Friday, April 30, 2010

One Laptop Per Child: But What About the Teacher?

It's quite a few years now since someone came up with the idea of giving a cheap laptop to every child in developing countries. The price mentioned was $100 and the laptop would have a device for winding it up for when there was no power, it would be robust against harsh treatment, dust, heat, humidity, etc. It would be simple but attractive and have everything that a child could want in a computer.

Well, such a laptop has been available for some time, but those who came up with the idea have not been able to persuade funders or governments of developing countries to order the things. They were hoping for orders of about one million at a time but they haven't even offloaded 2 million of them yet. The laptops come with Linux and Windows preloaded but they are selling for over $200. I'm not sure how much more than $200.

Some will remember, it's only a few months ago, that both Britain and the US governments decided to withold funding earmarked for education in Kenya. It was a paltry amount, less than $40 million in all. But many people here are having problems paying for school fees and costs because the so called free primary and subsidized secondary education still cost more than a lot of people earn.

There are about 9 million school children in Kenya at the moment. The figure should be a lot higher because some are not attending, though how many is anyone's guess. The money being witheld sounds like only a few dollars a head. But most schools are underequipped and understaffed. Infrastructures that the schools need are crumbling or non-existent, for example, electricity, water and sanitation. Even roads are appalling and transport to and from school is one of the biggest hurdles children have to face, to say nothing of the costs to their parents.

But the one laptop per child scheme, OLPC, that's a substantial amount of money. And they are hoping to raise the money for 30 million of them for the whole of the East African Community. Two hundred and something dollars could pay all the costs that are levied but not considered to be school fees, along with quite a number of other items. Books, for example, are in very short supply. Kids often come to school without having done their homework because they have no book (or because there is no lighting at home).

It's not that I don't think children (or adults) in developing countries should not have such a valuable tool as a laptop, it would be great if everyone had one. But I wonder if it's such a priority. So many infants and under fives are dying of preventable and curable diseases because of conditions such as poor sanitation. Malnutrition is rife and causes growth stunting and retarded intellectual development. And the list is endless.

Not only are there many things children need that would put laptops quite low on the list of priorities, but a lot of the things they need are quite cheap. For the sort of billions that are being proposed for OLPC, a lot of childhood health conditions could be prevented or cured. Children could go to school with things like books and other tools. Girls wouldn't have to stay at home several days a month because they are having their period. And pupils could have enough food to prevent them from falling asleep during classes or just not going to school at all.

Children have a lot of things to grasp when they are young, reading, writing, languages, mathematics, sciences, etc. It's easy enough to see how laptops could be used to help with this. But I have a suggestion: give free laptops to teachers in teacher training schools (who also lack the books they need, sometimes); teach them how to use laptops and how to teach with them. Then roll them out that way. Instead of spending the $6 billion dollars or more on giving tens of millions of children laptops, make sure the educational system is ready for the laptops.

There is no point in just spilling out a few more million to give a laptop to teachers as well. They have to be taughted how to use them and how to teach with them. When I was doing an MA at a London University college just a few years ago, an institute of education, no less, some of the academic staff there had no idea how to use computers to teach, so why should people who have never had the opportunity to even use them? In fact, teaching with computers comes with some huge pedagogical hurdles.

Frankly, I think the project stinks. But it could be turned around, it hasn't even started yet, to make African countries among the first in the world to use a laptop as their main teaching tool in primary and secondary education. Ok, training the teachers may not iron out all the problems of trying to do without books and other everyday teaching materials. But it sure as hell won't work if the teachers get no training (and no laptop). If you can raise that much money, OLPC, don't blow it on the laptops alone. It's not as if the laptops can be recycled if the project goes pear shaped.


Wednesday, April 28, 2010

Pills For Poverty

An article in entitled Don't Medicalize Micronutrient Deficiency argues that biofortifying foods or handing out food supplements is not a sustainable solution to malnutrition problems. Countries that have high levels of malnutrition have food and agriculture problems that pills or fortified foods will not solve.

This is a timely reminder, when so many 'solutions' come in the form of technical fixes that are often expensive, short term, inappropriate, unsustainable and often don't even work. I recently mentioned Bill Gates efforts to eradicate water borne diseases like polio, malaria and cholera by developing vaccines when the best strategy would be to improve water and sanitation. Water borne diseases can not be eradicated in areas where people don't have access to clean water and adequate sanitation.

Another problem with certain biofortified foods is that they have intellectual property rights associated with them, which adds a lot to their cost. Why should poor people suffering from nutritional deficiencies, instead of being enabled to produce enough high quality food, be offered something that is expensive and is just impoverishing their country further?

Some of the manufacturers of genetically modified organisms (GMO) have even got in on the micronutrient method of screwing yet more money out of developing countries. The vitamin A fortified rice, which was claimed to reduce blindness caused by vitamin A deficiency, springs to mind. Unfortunately, it contained vitamin A in a form that could not be absorbed and so it was a useless technology.

Poverty is the real problem when people can't afford a balanced diet for their family. If they are poor, they are certainly not going to be able to afford with the sort of premium price that intellectual property brings. And we have seen enough instances of poverty, disease and malnutrition being used as vehicles to sell expensive Western technologies, especially dangerous technologies that impoverish people further and that could even damage their health.

The attitude of multinationals, and that of certain people, seems to be to let people become sick and then come running with the pills or the GMOs or the technical solution. People need adequate economic means, food, food security, education, health services, water, sanitation, housing and the rest. In the absence of these human rights, they will suffer and die prematurely.

It may be the prerogative of multinationals and others to allow people to live in inhuman conditions as long as they can sell plenty of their goods. But it is not the prerogative of those who work in development or those who work to keep in check the excesses of multinationals. As the article in question points out, many of the people in the world suffering from malnutrition are farmers. They should be allowed to produce food that can provide themselves, their families and their countrypeople with a balanced diet. This would also improve economic circumstances and therefore health, education and other things, too.

If someone prescribes pills as a substitute for clean water or good food, they are probably a multinational.


Monday, April 26, 2010

Philanthropic Tokenism

Apparently Zanzibar succeeded in eradicating malaria in the 1970s, but it returned. Now they are about to eradicate it again, or at least, rates are far lower than they have been for a long time. However, there seems little chance that they will succeed in keeping malaria down for good.

Zanzibar, like many places in Africa, has problems with garbage disposal, sewage disposal, water, hygiene, infrastructure, especially roads and electricity, education, housing, poverty, health and many other things. These are the conditions in which a disease like malaria thrives. It is fairly certain that unless Zanzibar tackles these problems, malaria and other deadly (though preventable and curable) diseases will continue to be endemic.

The world was told that polio had been all but eradicated in the last few years and in a short time there would be no further cases. But polio has returned, partly because of a boycott on vaccinations in Nigeria due to rumours about their safety. As a result, there is talk of changing the polio eradication campaign from its present 'vertical' strategy to a more 'horizontal' strategy.

A vertical approach takes one disease and aims to vaccinate everyone who may be infected and, if possible, treat those who are already infected. A horizontal approach aims to provide health services for everyone and sees all diseases as being in need of prevention and/or treatment.

Realization that vertical approaches are not working and that horizontal approaches don't carry the kudos of being able to eradicate a whole disease gave rise to talk about health system strengthening and even 'diagonal' approaches, that would combine the horizontal and the vertical. Unfortunately, much of this has remained just talk.

There is even talk of Bill Gates taking a less vertical approach to polio eradication or risk seeing hundreds of millions go to waste. But I find that hard to believe. I don't think Gates lacks understanding of why polio (and other diseases) elude single disease approaches that involve some kind of expensive, technical fix. All he has to ask himself is why people are being infected by a disease that is spread through human feces. To put it another way, why are people drinking contaminated water?

Gates is fond of talking about water and sanitation but most of his money goes into things like vaccines. Indeed, much of it goes into US institutions and US citizens working on vaccines. Very few broad-based water and sanitation programmes, aimed at preventing all water borne diseases, are being financed by Gates.

Gates can spend his money and fail to eradicate polio or cholera or malaria or any of the diseases that he wants to be associated with eradicating. But as long as the water is contaminated, all his programmes will fail. As for his ideas on how to make the polio programme more 'diagonal', all that's mentioned is "training for health workers on topics such as hygiene and sanitation". Hygiene and sanitation are not just things people need to know about, they are things people need access to. It's no use health workers telling people to wash their hands and dispose of their faecal waste properly when they don't have clean, running water and adequate sewage disposal systems.

Maybe Gates will get involved in genuine 'health system strengthening', but just paying a few professionals more to work in his funded institutions is not going to help. That has just increased the brain drain from indigenous health institutions and taken attention away from health in general to concentrate on his favourites. But it seems more likely that he will continue to do what he is doing and put even more money into spin. After all, he has his agenda and evidence from the field has never affected that.

Diseases are not trophies and global health is not a matter of having a wall covered in certificates for attempting to eradicate a small number, or even a large number. Health depends on other crucial rights, such as food food and food security, water and sanitation, adequate living conditions and good education. Without these, throwing money at a handful of diseases will have little impact. Maybe some disease will be wiped out, or as good as, but people will continue to die of other preventable and curable diseases. Gates should work for human rights, any human rights or even all human rights. Instead, he's just wasting his money on philanthropic tokenism.


Sunday, April 25, 2010

Why is HIV Stigmatized and How Can We Reduce Stigma?

When HIV was first identified as the virus that causes the syndrome now known as Aids, it was quickly established that it could be transmitted through exchange of bodily fluids, blood, semen, breast milk and through other routes. This means that it can be transmitted through sexual contact, through blood contact (during medical and cosmetic procedures, also by intravenous drug users) and from mother to child (also called vertical transmission).

Nearly thirty years later, sexual transmission is still the mode of transmission that gets the most attention. The received view, supported by organisations such as UNAIDS, the WHO and others, is that the vast majority of HIV positive people in African countries were infected through some form of sexual contact. Of course, many probably were. But heterosexual transmission is not the most efficient mode of transmission. In fact, it is a relatively inefficient mode of transmission.

Mother to child transmission is an efficient mode of transmission without medical intervention. But with medical intervention, transmission is low, even in developing countries. Now, in countries like Kenya, an increasing number of pregnant women are being tested for HIV as soon as they start attending ante-natal clinics. They are usually monitored and treated if they are found to be HIV positive in order to prevent transmission of HIV from mother to child.

However, exchange of contaminated blood is a very efficient mode of transmission, whether it occurs through intravenous drug use, a visit to the doctor or even a visit to the beautician. One hopes that all the public information and education there have been about the risk of contracting or transmitting HIV through exchange of blood would make people aware of these risks, whether they are drug users, health care workers, patients or clients of hairdressers.

But as I have said, sexual transmission is the mode that has received the most attention. It has and continues to dominate HIV prevention programmes with any other modes of transmission receiving far less attention, if any.

So what is the meaning of the received view of HIV, that 80-85% of it is transmitted sexually? In particular, why would HIV prevalence in Greece be .008% when prevalence in Kenya is 8% and prevalence in Lesotho is 28%? Does this mean that Greeks have orders of magnitude less sex than people in Kenya and Lesotho?

Well, for a start, UNAIDS distinguishes between generalised and concentrated epidemics. Countries with generalised epidemics usually, but not always, have high HIV prevalence, above 1%, and affecting people who are not in groups thought to be at especially high risk. Those at high risk include men who have sex with men, intravenous drug users and commercial sex workers. Greece has a low level, concentrated epidemic. Those infected in Greece are almost all in one of those high risk groups.

In contrast, Lesotho and Kenya have generalized epidemics. According to UNAIDS, the WHO and others, sexual behaviour explains high prevalence of HIV in these two countries, but not in Greece. They say that risky sexual behaviour such as unprotected sex, high numbers of lifetime partners, high levels of concurrency (having sexual relationships with several different people where those relationships overlap to a significant extent) and others are responsible for the terrible HIV epidemics of the sort found almost exclusively in Sub-Saharan African countries.

The claim, then, is that people in these countries indulge in more risky sexual behaviour, but how much more? It would need to be a great deal more but there is little or no evidence to show that this is the case. Rather, when people are diagnosed as HIV positive in African countries, it is assumed that they were infected sexually, either by their main partner or by some other sexual contact. If their partner turns out to be HIV negative it is assumed that they had sexual contact with someone else.

Many people have been diagnosed as HIV positive and it has turned out that their partner is HIV negative. It is then assumed that the HIV positive partner, often the woman, had an affair with someone else. If she denies this, it is assumed that she is lying. Although that’s the case in Kenya and Lesotho, it’s unlikely to be the case in Greece or any other Western country. The assumption that people are just lying partly stems from the received view: that 80-85% of HIV is transmitted sexually in countries with generalized epidemics. Some may lie, but some may lie in Greece too. So how many instances like this have been investigated? In African countries, precisely zero.

Consider another phenomenon: infants and children who have been found to be HIV positive when their mother is not. It’s harder to claim that so many infants and children have been, one, sexually assaulted, two, sexually assaulted by someone who is HIV positive and three, that they were infected as a result of this sexual assault. South Africa recently found quite a worrying number of HIV infections among children who were not sexually active and whose mothers were not HIV positive. Further research was called for, into the possibility of sexual assault and the possibility of medical transmission. Neither, as far as I know, has yet been carried out.

Accepting that HIV is mostly transmitted by heterosexual intercourse means accepting that a lot of people are having a lot of unsafe sex with a lot of other people over a long period of time. It involves accepting that this happens in Sub-Saharan African countries to an extent not found in most other countries, indeed, to an extent that is just not credible.

If unbelievably high rates of risky sex are a figment of the imagination of those who work for or who follow the pronouncements of UNAIDS and WHO, what could account for all the generalized epidemics in Africa?

A number of suggestions have been made (by those who dare to diverge from the received view). Some have suggested that low levels of health care and education and high rates of poverty in many African countries make people more susceptible to HIV infection. But, while it is true that these circumstances are found in many African countries, they are also found in countries where HIV prevalence is far lower. And even in African countries, HIV prevalence has often been higher among the rich and well educated.

A better suggestion is that high rates of disease and low levels of nutrition make people more susceptible. Many preventable and treatable conditions, such as TB, malaria, human parasites and certain sexually transmitted infections have been shown to significantly increase the risk of HIV transmission, especially sexually, though also through blood contact and through vertical transmission.

But then this doesn’t really explain why well off and well educated people were infected in greater numbers than poor and badly educated people, especially in the early stages of the epidemic. Well off and well educated people would be less likely to suffer from these conditions and would have had better access to healthcare.

It’s time for people to question the idea that inordinately high levels of unsafe sex in certain African countries can fully explain the high prevalence of HIV found there. We need to re-examine all other modes of transmission, especially where blood exposure could be involved. Barbers’ and beauticians’ shops don’t always look too sterile. But nor do hospitals and clinics. Putting it a different way, it must be wondered how the sort of badly equipped, understaffed, overcrowded facilities found in African countries can avoid transmitting HIV and other diseases, at least sometimes. Questions about the safety of health and other facilities urgently need to be raised.

The received view, that 80-85% of HIV transmission in Sub-Saharan African countries has been through sexual contact, can not be correct. How much can truly be put down to sexual transmission is unclear because a lot of the research has just not been carried out. What research has been done has been ignored because it contradicts the received view. But we owe it to people who are HIV positive, despite never having engaged in unsafe or illicit sex, to do this research. We owe it to everyone who is HIV positive because we don’t know how they became infected. They may not even know themselves. The stigma comes from an assumption that we are not entitled to make.

If, as some people would argue, a substantial amount of HIV was transmitted by non-sexual means, perhaps a lot by medical transmission, this could explain why HIV reached levels where even sexual transmission started to become far more significant than in other countries, where prevalence remained low. Most children and pregnant women, especially, receive a lot of injections and other medical treatment and a very common form of contraception is given by injection. And many other people in African countries also receive a lot of injections, for example, commercial sex workers and men who have sex with men. The highly efficient transmission of HIV that would occur through blood exposure could quickly spread an infection to many people. There is no evidence that the same rates of transmission could occur through sexual transmission alone, even if risky sex was as common as claimed by the received view.

Reducing stigma is always going to be a difficult task, whatever its target. But it should be easier to reduce stigma once it is clearer how HIV really reached such high levels of prevalence in some countries and not others. Sexually transmitted HIV could only have infected large numbers of people once a high prevalence of HIV had already been reached through some other mode. Research to establish how HIV reached present levels is urgently needed, starting with medical and cosmetic transmission.

HIV is stigmatized because of the received view that it is mostly transmitted by heterosexual sex in Sub-Saharan Africa. However, rates of unsafe sex would need to reach incredible levels for this received view to be correct. Though stigmatizing sick people should always be avoided, there must be other reasons than sexual behaviour to explain why HIV prevalence is so high in some African countries, reasons which would show that this stigma is misplaced. Those who are infected through non-sexual routes, of course, can also go on to transmit HIV sexually. Therefore, a large amount of sexual transmission, which can occur once HIV infects a critical percentage of the population, can also be partly attributed to non-sexual transmission. Some, perhaps most, of this non-sexual transmission may come from unsafe medical and cosmetic practices.


Wednesday, April 21, 2010

Unnatural Disasters: GM and Biofuels

In an article about the highly suspect arrival of 40,000 tonnes of genetically modified (GM) maize in Kenya's Mombasa port, the BBC concludes "Many African countries are under increasing pressure to grow GM crops to tackle hunger and malnutrition, and drought in recent years has caused food shortages in Kenya."

This is very misleading, in several ways. Multinationals like Monsanto, which are having a lot of trouble persuading most countries to trust their attempts to take over world food production, want people to think that GM crops provide a solution to hunger and malnutrition. They want people to believe that their crops are resistant to drought, flooding, pests and whatever else. But none of these things are true. They have not developed crops that have any of these qualities.

Further, it has taken more than just drought to cause Kenya's food shortages. Much of Kenya's productive land is taken up with non-food or non-staple crops, such as sisal, flowers, tea, coffee, sugar and luxury fruit and vegetables. Most of these crops are for the export market. People cannot afford to buy food because they are poor. Because they lack empowerment, they do not have much choice as to what crops the country grows. And most people don't own large amounts of land, producing just enough to get by, if they are lucky. On the other hand, most of the industrial scale farms are owned by very few, well connected people, many of them foreigners.

The BBC article seems to take it as given that GM crops could play any part in reducing hunger and malnutrition. This couldn't be further from the truth. Most Kenyan farmers are subsistence farmers. GM crops were developed for rich farmers, mainly in the US. Some South Africans have fallen into the trap of accepting 'free' GM seeds and other inputs from the likes of Monsanto. Now they are stuck with contaminated land, crops they can't sell, rising input costs, shrinking profits and increased poverty and dependency levels. That's great if you're Monsanto but not so good if you're a small farmer.

This is probably the reason that the unwanted GM maize has ended up in Mombasa in the first place, but many Kenyans are wondering what it is doing there. Well, unless South Africans and some of the other poor fools who have been duped can now dupe others to take GM crops off their hands, they will have trouble shifting it. They have a surplus of maize in South Africa, which is bad enough, but a surplus of contaminated maize could prove to be a very hard sell.

High food prices, which are the real cause of hunger and malnutrition in Kenya and other countries, have a lot more to do with international speculation in staple food commodities. This speculation has recently been spurred by attempts by biofuel producers to buy up land cheaply in developing countries to produce yet more non-food crops or food crops that are destined for the petrol tanks of rich people. [Reuters have an interesting article about potential dangers of biofuels that the EU commissioned but subsequently 'forgot' to publish.]

Drought, flooding, pests and other phenomena can destroy crops and cause widespread poverty and starvation. But rich countries treating developing countries as mere inputs for the production of cheap raw materials, using cheap labour, is the real culprit in many of the famines and food shortages that are labeled 'natural' disasters. The real disasters are far from natural. They are artificially created for the benefit of the world's multinationals, the rich, the powerful and even those who just happen to live in the more fortunate countries.


Tuesday, April 20, 2010

Mining, Biofuels and Other Forms of Abuse

I'd like to follow on from yesterday's theme about developing countries being used to provide wealthy countries with cheap raw materials and labour. These developing countries are never helped to or even allowed to produce their own higher value goods so that they can improve their economies. On the contrary, wealthy countries go out of their way to ensure that poor countries stay that way. Several recent articles discuss other ways in which developing countries are held back from developing.

The European Community (EC) has set a target to source 10% of its energy from renewable sources. Rather than look for genuinely renewable source, the EC has latched on to biofuels as a means of achieving this target. Warnings were raised about the dangers of biofuels as long ago as 2004 but no one was listening then and few are listening now. Biofuel prospecting has gone on, as predicted, to destroy vast tracts of land, increase the prices of fuel, dispossess people of their land and livelihood and cause numerous other social and economic problems.

Like the US, the EC preaches against the use of subsidies. Yet they subsidize biofuel production (and anything else that suits them). Growing biofuels cannot be sustainable, there just isn't enough land, even if everyone in Tanzania and other developing countries are thrown off their land to grow the crops. Growing, processing, transporting and using biofuels does not reduce carbon emissions, they increase it. So even the rich countries are not gaining much by their quest for biofuels. Somebody must be making money out of it but Tanzanians and people in other poor countries will suffer increased poverty and hunger as a result. And there will be global level losses too.

In addition to having a lot of land, which rich countries are busy grabbing right now, Tanzania also has a lot of minerals, especially gold. But various murky deals mean that the country makes very little money out of these resources. Most of the money is made by foreign owned companies, especially companies from Canada, South Africa and the UK. The royalties Tanzania gets are tiny whereas the profits the foreign companies make are huge and are amply enhanced by the privileges and tax incentives they receive at the expense of poor Tanzanians and even indigenous Tanzanian companies, who are unable to compete with the foreigners.

Despite mining companies having a deplorable human rights and corporate responsibility record, laws, neither Tanzanian nor international, do not adequately protect those who have to work for the industry. In particular, laws do not protect those who lose their land, those whose environment and water supply are contaminated and those who formerly made a living as artisanal miners. Tanzania has enough valuable resources to improve the living conditions for all Tanzanians but the revenue from these resources always seems to leave the country. All that ordinary Tanzanians get is the pollution, the industrial problems and the social problems, the majority remaining very poor.

In Kenya, similar things are happening. Land is being grabbed to be used to produce food and biofuels for rich countries. This viable land is currently occupied by Kenyans but is being sold as 'unoccupied' and 'marginal'. Whole ecologies are being destroyed to produce unsustainable crops for the benefit of non Kenyans, but at the expense of Kenyans. The Kenyan government appears to be doing little to protect its citizens and seems to be keen to promote the interests of this land grabbing. As if things were not bad enough in the worst affected area, the Tana River basin, Tiomin are going to do some kind of mining there, a Canadian company with a disgraceful record of wanton destruction.

The only good news is that a few hundred families in the Tana River basin have been awarded 2.55 million Kenyan shillings each as compensation for their land. Unfortunately, the people involved were displaced for environmental protection reasons. It seems unlikely that there will be any compensation for people displaced to make way for the miners and land grabbers. WTO rules tend to defend such land grabbing and resource exploitation, protecting only the interests of the very rich. Condemning vast populations to generations of poverty, disease, dependency and degradation is all in a day's work. It's been going on for a long time and it's not going to stop now, not as long as there is money to be made.


Monday, April 19, 2010

Aid is But a Tiny Fig Leaf

While the Icelandic volcanic cloud means that people in Europe are having to cancel or postpone trips or find alternative ways of returning from trips, Kenyans are worrying about what is going to happen to their perishable produce, such as flowers, fruit and vegetables. Europe is their biggest market. Although owners of these industries make huge profits when things are going well, the employees, who make a pittance, make nothing at all when something prevents produce from getting to market.

At the same time, the BBC comments on a report that finds that the UK imports a lot of its water from other countries in the form of produce such as flowers, fruit, vegetables and other goods. Much of this imported water comes from developing countries, such as Kenya, where clean water and sanitation problems are responsible for high rates of avoidable mortality, especially among infants and children, and numerous treatable and curable illnesses. The report estimates that two thirds of the UK's water use is imported.

The mass production of non-seasonal food and non-food crops by developing countries results in much of the starvation that the UK and other rich countries seem to see as 'natural disasters', to be remedied by a sticky plaster, some handout or even a 'deal' of some kind that is calculated to do more harm than good (it benefits the donor, of course). Yet the industries that claim to be such a great source of foreign currency, fruit, vegetable and flower industries, are mostly foreign owned, British owned, in fact. They pay little or no tax in Kenya and, being offshored, little in Britain either.

When a country like Kenya starts to realise that their 'cash crops', such as tea, sugar or coffee don't make them much money, they seem to reach for another cash crop. The Kenyan cotton industry (along with that of many other developing countries) was wrecked many years ago by the US cotton industry successfully lobbying for subsidies to support them so that no developing country could compete. Subsidies are bad, according to the US, except when they are US subsidies. Sadly, Kenyans are calling for their government to help them return to cotton production. But this is unlikely to fly because US cotton is still subsidised to such an extent that no developing country can produce it as cheaply. And this is despite Kenya having pay and working conditions that would make Bill Gates proud.

But cash crops have always made very little money. Many of them here are grown as part of a kind of agreement that was formed with British land 'owners' after independence. They were allowed to keep their land and those Kenyans producing their (the colonial's) crop, tea, for example, were bound to go on producing tea. The law is slowly changing so that people may be allowed to stop producing tea and produce some food instead (God forbid!). But with sugar, the factories are demanding that even more land be given up to it so they can produce biofuel. Never mind that those whose land the sugar cane is planted on make little or no money from it.

It may well be wondered why farmers produce a non-food crop when they are starving and these crops don't make any profit for them. Well, aside from the promise to keep producing crops that only profit foreign companies, such as Unilever, farmers can't afford the inputs to grow food. They could make a lot of money from growing food and feed themselves at the same time. But as the government does little to support subsistence farmers, only being able to help the rich industrialists with tax breaks and other preferential conditions, farmers have to accept the generous offers from the likes of sugar companies to meet some of the costs involved. In the end, the farmer does all the work and gets little remuneration, if any. And they and their families starve.

Biofuels, like all the other luxury and non-food crops produced in developing countries, effectively export unthinkable amounts of water, along with vast tracts of land. The 'natural' disasters of flooding, drought, famine and the rest, are not as natural as they are painted. Rather, they result from explicit policies and agreements that keep things cheap for people in rich countries, profitable for foreign companies, and if any of those people in developing countries start complaining we can always point to the aid money we send them, whatever aid money even reaches the majority of people.

It's no secret that rich countries steal water from developing countries, preferring to feed ourselves luxuries and run our cars than allow undernourished and starving people to eat. But we steal a lot more than that. The majority of people in Kenya are subsistence farmers or workers. Even those who have jobs usually work for very little so that those in rich countries can afford cheap raw materials and goods. Many people have next to nothing, and that seems to be the way we in the West like it. And in return for extracting what we can, we send a little money every now and again and think of ourselves as very philanthropic indeed.

There is an alternative to rich countries sending ever increasing sums of money to developing countries. That is to identify some of the ways they extract even larger and faster increasing sums of money. That way, Kenya could be assisted to develop its own flower businesses. They could produce and process fruit and vegetables, thereby making more money from them. They could choose what crops to grow and in what quantities, especially crops that could be used to produce high value goods. In fact, the list of things that constitute extraction of wealth by rich countries from countries like Kenya is very long. Then Kenyans will be in a position to tell us what to do with our aid.


Saturday, April 17, 2010

Health Aid: Supporting People or Supporting Indicators?

While news that maternal mortality has been decreasing since 1980 has been welcomed by many, others point out that a significant contributor to maternal mortality is HIV. A lot of attention and resources go towards mother to child transmission of HIV (MTCT), but very little go towards the health and survival of the mothers. Concentration on the single indicator of numbers of infants infected by their mothers, also called vertical transmission, seems to have left the health of HIV positive mothers out of the picture.

Of course, it is madness to ignore the HIV status of the mother, for many reasons. For a start, mothers are people too, not just 'cases' or carriers of disease. They, like their children, husbands and other family members, are entitled to health and to treatment when their health is compromised. And it would be madness too to ignore any other diseases, in mothers and children or anyone else. But health funding is mad. Hence the selection of a few headline grabbing indicators.

HIV positive mothers can go on to transmit HIV to their infants at a later stage, through various routes, or to their partners. They are at risk of dying from Aids related illnesses or of suffering from serious and prolonged illnesses. These will also have an impact on the health of their children and other family members. Even the MTCT prevention treatment (PMTCT) can lead to drug resistance in mothers. In developing countries this can seriously affect the chances of the mother being successfully treated or cut the length of time that the treatment remains effective.

It seems extraordinary that health funders still take this piecemeal approach to disease reduction, even when it directly affects their chosen indicator(s). Unsurprisingly, the report was funded by the Gates Foundation. They particularly favour somewhat rarefied approaches to health issues, selecting the bits that they are interested in and leaving the rest. For example, the foundation is interested in finding a vaccine for cholera but not so interested in clean water and sanitation, which could reduce incidence of numerous water related health issues. (They give small amounts of money to water and sanitation projects but nothing like the amount going to vaccines and the like.)

A particularly worrying aspect of approaching MTCT in this piecemeal fashion is that as many as half of infant infections may result from mothers who were infected while they were pregnant or whose positive status was not detected while they were pregnant (perhaps because they were in the 'window' period, where they had not yet seroconverted). This occurred in a PMTCT programme in Malawi, considered to be one of the best. Another survey found that such missed maternal HIV infections resulted in a high percentage of infants being born HIV positive. Ironically, the paper also concludes that recently increased child mortality rates in KwaZulu-Natal could be caused, in part, by increased maternal mortality.

It has been suggested that this may be a potentially useful role for pre-exposure prophylaxis (PrEP). PrEP involves putting HIV negative people on antiretroviral drugs, usually where they are thought to be at particular risk of infection. Of course, some of these women may not have been infected through sexual intercourse. It is not even clear from the article whether the mothers of infants subsequently found to be HIV positive were also re-tested or were just assumed to be positive because their infants were. Apparently, an unusually high percentage of women who were not found to be HIV positive before delivery were later found to have HIV positive infants.

Concentrating on one disease or on that disease in one demographic, or even looking at absence of sickness as the only criterion for health, is not going to ensure the health of whole populations. The dominant approach to HIV and the almost universal adherence to the behavioural paradigm (the view that the disease is predominantly sexually transmitted) is wrong for many reasons that have been made clear, in particular, by our lack of success in significantly slowing the pace of transmission. It's time to look at HIV as being part of health as a whole, as being related to the totality of conditions in which people live and work.

If we continue to fail to ensure good health services, education, nutrition levels, food security, infrastructure and numerous other conditions, all diseases, including HIV, will continue to spread. This will reduce people's quality of life and life expectancy. Self serving reports that show how well some favoured indicator is doing should be seen for what they are. Billions of people still suffer from and die from preventable and treatable diseases every year. That's nothing to celebrate.

(For further discussion of PrEP, see my other blog,


Friday, April 16, 2010

Oxfam Abandons Development, Goes for Corporate Lobbying

It is easy and sometimes even right to criticize NGOs, especially big, well funded ones, for spending a lot of money on dubious programmes, such as technical aid that may only benefit a handful of rich Western 'experts'. But when it turns out they are using their money to support one of the most destructive agricultural processes to date, genetically modified organisms (GMO), it's hard not to be very angry. Yet Oxfam America seems to have been nobbled by the biotechnology industry and its supporters, the Rockefeller Foundation and the Bill and Melinda Gates Foundation.

Of course, Oxfam have pulled out the poverty and food security cards to make it look as if GMOs are just the solution they need. But production of GMOs requires industrial scale farming practices. Although these are found in developing countries, those involved are not poor farmers. Most farmers in developing countries are subsistence farmers. They cannot afford the sort of inputs required by GMO farming and where they have fallen for the lies and taken on GMOs, they have ended up in debt. In addition to the inputs being very expensive compared to non-GM inputs, yields at the subsistence level have not been higher, indeed, they have often been lower. So GMOs, despite claims to the contrary, do not scale down.

This is not to suggest that large scale GMO farming has been successful either. In the handful of countries where this has been practiced, the US, India, Australia, Canada, Argentina and a few others, yields may have increased for the first few years. But input costs have also risen, especially pesticides and fertilizer costs, and yields flatlined or decreased after that. US GMO farmers, especially, are finding out what it's like when superweeds take over, weeds that develop resistance to even huge applications of herbicide. And Indian farmers have found what it's like when pests develop resistance to the GMO industry's noxious sprays. Even Canada is realising what it's like to face blacklisting by many of the countries who have been buying their agricultural outputs because of contamination by an organism that has been banned there for years.

So what does Oxfam think they are doing, trying to trick the very people they are supposed to be helping? This may be related to funding they have received from Rockerfeller and Gates, who are wedded to the GMO industry till death do us part. Frankly, I think if Oxfam is willing to take funding from organisations that only have the interests of multinationals at heart, they should not be receiving public funding. They have, effectively, jumped ship. They should be treated accordingly. They should no more be considered to be independent or to be benefiting poor people in developing countries that they would be if they had decided to accept funding from the armaments industry. Of course, I don't know whether they already receive money from the armaments industry or not.

Farmers, especially those working small and medium sized farms in developing countries, need ecologically and economically sustainable farming practices. They certainly don't need expensive and highly damaging technologies that render the farmers slaves on land whose quality is fast diminishing. GMOs will increase food insecurity, dependency, poverty and low health. Ultimately, people will die as a result of embracing GMOs. And Oxfam, along with their friends in the Gates and Rockefeller Foundations, will be responsible for the resulting poverty, death and destruction. The latter two were set up to wreak destruction, despite their stated ambitions. But I don't believe Oxfam was set up for this, I believe they have more recently been injudicious in their choice of funders. Perhaps there is time to rethink this and, if necessary, send back the blood money they have received. Alternatively, they can admit that they are no longer involved in development and concentrate on promoting and lobbying for the systematic destruction of whole societies, economies and ecosystems. And then they may as well accept money from the armaments industry, while they are at it. It could make the job quicker.

Incidentally, the experience of African countries so far with GM crops is not good. Millions have been spent over a long period in Kenya to produce a GM sweet potato but nothing has been delivered yet that can outperform conventionally bred versions. South Africa found that Monsanto had blundered somewhat by supplying them with 'free' genetically modified maize that didn't produce any grain. But the industry is still doing everything it can to force more GMOs on South African farmers. Attempts to introduce GM cotton in West Africa have met with the same problems as GM cotton everywhere and Monsanto has even admitted that it has failed in India. However, their solution to this problem is that farmers buy a new and more expensive version of the failed crop. I assume West African cotton growing countries will receive the same privilege.

None of the arguments that Monsanto and the rest of the GMO bunch use to defend the technology work. The evidence has always shown that conventional crops and farming practices are the only ones that work and that are sustainable. This is especially true for small farmers, those who are most likely to suffer from poverty, food security and environmental degradation problems. It is to be expected that Monsanto and other interested multinationals will lie, cheat and pay through the nose (also known as lobbying) to make us think otherwise. And why wouldn't they when they receive so much public money to do this. But we also have to be aware of the influence of the rich privately owned institutions, such as the Rockefeller and Gates Foundations, who are supporting GMO. And sadly, we have to add Oxfam into the equation, unless they suddenly remember who it is they are supposed to be working for.


Tuesday, April 13, 2010

Visiting With SAIPEH

Although I am only in Mumias on a short visit, I brought a couple of solar cookers with me, along with some black pots. I was hoping I would be asked to demonstrate the impressive, but very simple, trick of cooking food without any costly fuel. Sure enough, I was taken to SAIPEH's feeding centre, where volunteers feed 100 or more children who are orphans, in some way vulnerable or disabled. They get through a lot of fuel every day and the cost over the course of a year is in the region of $1000. This is a very sizable sum to an organisation like SAIPEH. Any way of reducing it or eliminating it would be very welcome.

There were only a few people when I got there as it was far too early for lunch. But we set up the cookers to prepare some rice, just to demonstrate. We also set up a cooker to demonstrate how you can pasteurize milk or water to make them safe to drink. Solar cookers heat things up to 80 or 85 degrees, which is hot enough to cook and to kill all bacteria. In order to show that the water had reached the required temperature, we used a WAPI (Water Purification Indicator). This is a plastic cylinder with a lump of wax inside which melts at a little over 80 degrees. The wax is at the top of the cylinder when you start, but as it melts, it slides to the bottom.

Both the demonstrations worked well, despite a lot of thin cloud. The sun was hot even though the cloud didn't shift the whole morning. The rice cooked faster than I expected, in about one and a half hours and the water was ready in about 45 minutes. People were appropriately impressed. Every time I demonstrate, I keep thinking, what if it doesn't work. But it always does, as long as it doesn't cloud over. But in addition to being impressed, I would like to think that people would adopt the technology. They always say they will, but people who have been demonstrating for a long time say most people never adopt it. So we have to wait. Given that SAIPEH pay for the fuel, perhaps they will make sure that the fuel bill is cut, substantially.

We also had the opportunity today to demonstrate cooking baskets, at least, to some extent. There were lots of banana trees growing nearby and there were deep, round baskets available. We weren't organised enough to cook anything in one, they were too small, but I think the point got across. These can really save a lot of fuel and you can use them whether it's night or day, sunny or raining. They can be made of easy to find materials, such as straw, hay, newspaper, leaves, old clothes, etc, along with a bit of sacking material if you don't have baskets of the right size.

A technology we didn't have the opportunity to demonstrate yet, we just described it, is that of fuel briquettes made from organic waste, such as kitchen waste. They are made of various kinds of waste, finely chopped and mixed so they bind into a cohesive lump. These can be dried or compressed with a simple press made of wood or metal. We haven't got a press yet but we are still hoping to get one made as a template. Then they can easily be produced by 'jua khali' workers (jua khali meaning 'hot sun', they work outside).

If you combine these three technologies and put the required amount of work in, and that's not a lot of work, you can reduce your fuel bills to almost zero. Perhaps you can eliminate them but I suspect there will always be unforeseen occasions when you will need wood and charcoal. But even a few hundred dollars a year could mean better food for existing children or more food for more children. Now that the idea is there, hopefully there will be those who want to use these intermediate technologies. I'll be checking up on them now.

SAIPEH support several hundred children and teenagers and this brings up many problems that children have when they are orphaned, disabled or in some way vulnerable. A meeting revealed that some girls are still unable to go to school when they are having their monthly periods. I felt so bad when I heard that there was even a girl who reported using leaves because she didn't have access to any alternative. But it is unthinkable that even some of them are unable to go to school because of something like this.

Some community development workers in Kenya and other African countries teach girls to make re-usable sanitary pads out of flannel or other appropriate materials that can be recovered from old clothes. They are easy to make, especially for SAIPEH, as they have a training and resource centre that teaches tailoring. Making sanitary pads would be a great thing for prospective tailors to start off with. You can start and finish several of them in a few hours. A perfect lesson plan! Again, I hope there are people willing to adopt this simple alternative to commercial disposable sanitary pads. They are very expensive and ultimately unsustainable, both economically and environmentally.

No matter how good these intermediate technologies are and no matter how appropriate they are, the main challenge is getting people to adopt them. Just being impressed is not enough. You may think that anything would be better than using leaves instead of proper sanitary pads, but these technologies have been promoted elsewhere and they haven't always taken off. For me, it's all very well doing the research and giving people the plans and diagrams, but I'd really like to crack the nut of why people seem unwilling to adopt things that seem so obviously good and how I can meet this challenge. If and when the scales drop from my eyes, I'll report back.


Rambling in Kenya

Yesterday, I made the fairly familiar journey from Nakuru in Rift Valley province to Mumias in Western Province. There are many beautiful sights on the way and the weather was good for travelling, sunny but not too hot. The roads for some of the journey have been improved, some are sill in the process of being improved and others are disintegrating and in a very dangerous condition.

Infrastructure conditions in Kenya have a lot to do with structural adjustment policies imposed by the IMF (International Monetary Fund) and the World Bank. These were first imposed in the early 1980s and they are still used, but they go under different names sometimes. Whereas, the road and other infrastructure improvements have a lot to do with Chinese development, which is carried out without the same level of conditionality.

Much of the fertile land in Nakuru is owned by a handful of very rich people, many of whom are members of political families, the Mois and the Kenyattas, for example. And like a lot of rich landowners, they don't feel the need to grow food crops or, at least, not food crops for Kenyans. You might think that wheat, sorghum and millet are food but the large scale producers, apparently, grow these crops to sell to breweries.

A few hours from Nakuru, the next big non-food product is tea, which dominates Kericho. Most of the industry is foreign owned or run and Kenyans make very little from this monoculture. It may be a world renowned product, but employees are paid very little, live in bad conditions and have few labour rights. That applies to those who have real jobs, rather than the far larger number, who have to take whatever bit of work that crops up, however rarely and however badly paid.

One of the big employers there is Unilever. You can read up on their level of corporate social responsibility on the Corporate Watch website. Suffice to say, they tick all the boxes that you'd expect of a multinational; monopolistic practices, unsustainable agriculture, exploiting cheap resources and labour, environmental degradation, appalling health conditions and a whole lot of other things. It's a long and depressing read.

Long before you reach Mumias you begin to see the sugar cane fields, sugar being another of Kenya's handful of monocultures that have played a big part in keeping Kenya poor for many decades. While sugar cane has long been grown in Mumias to be used as sugar, now there are plans to grow even more sugar cane destined for the biofuel market. Yet more land that could be used for food is being sacrificed for the blessed export market. The profits will go to a handful of rich people. Mumias Sugar Company does pay its employees well but the majority of people who work for the Sugar Company are not considered to be employees. They are casuals, contractors, outgrowers, etc. The majority of them make bugger all.

It probably sounds like I have a thoroughly miserable time travelling through Kenya, thinking about how much of the country is dedicated to exploitation. Well, there are still a lot of beautiful sights, if you are in a position to enjoy them. There's a good reason why tourists come to places like Kenya and even the trip to Kakamega Rainforest, Mount Elgon and Lake Turkana can be a great way of seeing the country. But even the tourist industry is another case in point; very few people make most of the money. The majority eke out a living somehow, but much of the tourist revenue doesn't even stay in the country.

Such conditions in developing countries may be, to some extent, influenced by their own governments. There are, indeed, many corrupt politicians and other parties and they have made themselves very rich. But governments, multinationals and other parties in rich countries have also made themselves rich by grabbing much of the wealth to be made in developing countries. And institutions like the IMF and the World Bank (and the World Trade Organisation) are simply some of the tools by which the rich and powerful extract huge amounts of wealth from the poorest and most vulnerable people in the world.

Poverty and underdevelopment are not remote phenomena, far from Western style homes and living conditions. The forces that create and exacerbate poverty also bring to those living in comfortable conditions many of the cheap products that make their lifestyle possible. Tea, chocolate, coffee and other things that come, primarily, from developing countries, are only affordable because of policies created by undemocratic institutions (who, ironically, constantly talk about improving democracy in developing countries). Even Ipods, Iphones and Macs, made by a company that likes to boast about how responsible they are, depend on (high value) materials extracted cheaply from countries like the Democratic Republic of Congo.

Much of Western democracy itself, and much Western wealth, depend on the terrible conditions that are created and maintained by undemocratic international financial institutions, multinationals and powerful governments in developing countres. It doesn't seem possible for every country in the world to end up with the same kind of democracy enjoyed by a handful of the world's people. I don't want to argue that democracy is impossible or that it is wrong. Perhaps, as Amartya Sen has argued, there is not enough democracy. Perhaps it is not widely enough distributed.

But if Sen is right and there were more democracy in the world, I think it would look a lot different. The small number of countries that have enough, too much in fact, use more resources per head of population than the world can provide. The level of choice that some people enjoy, the range of goods and services, necessary and unnecessary, the opportunities to overconsume with impunity, could not be offered to all peoples, equally. But I haven't gone deeply enough into political philosophy yet to figure out what sort of democracy would be sustainable democracy. Perhaps I'm just rambling.

I'm in Mumias to visit a very fine NGO called SAIPEH (Support Activities in Poverty Eradication and Health). Like the community based organisation I work for, Ribbon of Hope, Nakuru, they work with HIV positive people and their families, people suffering from hardship, orphans and vulnerable children. (Except that SAIPEH has been going for about 14 years, Ribbon of Hope is still small and young, not much over a year old.) Anyhow, they run all kinds of income generation schemes, such as growing food crops and livestock, teaching people trades, such as tailoring and computing and various other initiatives.

I'm hoping that SAIPEH will be interested in schemes that reduce spending too, such as solar cookers, cooking baskets and fuel briquettes made from organic waste materials. For lack of a convincing political philosophy, I'll stick to a more Aristotelian form of home economics in the hope that, although people will not end up rich, they may end up with a bit more cash than they had before. After all, for Aristotle, all economics was home economics.


Saturday, April 10, 2010

Food Security Means Non-GM Food

Not content with contaminating their own country with genetically modified organisms (GMO), American GMO patent holders are busy getting politicians and other powerful people to help them in their quest to contaminate whole continents, such as Africa. African countries haven't proved to be the pushover that these GMO multinationals would like, but there are powerful people willing to give them a helping hand, such as Bills Clinton and Gates.

Despite spewing out the mantras about free markets and lowering barriers to trade, patenting is the ultimate form of protectionism. Owners of American GMO patents don't even need to grow their contaminants in America to reap vast profits. They can simply palm them off on poor farmers in far away developing countries, for whom GMOs are entirely inappropriate, and rake in the cash royalties.

The two Bills are supporting what is known as the Global Food Security Bill. Despite the name, this bill aims to foist GMOs on people in developing countries by dressing them up as aid. The idea is not a new one; public money is used to open up new markets for these thugs and they pocket the profits. Only the very rich and powerful will benefit from all this. But isn't that what aid is for?

For many years now, millions of dollars of 'aid' money has gone into developing a genetically modified sweet potato in Kenya. Strings have also been pulled to get some laws adjusted so that such crops can be commercialized. The problem is, this potato hasn't really taken off. Local varieties have performed far better in trials. To add insult to injury, breeders in Uganda have developed a virus resistant sweet potato using traditional methods while working on a shoestring.

GMOs of any kind would be a disaster for Kenya and for any other country. Just look at the problems the US, Canada, India, Argentina and Australia are having with their contaminants. But the organisms are particularly dangerous for developing countries. The last thing small farmers need is crops that cost a lot to grow (GM seeds are far more expensive than conventional ones), that develop serious yield and pest problems and that systematically destroy the ecosystem. But that pretty much sums up GMOs.

Anyone interested in reducing hunger should encourage sustainable agricultural practices that are appropriate for small farmers, because most farmers in developing countries are smallholders. They should steer clear of expensive and inappropriate technologies, such as GMOs. These were developed for rich, large scale farms, although they don't even seem to be benefiting them. For every advantage claimed for GMOs so far, conventional breeding practices have surpassed those claims. GMOs are not just unnecessary, they are highly undesirable.


Friday, April 9, 2010

Malawi Needs Good HIV Research, Not Bad HIV Laws

Malawi has this cunning plan to 'outlaw HIV transmission' by making it a crime to 'knowingly' transmit HIV. A spokesperson for the ministry involved said "The underlying factor is that if anybody knowingly infects somebody...that means he commits an offence." I haven't been able to find a copy of the bill but apparently it means that if a HIV positive sex worker fails to let partners or clients know their status, they will be liable to prosecution.

I wonder if their partners or clients will also be liable to prosecution for failing to reveal their status. After all, people availing of the services provided by sex workers should be equally aware of the danger of transmitting and of being infected with HIV, along with various other sexually transmitted infections (STI). The spokesperson was unable to say what would happen if both parties were HIV positive and referred to the bill as a challenge. He also said what they are doing is educating the populace. I assume he was trying to make a joke, however inappropriate.

I would also like to know where the law would stand with regard to non-sexual transmission of HIV. For example, where health services use shared needles, syringes or medicine vials or engage in other potentially hazardous practices, would they be liable to prosecution? Supposing they failed to take precautions specified under normal occupational procedures, how would the law stand? Could a HIV positive mother be accused of criminally infecting her child, either in the womb, during birth or through breastfeeding? Would a HIV positive intravenous drug user (IDU) be liable by sharing injecting equipment?

If you accept the received view of HIV transmission and believe that 75% of it is transmitted through heterosexual sex and only a very minor proportion through unsafe medical procedures, you may not worry about medical transmission (though this doesn't answer the questions about IDUs or transmission by mothers to their children). But if doubt were cast on that received view, if medical transmission were more common than previously supposed (admitted?), or if it were even more common than heterosexual transmission, you might consider the question more important, especially if you were a health professional.

The trouble with medical transmission of HIV is that it has received very little research. Figures you hear bandied about are mostly based on assumptions which should never have been allowed to stand untested, as they have been, for several decades. But among the few bodies of data that have been collected, medical transmission has been found to be a risk in almost all of them. This doesn't mean that medical transmission has been demonstrated, just that those receiving injections have a higher risk of subsequently being found to be HIV positive. Notable also is the fact that some of this research goes back to the mid 1980s.

Data from Malawi is the most shocking. 54% of HIV infections are found among those who have received injections in clinical settings. Other countries report lower percentages but the average is 21% and the mean is 19%. For me, the worst aspect of this is that none of these pieces of research are national in scale and only a handful of countries are involved (DRC, Uganda, Rwanda, Tanzania, Zimbabwe and Malawi).

The Malawian spokesperson is right in saying that there no straightforward answers to questions that arise about this proposed bill, but not for the reasons he thinks. If medical transmission of HIV is higher than has been previously assumed, it would be more worthwhile, indeed, more straightforward, to investigate this and provide some remedies. That would certainly be more feasible than trying to create laws of dubious ethical standing to reduce HIV transmission.

On the whole, it would be a good thing if HIV was less likely to be transmitted sexually because it is difficult to influence the sexual behaviour of whole populations and efforts so far have failed. In contrast, it should be much easier to influence the practices of existing health personnel, increase the number of trained personnel, increase the resources available to them and increase access to health services. And improving health services will have benefits that far exceed those to HIV alone. As to how providers of medical services can regain the trust they will have lost, that will be no easy matter. But I don't think anyone would opt for continuing to transmit HIV through medical procedures, if this is actually happening.

The admission that medical transmission of HIV could be higher than previously thought, and even that sexual transmission could be lower, may be a hard one to make. Of course, it may not even be true that medical transmission is higher and sexual transmission is lower. But now that the possibility has been raised, we can not continue to fail to research this vital area of HIV knowledge. Let us stop lying about what we don't yet know.


Thursday, April 8, 2010

The Biggest 'Omission' in Medical History?

Sometimes you come across a theory that can explain so much that you wonder why you have been flailing around hopelessly for so long. One time I was looking around one of those electronics shops that you find in every terminal in London's airports. I was marvelling at the things that can be made and even purchased at fairly reasonable prices. Because I was studying development at the time, I was trying to think why the sort of ingenuity that that goes into these products, which were hardly vital to humanity, didn't go into development. The proto-theory I came up with was that some people just don't matter.

I was horrified that this thought could go through my mind just then, because it is a value judgement, not a scientifically testable theory. Surely it has no place in development theory, especially in the specific area of HIV research, a field peopled by some of the most brilliant scientific minds alive? But the thought never left my mind because it seemed to explain so many things. How else could you explain the way people in rich countries treat people in poor countries? The more I studied, the more I realised that some people believe that (or behave as if) other people don't matter, either because they are far away, they are foreign, they are poor, they are sick and needy or are just not worth considering.

While studying HIV, I was unconvinced that the entire explanation for the rate of HIV transmission, in some countries only, could be explained purely by differences in sexual behaviour. I was equally unconvinced that so called HIV prevention programmes could possibly have any influence on sexual behaviour. And when countries boasted about how successful they were in reducing HIV transmission as a result of these prevention programmes, I thought they were unclear about why HIV prevalence had dropped and didn't really care why, they just used the circumstance for publicity.

I had to limit my study to make it manageable and did so by concentrating on heterosexual transmission of the virus, since it is the received view that this is the main mode of transmission in countries with a generalised epidemic, such as Kenya. And it turns out that that is one highly dangerous received view, for many reasons. Heterosexual transmission of HIV is definitely one mode of transmission, but the extent to which it drives generalised epidemics is completely unclear, and it always has been.

So my objection to the main players in the HIV industry is this: why has so much money and effort gone into programmes that assume the precedence of heterosexual transmission when this is just an assumption? The whole idea that there are some people who have more sex than others, or more sexual partners, or who are more likely to engage in unsafe sex, is a value judgement. But it is the value judgement that has launched a thousand careers for politicians, religious leaders, social and religious leaders, professionals of all kinds and who knows what else. It is a value judgement that drives global HIV prevention policy and spending.

There are many warning signs that heterosexual transmission of HIV does not explain extremely high rates of transmission in some countries. No credible correlation has ever been found between rates of transmission and levels of the kind of sexual behaviour that would be required to drive the sort of epidemics found in Kenya, South Africa, Lesotho, Swaziland and anywhere else. There are so many contradictions and non-correlations that many professionals in the HIV industry must have been asleep since some time in the 1980s, because there were obvious problems with the sexual behaviour paradigm even then.

Even back in the 1980s, not long after HIV was identified as the virus that caused AIDS, medical transmission was recognised as one of the possible modes of transmission. Small amounts of research went into establishing the extent of unsafe medical practices and the results suggested that these practices could transmit HIV to many people. But little further research was carried out. WHO, various UN agencies, leaders of all descriptions, professionals of all descriptions, various globally represented organisations, institutions, universities and others flew the flag for heterosexual transmission of HIV in developing countries (though not in developed countries). There were few exceptions and they were considered to be denialists or trouble makers. There are still few exceptions and they are still considered to be denialists or trouble makers.

Well, maybe medical transmission of HIV is not very high, maybe it is lower than heterosexual transmission. Maybe all the fuss is about nothing and maybe I'm just one more person poking his nose in where it doesn't belong. But that is the point: I want to know why medical transmission of HIV has not been properly investigated, why it is still dismissed as being almost non-existent. The recently published (though based on out of date data) Modes of Transmission Survey for Kenya suggests that medical transmission accounts for 0.6% of all transmission, based on an assumption that seems to have been pulled out of thin air. They also note a finding that puts the rate at 2%, over three times higher. But this is still dwarfed by most of the other modes of transmission, especially heterosexual transmission.

But those who are still being branded as mavericks for questioning the received view point to many bodies of data that have managed to investigate medical transmission rates of HIV. Those bodies of data show that medical transmission is very significant, perhaps even more significant than any other mode of transmission, including heterosexual transmission. All they are asking is that these results be taken seriously and subjected to rigorous testing. If medical transmission of HIV even stands at 5%, this would still account for millions of people currently living with HIV and hundreds of thousands of people who have died of HIV.

One of the most heartrending things about people dying of HIV, as opposed to other diseases, is that they are, because of the unexamined and long held value judgements of so many 'brilliant minds', vilified, ridiculed, shunned, persecuted, sneered at and humiliated just when they are in most need of sympathy, love and basic humanity. If it is even remotely possible that we as people are guilty of such terrible injustice to fellow human beings, surely that is in urgent need of investigation? Far from dying because they have engaged in what may or may not be risky sexual activity, people may be dying because they have followed the advice of well educated professionals.

It's almost unthinkable that much, or even any, recent cases of HIV have been transmitted by the very professionals that are supposed to be preventing and treating HIV. But it is even more unthinkable that we could suspect such a thing is happening and do nothing about it. Maybe there is a danger that people will stop going to health professionals and stop seeking medical treatment, even vital vaccinations and life saving treatment, because of a complete lack of confidence in the profession. But that is something the profession will have to deal with because they certainly don't deserve any confidence or respect until they have fulfilled obligations that have so long been outstanding. In fact, in some countries, going to the doctor may curently be a health hazard, carrying risks of infection with HIV and many other blood borne diseases.

In the field of HIV, nothing is more important right now than establishing the extent of HIV transmission through medical treatment.


Wednesday, April 7, 2010

European Protectionist Agreements

Recently, I expressed a sceptical view of the EU's proposed Economic Partnership Agreements (EPA) with African countries. I suggested that while the EU pretends such agreements are for the benefit of Africans, this is just a sham and that they are unashamedly beneficial to rich countries and detrimental to the development of poorer countries. The former president of Tanzania, Benjamin Mkapa, is in agreement with me, warning that EPAs are a form of neocolonialism. The EU have been quick, but unconvincing, in their denial of any underhand intentions.

Their response is unconvincing because they are effectively just offering more of the same. African countries will produce low value goods and raw materials, which the EU will buy for as little as possible. In return, the EU will sell African countries high value products that have been produced cheaply, in part, because of the low raw material costs. Sometimes, these high value goods will even be produced using badly paid Africans, which will further increase the profits for the EU. The EU assures African countries that they will be allowed to phase out some tariffs more slowly than others. But ultimately, the EPAs need to obey the strictures of the WTO (World Trade Organisation), where 'world' means 'rich countries, especially the US'.

While the EU is pumping out the woolly rhetoric about African countries removing barriers, they are piling up the barriers to make it more difficult for African products to reach the EU markets. It's the time honoured process of protecting their markets while accusing weaker economies of protecting theirs, a process particularly relished by the US and UK when it suits them, only to be replaced with a sanctimonious plea for free trade when the conditions are right.

Incidentally, a piece of particularly woolly rhetoric is the 'Agreement on Sanitary and Phytosanitary Measures', which you may need to read several times only to remain totally confused. The EU can insist on certain standards for food coming into the region that make exporting by African countries to the EU too expensive. According to these measures, that is not what is supposed to happen, but it effectively means that most African countries can't export to the EU. And the EU supports those exporting goods to African countries by methods that would be considered to be subsidies if they were implemented by Africans.

Even the private sector in Africa is suspicious of EPAs and they are the people who may be expected to have most interest in them. So if the private sector and other influential people are not about to be hoodwinked yet again by the protectionist West, perhaps there is hope that African countries will have some influence on other trade issues that have, so far, kept most of them underdeveloped.


Tuesday, April 6, 2010

Medical Transmission of HIV May Be Widespread in African Countries

A couple of weeks ago I was taken to see a woman in a rural area who was very sick. She was terribly emaciated and the place she lived in had clearly not been looked after for a long time. The woman insisted that she did not have HIV, although she also claimed not to have been tested. After a few days, she was taken to the local health centre. There, it turned out that she had already been tested for HIV, was found to be HIV positive and was put on antiretroviral drugs (ARV). But she refused to take the drugs and agreed to be sent home, as the health centre was unable to do anything for her. She died about one week later.

All we could do was insist that she went to the health centre to be tested and take her drugs. She reluctantly went to the health centre but refused to take her drugs. It was as if that was all that was left to her to preserve her dignity. For some time, she had refused the advice of neighbours and health volunteers. And they were growing less willing to visit her, because they knew that she was going to die. On the day she went to the health centre, she looked humiliated and perhaps even angry.

The stigma that still attaches to HIV/Aids, and even TB because of its association with HIV, may seem like a sticking point that results in people wishing to deny that they have been infected, even when the cause of their illness is undeniable. But the stigma is real. People are ostracized and treated differently because they have a disease that is associated with illicit sexual activity, either on the part of the sick person or on the part of someone with whom they are intimately connected.

The 'behavioural paradigm' for explaining HIV transmission is widely adhered to and informs most HIV prevention programmes. From the extremely naive ABC (Abstinence, Be faithful, use a Condom) to the downright foolish mass male circumcision (MMC) campaigns, the assumption is that because HIV is mostly transmitted by sexual intercourse, all we need to do is get people to change their sexual behaviour.

So far, I have accepted the often published claim that most HIV is sexually transmitted. But I have argued that the circumstances in which people live and work, for example, may determine who they have sex with, when and under what conditions. Trying to influence their sexual behaviour without examining these circumstances too, will result in a lot of failed prevention programmes. Most prevention programmes to date have, indeed, failed.

But perhaps, while rejecting the behavioural paradigm, I have fallen into the trap of accepting something like a sexual paradigm, that most HIV transmission is sexual transmission. Perhaps this is not even true. I was aware that there were people arguing that non-sexual, particularly medical transmission, could be far higher than accepted by many theorists. But I had to exclude certain lines of enquiry in order to limit my dissertation to a manageable field. Now that I am no longer so constrained, I have time to revise this limitation.

If medical transmission of HIV is significantly more common than supposed by most HIV analyses, a lot of questions could be answered. For example, perhaps more women than men, especially women of childbearing age, are infected because they receive more medical treatment. Perhaps many children who have been infected, especially those whose mother is not infected, have been infected by medical treatment. Perhaps the reason those in Northern Kenya, who have least access to modern medicine, also have very low levels of HIV because they are not being infected by medical procedures.

I have been reading a book by Daivd Gisselquist called Points to Consider: Response to HIV/AIDS in Africa, Asia and the Caribbean, conveniently published on the internet. Some of the things revealed in this book are truly shocking. When I have finished, I have to go through everything I have written about HIV and reconsider my whole view of it. My view of development will probably remain the same, but the way I reached some of my conclusions will have to be revised, considerably.

If Gisselquist and others are right, and I have no reason to believe they are are wrong, the woman who refused to take her medication could have been a victim of stigma, not primarily emanating from her own neighbours, but from some of the most eminent health professionals in the world. That HIV is primarily sexually transmitted in African countries is a long held, received view. Because of this received view, people who say they have not had sex in the period in which they became infected have not been believed. Women who are infected when their husbands are not are assumed to have had extramarital sex. Where couples are infected with different strains of HIV, they are both assumed to have been promiscuous, rather than just one of them.

This received view is in need of thorough testing and it is incredible that it has been used to face down challenges for so long. The view has shaped most of the (highly unsuccessful) prevention campaigns, but also people's reaction to their being infected with HIV or the reaction of others when faced with someone who has been infected. How many innocent people may have died in shame, misery and isolation because the health profession has refused, for whatever reason, to investigate its poorly supported assumptions about frequency of transmission of HIV in medical contexts?


Sunday, April 4, 2010

Excessive Drug Prices Promote Counterfeit Drug Industry

According to the WHO, lifesaving drugs are not exempt from the trade in counterfeit medicines. But nor are they exempt from the rights of powerful multinational pharmaceutical companies to make obscenely high profits, regardless of the cost in terms of sickness, suffering and death in developing countries. Organisations like WHO and Interpol (effectively, publicly funded) are busy trying to help these poor victims, the pharmaceutical companies, that is. Otherwise, their ability to extract higher and higher profits every year may be compromised.

Yes, the WHO is right, it is cynical to produce counterfeit drugs, some of which may not help the person taking them; some may make them worse or even kill them. But it is also cynical for Big Pharma to put such impossibly high prices on drugs, spend far more on marketing and lobbying than on research, compromise doctors and other health professionals to push their products, produce goods for the rich world while ignoring the poor majority, using people in poor countries as cheap research fodder for drugs intended for the rich world, preventing poor countries from producing and making generic equivalents of overpriced branded drugs, lobbying the WTO (World Trade Organisation) to make laws that protect Big Pharma at the expense of poor countries and generally frustrating any attempts to regulate them, even slightly.

I don't know how many people die from counterfeit drugs but I know that an estimated 14 million die every year from infectious diseases, many of them preventable or treatable. The policies of Big Pharma ensure that the majority of people who need drugs most will never be able to afford them. A notable exception is antiretroviral drugs (ARV) for HIV, which have only been reduced slightly in price and only because they are being paid for by aid money. And no one need worry that production of ARVs on a massive scale at slightly reduced prices causes Big Pharma to suffer in the least. If they didn't get the HIV industry to buy their drugs, the market for them would be miniscule in comparison to what it is now.

So the humbug WHO claim to be worried about ordinary people being exposed to counterfeit drugs. But this is just an excuse to use lots more public money to protect the interests of Big Pharma. Already, public money has gone into the research the pharmaceutical industry claims to do. But most of the costs of drug research are met by publicly funded bidies, such as research institutions, laboratories and universities. Then the drug companies slap a patent on the results and pocket all the profits. If the WHO was really concerned about endangering the public they would lobby Big Pharma to do one simple thing: lower their prices.

But that is one thing the industry will not do. Far from it, they will continue to lobby to be protected so that they can continue to make far bigger profits than most other industries. Lowering their prices, or even lowering their prices to affordable levels for drugs needed most by developing countries, would have little negative impact on their profits. In fact, like with HIV drugs, they may discover a market they have long been ignoring. But they would prefer to fight for their right to charge more than people in developing countries can afford, perhaps by lobbying for aid money to be spent on drugs other than just ARVs.

As long as patented drugs continue to be too expensive for people in developing countries, it will be worthwhile for counterfeiters to target them with their products. As long as Big Pharma lobbies against the production and distribution of generic versions of patented drugs, people in developing countries will have no option but to look for cheaper alternatives. Big Pharma, in its efforts to maximise its profits, is creating the ideal market for counterfeiters. Getting Interpol and the WHO to spend increasing amounts of money and creating more sophisticated law enforcement systems is pointless. Counterfeiters will also become more sopisticated, as they are amply demonstrating.

Why? Because there is good money to be made. Pharmaceutical products don't just include drugs, the number of products that are artificially overpriced because they are produced by this industry is enormous. Who wouldn't grasp the opportunity to take advantage of the opportunity to produce relatively cheap products that can be sold on at ridiculous prices, only slightly less ridiculous than the prices charged by Big Pharma?

It's because I sympathise with vulnerable people, mainly in developing countries, that I think that drug counterfeiting should be stopped. It's not because I think the pharmaceutical industry should be allowed to hold the world to ransom. But I think the industry itself is creating the problem. The cost of drugs needs to be reduced to make them affordable in developing countries and it needs to be possible for developing countries to produce and/or buy generic equivalents of life saving drugs because they will never be able to pay the prices currently demanded by the industry.


Saturday, April 3, 2010

The Pretence of Aid

Some of the issues this blog is particularly concerned with include unfair trade policies that aim to keep developing countries in their current state of underdevelopment, the use of developing countries to produce low value goods and raw materials, but not high value goods, which they have to import from rich countries, and the use of developing countries for growing monocultures and single resources that are often processed in rich countries, earning poorer countries very little.

Economic Partnership Agreements (EPA) are, to a large extent, behind these and other issues. Rich countries have been busy for a long time trying to persuade African countries to sign up to these EPAs, without much success, yet. But as the number of poor people in African continues to rise, mostly as a result of the 'pro-poor' policies of rich countries, it should be possible to persuade more countries to put the noose around their neck in return for some short term handouts that they need for an emergency.

Perhaps Kenyans think there is no alternative, perhaps there is no alternative for them, but they seem to be getting further and further into the noose of producing cheap primary goods for export. Huge areas of land are being diverted to use for biofuels and other things that people here are not in great need of. At the same time, small farmers, who produce the bulk of what Kenyans eat, are slowly losing access to land as they are pushed off by rich industrial scale agricultural interests and as the prices rise to levels they will never be able to afford.

Rich countries used trade tariffs to get to the position they are in today. Now they want poor countries to remove their tariffs so that the rich countries can expand their markets and compete, under completely skewed conditions, against the poor countries' markets. EPAs are dressed up as being advantageous to African countries but so far, most African leaders have not been fooled.

The East African press generally seem uninterested in non-national matters, so I was surprised to come across an article that discusses the difficult area of EPAs in simple language for a non-political economist like myself to understand. This article sees EPAs as the wrong kind of development model and discusses a number of key points. One of these concerns EPA provisions that are highly detrimental to African countries' development. The EU claims that dismantling tariffs will promote growth, despite the fact that this has never been the case, in any country, or at any time in history. On the contrary, tariff cuts have taken countries in the oppostie direction, leading to stagnation and de-industrialization.

Kenya is typical of the countries who will suffer if they sign up to an EPA. They depend on a handful of low value primary goods that are often produced by farmers at an extremely small profit, even at a loss: sugar, sisal, coffee, tea, fruit, vegetables and the like. It would be extremely advantageous to Kenya to use those primary goods to supply an industrial sector, if they had an industrial sector. But much of the industry they do have is owned by foreigners from rich countries, who are effectively subsidized to be here. They get tax breaks and other incentives so that Kenyan industrialists have no chance of competing with them.

Of course, the EU would not want Kenya to develop an industrial sector, not an indigenous one, anyhow. Their economies depend on cheap goods and cheap labour from developing countries. So they dress  up their policies and 'contributions' as 'aid' and they talk the talk of development. And for the EU and other rich parties, African countries are not just sources of cheap goods and labour, they are also important markets, where very expensive goods, often made with cheap African raw materials and labour, are either sold or dumped on the African market.

It's a disgusting thought, but all the land that has long been used to produce non-food or non-essential food products in developing countries could have been producing food for starving people here in Africa. Instead, starving Africans get a pat on the head and a hand-out from the rich world. Now that some rich countries are unable to produce enough food for themselves, they are buying up African land. Others are buying up African land to produce biofuels. Africans can expect more pats on the head and more hand-outs whenever enough Western attention is drawn to some drought, flood or other 'natural' disaster.

And don't be fooled into thinking that most of the disasters that strike poor countries are wholly natural. Many are not in any sense natural. People starve, become sick and die during what are referred to as disasters, usually, because they don't have access to the food or the water that is being extracted by foreign interests. The 'shortages' of food that Kenya has experienced recently and will continue to experience into the future have been manufactured. The bulk of land, and therefore water, in Kenya is devoted to producing goods for export. Even those goods that consist of food items are destined for Europeans who can afford it, not Kenyans, whose buying power is undermined by various agreements with the EU and other rich countries and zones.