wednesday, February 4, 2009

Disaster and Vulnerability

Tomorrow evening, if all goes well, I'll get a bus from Nairobi to Mwanza, arriving there some time the next morning. I'm very sad to leave Kenya and even Nairobi, although the city can be trying at times. The last three months have flown by but I have heard and seen many things, good and bad.

On the positive side, there are the people working to improve the lives of those around them, people working in organisations, often small and under funded organisations, also some people working on their own. There are so many ideas and initiatives and some people have the motivation to put them into effect and the determination to keep at it. And this despite the fact that much needed support can be a long time coming.

On the negative side, I have heard of politicians, police and others in positions of power abusing their positions. The results are all around us, millions starving, millions with curable diseases, millions more facing starvation and disease; and a handful of very rich people in big cars who appear on TV every evening to promise to make everything better and to blame something or someone else, lest anyone think they may have been responsible.

A recent haunting image on TV was that of a child scraping the remains of ugali off a big pot and eating it. There is a shortage of food in some areas, partly blamed on the post election violence, climate irregularities and various other things. But it has been known for a long time that famine is not just due to a shortage of food. Some of the food imported to alleviate the shortage just disappeared; some farmers are holding on to their stocks because the shortage of food may well continue, etc. This has all been building up and, like all disasters, it has multiple causes.

But one of the most awful things I have seen, perhaps in my whole life, is the film of the Molo fire, taken by someone on their mobile phone. In fact, it was less a matter of what you could see in the film and more a matter of what you could hear: people screaming and shouting, close by and far away. There were harrowing accounts in newspapers of the things people did to alleviate their suffering. I was so moved by them that the sight of a dead body (killed in a road traffic accident, yesterday) lying on the side of the road had little impact. It only made me think of the blackened bundles that marked the place where some people burned beyond recognition near Molo.

Incidentally, Molo is one of the places that suffered very badly during the post election violence of last year. If you drive through Molo Junction, you will see many charred remains of houses and premises and blackened squares and rectangles that were once buildings. There are still rows of tents nearby to house some of the many people displaced in the violence. But areas scarred by multiple problems are not rare, they are the norm. They are the areas where the most vulnerable people live.

One politician, George Saitoti, Minister for Internal Security, said publicly that the people who got burned had learned a lesson. Lucy Kibaki, the wife of the president, asked how people could have learned a lesson if they are dead. But another question is, who most needed to learn a lesson? The government is aware of the problems with the country's roads and emergency services, in particular. This is not the first disaster caused by such neglect, nor is it the first time that the ability to react to disaster was hampered for the same reasons.

The remark reminds me of a woman interviewed a few months ago because she had written a book about HIV with a provocative title, The Wisdom of Whores. She concluded that there are serious HIV epidemics in some countries because some people do stupid things. But she's wrong; people in all countries do inadvisable and risky things.

It's risky to have unprotected sex with someone you don't know, even with someone you do know. And it's risky to siphon petrol from a crashed tanker. But many people know they are taking risks, so it's pointless to tell them, especially if you don't offer them an alternative. If you need money, you will consider even the riskiest ways of getting it and the same may go for any other opportunity that arises.

In Kenya there currently crises (and scandals) relating to food, water, fuel, energy, health and many other things. But none of them are new. There have been warnings about all these issues for decades. Fires like the ones in Nakumatt and Molo and the lack of resilience that followed them can be traced to cutbacks at least as long ago as the 1980s, before many of the people who died were even born. The country’s health problems relate to similar cutbacks.

In contrast, all the politicians and many other powerful people around today were also around in the 1980s. It is they who should have learned lessons. Perhaps they, including George Saitoti, didn't learn lessons because they are not the ones who have suffered any of the painful consequences?

Saitoti shouldn’t be sacked because he could have prevented those two terrible incidents of last week but because he and his colleagues have spent several decades refusing to put in place the conditions under which accidents like that do not happen. He and his colleagues have failed to improve access to health, education, infrastructure and other social benefits and thus created a population of highly vulnerable people.


Sunday, February 1, 2009

Sun Worship and Self Reliance

A couple of months ago I had the pleasure of visiting a company in Nairobi that makes, demonstrates and sells solar cooking devices of various kinds; Solar Cookers International (SCI), based in Kileleshwa. These cookers can be used for more than just cooking. They are also great for pasteurising water for consumption, heating water for cleaning, drying foods to preserve them and various other things.

This has numerous advantages: it saves money spent on fuel, prevents destruction of trees and forests, reduces people's exposure to smoke and fumes, cooks food without denaturing nutrients, cooks without dangerous levels of heat, has a very low capital outlay, employs easy to find materials, and even recycled materials, to construct.

I also had the pleasure a couple of months ago of visiting a small community based organisation called Shining Hope for Community (SHOFCO), based in Kibera. They are involved in several projects that support community members. For instance, HIV positive women come to the headquarters several times a week and make bead jewellery which SHOFCO sells on their behalf. Young girls and boys do theatre and other performances to highlight issues that people in Kibera currently face, such as violence, HIV, water and sanitation problems and the like. They also distribute sanitary towels to girls and food to families, when possible.

On Friday, Solar Cookers International visited SHOFCO and spent the best part of the day setting up and demonstrating the process of cooking by sunlight. As a matter of fact, setting up a simple cooker takes seconds, but a number of different styles of cooker were demonstrated. The food was bought and prepared and after around three hours (there was a fair bit of passing cloud to interrupt the vital process!), ten or twelve of us sat down to copious amounts of rice, vegetable, sweet potato, ugali, meat and tea. There was even lots of hot water to do the washing up afterwards.

Before the preparation started there were some sceptical faces, but everyone was fired up by the prospect of seeing this process in action and the added treat of a hearty meal. Faustine and her colleagues from SCI made sure that everyone had a hand in peeling, scraping, chopping and preparing the food. This gave her the chance to insist on rigorous handwashing and care when preparing food. By the time people had got down to the work, they had forgotten their doubts and it wasn't long before the smell of food cooking reassured the doubters.

There was then time for us to go inside and shelter from the blazing sun and discuss what we were involved in. Faustine got people to volunteer answers to questions arising about why anyone would want to use solar cookers. Indeed, people came up with most of the reasons themselves, with little prompting. There were also some welcome questions about some of the drawbacks of these cookers. For instance, what if you are in a hurry, what if it is dark or cloudy or raining?

The answer is that you can't use them under such conditions. The answer is in the question, really. You then need wood, charcoal, kerosene, gas, whatever else you can use for cooking. But even in Nairobi, where there is not all year round sunshine, you could still save yourself a lot of expensive fuel. It's just one technique. Not far from SHOFCO there are people experimenting with biogas. Others use photovoltaic panels, which allow you to charge up batteries to be used later.

When I originally visited SHOFCO I asked them what income generation schemes they had. They mentioned that they made bead jewellery, and that is the main one, at present. Just as solar cookers can't be used when it's raining, bead jewellery can't be sold when there is little or no market. Women make the jewellery but there are few tourists this year because of the post election violence last year. While it is sometimes possible to sell things abroad, markets are difficult to access and not too reliable.

It's still too early to say, but hopefully solar cookers will provide income generating opportunities for organisations like SHOFCO. They could sell, demonstrate or perhaps even make solar cookers. The market is on their doorstep. They will be selling to other Kenyans and benefiting the broader community, not just themselves. There are many other community based organisations that may also be interested in solar cooking.

But there are other technologies that save people money and can even make people money. It's just a matter of people getting together, sharing their ideas and putting them into action. After the solar cookery demonstration, the drama group went to rehearse for a performance. This performance will involve people walking through a market and stumbling upon a solar cookery demonstration. They start off sceptical but gradually see that there is something very interesting to be learned.

Before SCI left SHOFCO, members of each organisation had discussed projects that could be mutually beneficial. I hope those projects are realised. As I said, it's early, but I'll keep in touch and look forward to hearing what happens.

On a similar theme, yesterday I travelled to a village near Thika to visit an orphanage called Watoto wa Barakai (Blessed Children). There are 25 children there but a far larger number of orphans are supported while living with relatives. The place is more like a big family living on a small farm, a beautiful farm. They have cattle, pigs, rabbits and various food crops and they are expanding fast. The people running the orphanage have been very enterprising and have raised a lot of money for the expansion and development.

More importantly, they are interested in sustainability, in particular, in the area of cooking. Trees in the area are being cut down and not replaced. Fuel is expensive and the children (and adults) suffer from respiratory problems. Respiratory problems underlie a huge number of deaths in Kenya, especially among infants and children under the age of five. People running Watoto wa Baraka had already started researching potential technologies, they already have a solar shower and a photovoltaic panel to light one of their buildings. They harvest rain and consider the sustainability of all their projects.

Many people are inspired by intermediate technologies but only some adopt them, ultimately. I think Kenya will only develop if Kenya do the developing and that in many cases, the less Western countries do, the better. Perhaps intermediate technology will be one way that developing countries can become more self reliant.