Monday, August 30, 2010

Poverty Makes the World Go Round

How do you undermine the rights and autonomy of whole populations and, instead of censure, receive only praise? Simple, you just call it development. A multinational that respects little aside from money, and certainly has no time for democracy, is bad enough. Yet, when it joins forces with an institution with similar qualities, but happens to be an international 'charitable' foundation, there is very little anyone can do to rein in their actions, no matter how exploitative, destructive or manipulative they may be.

The Gates Foundation has been bullying countries into dancing to its tunes for some time now. And Monsanto's monopolistic behavior is legendary. But both these institutions recognise just how far they can go as long as they bleat on about 'helping' people, saving lives, feeding the hungry, etc. How can anyone object to such philanthropic actions, whatever their motivations? They certainly couldn't object to 'donated' food merely on the grounds that it is genetically modified (GM), could they?

Some like to make out that opposition to GM is based on a fear that the foods are damaging to people's health. Perhaps some people do have such fears. And those with an interest in pushing GM do not themselves know what effects the technology could have on health or the environment (or if they do know they have never made their findings public), so they certainly don't want anyone else to know. Because people's fears are based on lack of information, rather than availability of information, the industry can churn out any kind of deceit to defend themselves (or pay pseudo-academics to do it for them).

But others are more worried about the fact that multinationals like Monsanto want to monopolise agricultural production, from the choice of seeds, the varieties of produce, the agricultural inputs, the agricultural practices employed, all the way to what people eat, how much they know about what they eat, how much they pay for it, how food is produced and stored and anything else they can control. They are not just food facists, Monsanto runs the whole gamut of facism.

Couple this with the man who wants to do for food what he succeeded in doing for software and you've got a real threat to democracy, health, the environment, the economy and even global security. If there’s anything about facism Monsanto doesn’t know, Bill Gates and his Foundation will soon fill in the details.

People in developing countries may have been kept in the dark but they are not stupid. They know that there are reasons for high food prices and lack of access to food; they know that the prices are not necessarily high because of shortages and that lack of access to food is not necessarily because of their country's inability to produce it.

There is little secret about the fact that famines, food shortages and food insecurity, including recent instances of these, are not caused by lack of food; many countries experiencing these phenomena have plenty of food. It is obvious to many that it is people with large amounts of money who created prices beyond the means of those living in developing countries. And you don't need to be a genius to know that shortages of (edible) food can be created when most land is used for products destined for the rich; biofuel crops, flowers, luxury fruit and vegetable, tea, coffee, cocoa, rubber, sisal, animal feed (for Western animals) and the like.

One of the financial institutions that did very well out of the recent handouts to the rich, Goldman Sachs, also made a lot out of the food price speculation that created the food crisis a few years ago. They raked in an estimated billion dollars; even by Gates’ standards, that’s a lot. They do very well out of human misery, benefiting from it, as well as causing it. So who would pass up the opportunity to share in their returns? The Gates Foundation certainly wouldn't.

Is it really philanthropy to extract money from people and then give some of it back to them? We don't really know how much the Gates Foundation's ill gotten gains come from the countries that eventually 'benefit' from its 'largesse'. The Foundation, in its great (undemocratic) wisdom, decides who benefits as well as who loses and they are certainly not going to tell members of the public, especially not in developing countries. The Foundation aims to keep its wealth intact, regardless of how it achieves this. Any doubts or worries that arise can be assuaged by some pretty pictures of happy children or mention of names like ‘Kofi Annan’.

It comes as no surprise that the Foundation now has a considerable investment in Monsanto. This multinational has much to gain from developing countries and has shown that it is unscrupulous enough to do whatever is required to maximize its gains. The Foundation's sham 'Alliance for a Green Revolution in Africa' (AGRA) has never denied that it will take advantage of GM if and when it sees the benefits. Gates has been investing in Monsanto for years. Some have probably been wondering when pay day was due.

This diabolical coupling does have one feature that may not be completely negative: it brings into clear focus the intimate connection between the unscrupulous grabbing by some institutions and the equally unscrupulous ‘philanthropy’ of others. Gates and a small handful of other rich people and institutions control the means of production where the products include poverty, disease, starvation, environmental destruction and a whole lot of other ills. And where would we be without all of them?


Sunday, August 29, 2010

Who Will Educate the Educators?

After leaving Maker Faire Africa on Friday, inspired by much of what I saw there, I returned to Nakuru, where many of the town's residents stand or sit in the same places every day, staring at passers by, shouting the odd bit of abuse and joining in any commotion that happens to relieve the monotony.

I admit, I was a bit annoyed when I compared how some people do amazing things with their time and others do not. I always have to go through the same thought process; first I get exasperated and then I remember that there can be reasons why some people energetically pursue things that benefit them and others while some people seem condemned to get up every day and stare into the middle distance until it gets dark.

The vast majority of exhibitors that I talked to at Maker Faire were well educated and some were clearly from well off backgrounds. This means nothing on its own. Those with lots of education from well off backgrounds can also end up doing little with their lives. And some from poor families with only a basic education achieve great things.

But some of the exhibitors were also wondering why some of their fellow Africans didn't do what they were doing. And one reason I would suggest is lack of basic education and training in skills that allow people to prosper, or at least to get by better than they do now. When I attempted to demonstrate to people around Nakuru how they could make and use simple technologies, they went through a few phases: they were curious, even surprised; they raised objections; they became silent and sat on their hands.

I admit, they may not have had the best teacher. But I think there is something about education beyond what is imparted by a teacher and embraced by a learner. People didn't sit on their hands because they were unable to cut out shapes using patterns and stick things together with glue. They are well able to do such things and many others. I would guess that most of them could have done much of what the exhibitors at Maker Faire did.

What people gain from education, I hope, is the ability to make what they learn part of their day to day lives, whether this involves various bodies of knowledge or sets of skills. What people with a poor education receive is lists of things to learn off so that they can get the requisite number of ticks in order to graduate to the next class. These ticks are rarely, if ever, of any use to people thereafter. But once people have mastered the pretence of being educated, they have no way of taking their education further.

I'll say it again, people with education and training may not necessarily do much with it. And those with little education and training may spend their lives enhancing what they have got and benefiting themselves and those associated with them. But that seems like leaving things to chance for the majority, while allowing a minority quite an advantage, whether they use it well or not.

Development projects can be very narrowly focused. For example, many education projects focus on a few indicators, often the ones that show the project in a favorable light but give little benefit to the recipients. They might concentrate on enrolment but not attendance, exam results without any evidence of learning or the ability to continue learning after school has finished, gender parity without any change in genuine inequalities, etc. 'Success' in development projects can resemble the 'success' of students who have received a poor education.

HIV projects can involve huge amounts of money and produce amazing statistics about the number of HIV transmissions prevented, the number of deaths averted and the number of condoms distributed. Yet people are suffering from and dying from very ordinary diseases that are easy to prevent and cure. Health is not just a matter of disease or being free of disease and it's even less a matter of one virus (which is still endemic in many countries in the world, despite hundreds of millions having been spent on 'prevention' programs).

There seems to be an emphasis on size and magnitude and the measurement of these development projects, as if there is some great prize to be won on the basis of a few hackneyed quantities. Is the aim of development not to ensure that there are fewer millions of people receiving little or no education, suffering from and dying from preventable and treatable illnesses, unable to afford basic nutrition or water and sanitation? Of course you have to count people, but people are not indicators, nor are health or education.

Many of the projects at Maker Faire were about things that matter to people in their day to day lives, food, water and sanitation, agriculture, communication, income, energy, lighting, raw materials and the like. There was less emphasis on education that I would have expected, unless you count some electronic device that 'helps children learn to read'. But these are all concerns that are raised when you go to villages, slums and isolated areas.

Levels of education, especially among girls and women, can be shockingly bad. Many primary school teachers are said to have a low understanding of the subjects they teach and even those who know more don't manage to impart much. But education is not just a process of 'attaining' a set of facts or skills. It is the preparation that everyone needs in order to ensure the education and health of themselves and their families and to ensure that they grow up to be able to provide for themselves and their families, in turn.

A lot of development is dominated by quantities and measurement, a set of boxes to be ticked, regardless of the irrelevance of such processes to people's lives and livelihoods. The Millennium Development Goals, mentioned several times at Maker Faire, are the epitome of such a lifeless and administrative view of development. People need basic things, education, health, nutrition, income, water and sanitation and infrastructure, but they also need to be able to provide themselves with these and other rights. These are not things you can pack in sacks and send them off in an aid convoy.

Significant feats will not be achieved by hordes of administrators with clipboards (or technological variants of clipboards) recording a handful of indicators as people die prematurely and needlessly, though this is a great way of spending billions of dollars. I suppose development will only achieve anything when it has put people in developing countries in the position where they can do the development. So far, we have not been very good at this (and I include myself, of course).

That development needs to be sustainable, that it needs to give rise to further development, seems clear. But it also seems to matter a great deal who is doing the development, who is able to do it, whether it is outsiders from developed countries or insiders from developing countries. Which is very similar to the conclusion I came up with yesterday! I could go on, but tomorrow is another day.


Saturday, August 28, 2010

Maker Faire Africa; an Exhibition of Brilliant Ideas

I was in Nairobi yesterday to visit Maker Faire Africa, a trade exhibition for people who make things, invent things, develop things and use things to achieve worthwhile ends. The exhibition divided roughly into crafts and technologies. The crafts ranged from highly original to original variations on a theme. And the technologies ranged from pretty low tech, through intermediate and right up to high tech exhibits.

Many of the exhibits were familiar to me in some way, largely through the blog This blog searches for and covers any really good ideas and they are often just the kinds of ideas I've been searching for, in one way or another.

For example, I work in a place where sisal is grown but no high value goods are made from it here and no local people make anything more than a pittance as a result of working with the crop. But I came across a set of jewellery made from sisal, made in Rwanda, something that people here could easily make (I include links where possible but the majority of them didn't work for me). There was also a man who had developed a small machine that one or two people could use to make sisal string and rope. At present, the industry is dominated by a handful of foreign owned factories that date back to the 1950s.

I have also been trying to persuade people that they could use a lot of their organic waste to produce fertilizer or to compress into briquettes that can be used instead of charcoal, wood or other expensive fuels. There was a company exhibiting that makes presses that can be used for producing oil (from seeds), produce low cost and highly resilient bricks and compress fuel briquettes. There was also a group of people producing low cost fertilizer from organic waste. There's a shortage of affordable fertilizer here and far too much dangerous waste, so there's nothing like a product that has a whole range of benefits.

The issue of water hyacinth infestation in Lake Victoria and other inland waterways has long been an environmental challenge. Yet, there was already plenty of technologies and knowledge about how to use the hyacinths as biomass to make into fodder, fuel, fertilizer, furniture, household goods and anything else people can make, depending on their ingenuity. After all, the infestation is relatively new in East Africa but not in Asia. I saw an example of the many possible products, yesterday, made from water hyacinth grown in Nairobi Dam.

Bicycles are a very familiar and useful technology here and there were demonstrations of how to use them to charge mobile phones and other devices. Also, there was a young man demonstrating a bicycle powered maize shucker. People beat maize cobs in sacks at the moment to get the grain off the cob. The bicycle shucker is far quicker and more efficient. This young American man working in Tanzania also had an excellent command of Kiswahili, I was envious. A similar technology can be used to grind the maize, which could save people a lot of money and time as well.

While there was some medium to high technology being exhibited, much of it seemed of little interest to the places where I work, where most people don't have electricity, let alone TV or computers. Even internet cafes are expensive and slow and few people would even know how to use them, or have any inclination to do so. Technophiles forget that basic education is a prerequisite to many things, technology is just one of them.

Anyhow, there was a man from South Africa demonstrating a small (but scalable) telecommunication system which would be ideal for villages, especially where they have also looked into some locally available source of power, such as wind or solar (or a combination). It was unsurprising to find that this man had worked in development for many years and understood some of the hurdles that people face, instead of producing something that has no application in the sorts of places it was intended for.

Spanning design and craft, there were some young women who were making solar powered LED torches, which use local wood and are shaped to have a large surface available for the solar panel. The panels come from Switzerland, which probably explains the high cost of the torches. I also met a man from Malawi who had built a device that cooks ugali (maize porridge, the Kenyan staple, revered but ultimately tasteless, nutrition free and responsible for high rates of diabetes here. He was very enterprising and well informed and it's not his fault that the staple food is not ideal!). He also worked with windmills and other technologies. I'd love to see people building and using windmills in Kenya.

On the craft side of the exhibition there was some amazing ceramic work by a small company called 'Beauty for Ashes Pottery'. Most of the ceramic work I've seen here is just copies of copies churned out for tourists and it's refreshing to see genuine art mixed with this practical and indigenous skill. There was also a young design student who had pushed the boundaries of jewellery and accessory design using recycled materials and I regret not having any contact details for her. But I think the word will get around.

A man who used recycled materials to produce the most bizarre looking novelty glasses got a lot of well deserved attention. An example can be seen on the Maker Faire site at the moment, but you'll have trouble visualizing the length he has gone to in using highly unlikely materials. Other designers used well-known recycled materials to make commonly made products, but some had modified processes in interesting ways. There were the predictable accessories made from the caps of beer bottles but one woman was creating a nice effect by covering each cap with cloth so the bags, wallets, etc, looked a bit like armour plating. Very eye-catching.

On both the design and the technology fronts, there was a very noticeable presence of Kibera, people from Kibera, organizations with Kibera in their name; it's almost a brand. Perhaps in NGO-speak it really is a recognised brand. Journalists seem unable to mention poverty in Nairobi without mentioning Kibera and a handful of factoids about it. But journalists seem unable to mention anything that isn't also mentioned, frequently, by other journalists. And they don't seem able to mention things that haven't been hyped, that's just the way journalism works, it seems. They rub our faces in what we know already, perhaps in the hope that we won't notice that there is anything else.

You'd think there were no other slums in Nairobi, when in fact the majority of Nairobeans live in a slum that is not Kibera. The majority of Kenyans live in a slum that is not in Nairobi. But then, those slums haven't had films, computer games, pop videos and documentaries in them. They are not home to hundreds of NGOs and thousands of development projects. It's hard to believe that there is anyone poor left in Kibera but if there are (and I think there are many), what the hell are all these organizations and their millions of dollars doing?

I didn't get to talk to all the exhibitors, that's just a list of the ones I did get to talk to. Most were very fired up by what they were doing and they all had a spark of originality, also the desire to produce and do things that are needed, rather than copying what millions of others are doing. There was a real spirit of adventure in most of the people I met, I think anyone who meets them and sees what they are doing will want them to succeed, will want to think that they will hear more about these and other great ideas.

I suspect there are many 'makers' of all descriptions around Kenya and other African countries but they can be very hard to find. I've found that myself, other people working in community development have said the same thing. Almost all the people I talked to had some, probably good, access to the internet and other technologies, even where their work is not technological. But some of the people who organized the event have put a lot of effort into finding the best exhibitors and I think the next fair will be even bigger.

I warmly congratulate the people who organized the Maker Faire Africa exhibition and those who exhibited. I was very impressed, both with those who demonstrated things I had heard of but not seen and those who demonstrated things I had not heard of, despite searching high and low for good ideas. I hope people who can benefit from these ideas get to hear about them so that those who develop the ideas can prosper and produce more good ideas. Some people say that development must come from Africans themselves, and I agree. And there is some evidence that this is already happening.


Wednesday, August 25, 2010

Harm Reduction Needs to Start in Health Facilities

Now that PEPFAR (the US President's Emergency Plan for AIDS Relief) have revised their Bush era decision to refuse funding to harm reduction programs, the Kenyan government may also consider changing their policy towards intravenous drug users (IDU). According to the head of Kenya's National Aids Control Program, addiction will be treated as a health issue and needle exchange, methadone and condoms will provided for IDUs.

Although the contribution of intravenous drug use to Kenya's epidemic is currently estimated to stand at about 4%, this kind of exposure is a highly efficient transmitter of HIV. Heterosexual sex, on the other hand, is not such an efficient transmitter. In some countries, sex workers are only likely to die of Aids if they are also IDUs.

Commercial sex work can be one of the few ways to make enough money to feed a drug addiction. The drugs have to be paid for, but injecting equipment can be, and often is, shared. So a source of clean injecting equipment for IDUs could play a big part in reducing HIV transmission by this route. However, the decision to fund HIV programs that target HIV transmission among IDUs may also allow better estimates of their full contribution towards Kenya's epidemic. It may also allow a better evaluation of the part that commercial sex work plays in the epidemic.

Very few HIV positive IDUs are currently on antiretroviral treatment. Such treatment could significantly reduce sexual transmission of HIV, though it may not reduce non-sexual transmission so much. But giving IDUs better access to diagnosis and treatment should improve conditions for them and reduce further HIV transmission.

Sadly, the Kenyan police force may need more than a change in the law. As long as they and others can make money out of drug users, it's unlikely they will all turn into social workers overnight. Nor are NASCOP in a position to decriminalize drug use on their own. So let's hope decriminalization becomes a reality. If the administrators of PEPFAR can change their minds for ideological reasons, I'm sure the relevant people in the Kenyan government could change theirs for pragmatic reasons.

But any kind of re-evaluation of non-sexual modes of HIV transmission would be welcome in Kenya, in fact, in all African countries. If donors, governments, health professionals and other big players in the HIV scene start to think about highly efficient modes of transmission, as opposed to the low efficiency of most types of sexual behavior, ordinary academics, epidemiologists and others may eventually be allowed to research and publish data that currently appears to be deprecated (to put it mildly).

Those with the money, however they managed to get hold of it, decide how that money should be spent. There's little point in waving a lot of drug addicts in front of donors if those donors are opposed to working with drug addiction. With such restrictions lifted, who knows, drug addiction, and therefore HIV transmission among IDUs (and those they associate with), may turn out to be more common than previously assumed.

Perhaps donors and governments will eventually revise their attitude towards commercial sex work, especially in view of its interconnections with drug use. This could even lead to questions about exactly how much sex has to do with HIV when the far more likely transmitter is non-sexual.

And, it's a long shot, but if the HIV industry is willing to accept that some HIV is transmitted non-sexually, even among people who are said to have a lot of 'unsafe' sex, they may even wonder if ordinary people engaging in ordinary amounts of 'safe' sex are being infected non-sexually too.

Drug users are not the only people who use injecting equipment. More disturbingly, they are not the only people reusing injecting equipment. Some people get a lot of injections, because they are sick, pregnant, an infant, a sex worker, whatever. And in populations with high HIV prevalence, all of those people are at heightened risk of being infected with HIV, non-sexually.

Maybe we’ll live to see the day when sex is viewed once again as an aspect of health and life rather than as a spreader of disease. But first, we have to accept that poor health care can be a significant source of disease. Harm reduction programs, now that health care professionals and governments are allowed to talk about them again, need to start in health facilities.


Tuesday, August 24, 2010

UNAIDS Suppresses Revolution in HIV Prevention

In 2002, a number of articles were published in the International Journal of STD and AIDS (IJSA) that questioned the contribution of sexual transmission to HIV epidemics in African countries. They raised the possibility that non-sexual transmission, especially unsafe medical injections, contributed a far higher percentage of HIV transmission than previously recognised.

Given the amount of evidence presented in these articles, one might expect HIV epidemiologists and infection control experts all around the world to sit up and take note, broaden their research interests or even rethink some of the current ideology.

But very little indeed happened. An improbable number of people put their names to a short article denying that non-sexual HIV transmission plays a significant part in African countries' HIV epidemics. The authors reasserted that sexual transmission 'continues to be by far the major mode of spread of HIV-1 in the region'. Worse still, they reassert the need to increase efforts to reduce sexual transmission of HIV.

Almost a decade has passed since these IJSA articles were published and quite a number of additional articles have appeared, also casting doubt on the 'behavioral paradigm', the view that HIV is almost always transmitted sexually in African countries. These have been almost entirely ignored.

If the view of UNAIDS and the HIV industry is that HIV is mostly transmitted sexually, per se, that it is primarily a sexually transmitted infection (STI) which may sometimes be transmitted non-sexually, that would be easier to deal with. They would be quite wrong and the evidence against their claim would be undeniable (which is not to say they wouldn't deny it).

But things are not that simple. UNAIDS and the HIV industry claim that HIV is mostly sexually transmitted in African countries. They accept that non-sexual transmission occurs in non-African countries, especially among intravenous drug users. Contaminated blood is one of the most efficient routes for HIV transmission, so it is obvious that HIV positive people sharing injecting equipment run a very high risk of transmitting the virus or being infected with it.

Yet again, though, while going with the argument that transmission occurs when drug users share injecting equipment, the HIV industry does not accept that HIV transmission through reuse of contaminated medical equipment occurs to any great extent in Africa.

The WHO (World Health Organization) admits that up to 10% of blood transfusions in developing countries may be contaminated, and therefore be responsible for transmitting HIV and other pathogens. The WHO also accepts that as many as 17% of injections may be unsafe and they even estimate that about 70% of injections in developing countries are unnecessary.

This is why I accuse UNAIDS and the HIV industry of institutional racism: they believe that non-sexual HIV transmission occurs but they won't accept that it's a problem for Africans. This is an important distinction because they accept that medical practices are so unsafe in African countries that they won't allow their employees and associates to risk using them. But these same medical facilities, they claim, pose little or no risk to Africans; at least, not to the extent that they or anyone else should do anything about it.

No matter how you look at it, that is institutional racism. Evidence that should give rise to a revolution in HIV prevention programmes in African countries has been ignored. Instead of targeting risks, such as those that could be found in plenty in medical facilities, UNAIDS and the HIV industry have chosen to ignore anything that doesn't relate to sexual transmission of HIV, in Africa.

The majority of HIV positive people globally are from Africa and most of them live in Africa. Medical standards are so low in many African countries that a lot of people receive little or no health care, good or bad. Ironically, this may protect a lot of people from HIV and other viruses, such as hepatitis C virus. Certainly in Kenya, HIV is lowest where health care coverage is lowest and the virus tends to spread very slowly to places where people have little or no access to medical facilities.

The majority of HIV positive people in African countries are women. This is why I accuse UNAIDS and the HIV industry of institutional sexism. The view that HIV is almost always spread sexually (in African countries) is translated into the view that women spread HIV. The stigma that HIV inevitably brings with it derives from the behavioral paradigm. If most HIV is transmitted by unsafe sex, it follows that most HIV positive Africans have a lot of unsafe sex (there has to be a lot of unsafe sex because HIV is not easy to transmit sexually). If most HIV positive people are women (and the ratio of infected females to males is usually very high), HIV is mostly transmitted by women.

Of course, most women have sex with men and they are unlikely to transmit HIV to other women directly. And the many men these women do not transmit HIV to can not go on to transmit it to others. But questions about why so many more women are infected, why so few men in some areas are infected (if they are so sexually irresponsible, etc), why some infants and children are infected when their mother is not, any questions that make the behavioral paradigm seem less tenable, are either dismissed by the HIV industry or just not raised.

Instead of a revolution in HIV prevention, we now have reaction, a refusal to consider the role of non-sexual HIV transmission in African countries. We are left with a preponderance of 'prevention' programs that don't work, not because they are inherently ineffective (though they are) but because they bear little relation to how HIV is being transmitted. I accept that I don't know what proportion of HIV is transmitted non-sexually. But nor do UNAIDS or the rest of the HIV industry. I am asking that they deal with the evidence that has been presented to them, rather than sweeping it under the carpet.

In 2002, a new form of HIV denialism was institutionalized by UNAIDS. It was based on prejudices relating to race and gender. According to the institution and its followers, HIV is an STI; but only in African countries. HIV can also be transmitted by unsafe medical treatment; but only to non-Africans. The earlier denial of the connection between HIV and AIDS was bad enough, but the UNAIDS brand of denialism is internally contradictory. You can't even articulate it without being struck by the crudeness of its logic. However, if the rantings of the recent Vienna AIDS conference are anything to go by, this denialism is the state of the art.


Saturday, August 21, 2010

Prejudice Wins Over the HIV Industry

It has been well established that HIV is transmitted through sexual contact, through contaminated blood and other bodily fluids and from mother to child. However, UNAIDS and the HIV industry have a rather anomalous view of the disease. They have decided (or decreed?) that HIV is primarily spread through heterosexual sex in African countries (and from mother to child). But in other countries, so the story goes, HIV is primarily spread through contaminated blood, by intravenous drug users and unsafe medical practices, through men having sex with men and among commercial sex workers and perhaps their clients.

If HIV is mainly spread through blood-borne transmission, one would expect it to follow a similar pattern to other blood-borne diseases, such as hepatitis C virus (HCV). Two researchers have found that to be the case in a number of Asian countries. Countries with low HIV prevalence also have low HCV prevalence and countries with high HIV prevalence have high HCV prevalence. This means that countries with low HIV prevalence might see rates increasing at some stage in the future.

If HIV is mainly spread through heterosexual sex, as it is said to be in African countries, one would expect it to follow a similar pattern to other sexually transmitted infections. But this is not the case. Sexually transmitted infections are very high in many countries where HIV prevalence is not very high. Also, sexual behaviour that is said to increase the risk of HIV transmission tends to be a lot more common in countries that have relatively low HIV prevalence.

Differences between male and female sexual behaviour are also telling, where such differences have been detected by empirical enquiry, as opposed to speculation and assumption. Whereas males are more likely to engage in unsafe sexual practices, females are more likely to be infected with HIV. Men also tend to have more partners than women. But there is nothing to suggest that what is mainly a blood-borne disease in some countries should be mainly sexually transmitted, and rarely blood-borne, in others.

So, UNAIDS and the HIV industry are wrong in (at least) two important respects: firstly, it is unlikely that HIV is transmitted primarily through unsafe heterosexual sex in African countries because there is no evidence that levels of unsafe heterosexual sex there are high enough; and secondly, it is unlikely that HIV is rarely transmitted through unsafe medical procedures and other possible blood-borne routes. Conditions in African medical facilities are poor, just as they are in many Asian medical facilities.

In fact, in African countries where many people have (or at one time had) access to medical facilities, HIV rates are the highest in the world: South Africa, Zimbabwe, Swaziland, Lesotho, Botswana and others. In countries where many people have little or no access to medical facilities, HIV rates are far lower. For example, Kenya, Uganda and Tanzania, especially the rural parts of these countries. And in almost all areas with high HIV prevalence, more women than men are infected, often far more women.

So UNAIDS and the HIV industry have spent years tying themselves in knots trying to explain why a disease that is both sexually transmitted and blood-borne is mainly sexually transmitted in some countries and mainly blood-borne in others. This is especially difficult when neither levels of sexual behaviour nor conditions in medical facilities bear out such a conclusion. But if you supplant evidence with prejudice in developing a health strategy, you are bound to end up with such anomalies.

This sort of institutional racism results in the rather obtuse view that Africans engage in inordinately high levels of sexual activity, despite evidence to the contrary. HIV prevalence has reached hyperendemic levels in many Southern African countries, so the HIV industry insists on sexual behaviour change. Why these racists have also concluded that virtually no HIV transmission occurs as a result of unsafe medical practices is a complete mystery. But as a result, the industry feels that no effort need be made to improve conditions in medical facilities.

HIV, which is difficult to spread sexually, quickly spread to every country in the world throughout the 80s and 90s. In most countries, prevalence has remained below 1%. But in some countries, over 25% of sexually active adults are infected. No adequate explanation has been given as to how this could happen if HIV is mainly sexually transmitted. On the other hand, there have been several outbreaks of medically transmitted HIV (that have been properly investigated. In addition to Romania, there were also outbreaks in Libya, Kazakhstan and Russia that were caused by unsafe healthcare). The combination of sexual and blood-borne infection could help explain how these hyperendemics occurred.

This is not a conclusion. All we can conclude is that non-sexually transmitted HIV plays some part in countries with high HIV prevalence. The part that non-sexual transmission plays may have been more significant in the past, certainly in countries that have had the capacity to improve medical and other facilities. But rates of HIV transmission in some hyperendemic countries are still too high to be explained by sexual transmission alone. This means that a lot of work needs to be done to ensure that medical facilities and other places where blood-borne risks exist are made safe.

But first, UNAIDS and the rest of the HIV industry need to agree to investigate the extent of non-sexual HIV transmission. They need to agree to prevention programs that target non-sexual transmission, in all its forms. Unless people are aware of the risks they face, they will not know that they need to avoid these risks, let alone know how to avoid them. Surely levels of institutional racism and sexism that allow millions of people to become infected with HIV and to die of Aids are serious enough to deserve the world’s attention?


Thursday, August 19, 2010

UNAIDS: HIV, Your Name is Africa

This blog is beginning to sound like Dr Chasuble in The Importance of Being Earnest, whose sermon on the meaning of manna in the wilderness could be adapted to almost any occasion. But the theme of the 'behavioral paradigm', the view that almost all HIV is transmitted by heterosexual behavior in African countries, must be discussed over and over again. That's because the consequences of adherence to this paradigm are many, and extremely serious. It leads to a misconception of HIV that drives the epidemic.

If you explain a massive HIV epidemic like that in Swaziland by reference to sexual behavior, you thereby stigmatize every Swazi who is HIV positive. Because roughly one quarter of sexually active Swazis are HIV positive, every sexually active Swazi could eventually become infected, and also stigmatized. The entire population of Swaziland, along with most other Africans, is stigmatized by the behavioral paradigm, the backbone of the HIV industry's ostensible theory of how HIV is transmitted in Africa.

To accept the behavioral paradigm and declare oneself to be opposed to stigma is a crude contradiction. The behavioral paradigm is the source of HIV related stigma. According to it, if you are a HIV positive African, you have almost definitely engaged in unsafe sex. You cannot, logically, be opposed to stigma and at the same time adhere to the behavioral paradigm, either through argument or through action. In fact, you could go further; if you are African, you are HIV personified, according to the HIV industry. Because you are unsafe sex, the product of it and the perpetrator of it.

Unsafe sex is, of course, an undesirable thing, regardless of whether HIV transmission is involved. There are many sexually transmitted infections (STI) one can catch and there is also the possibility of unplanned pregnancy. It's not called 'unsafe' sex for nothing. But neither is all sex is unsafe. Even those who have no moral objection to sex between consenting adults would warn against taking such risks. And, contra the HIV industry, unsafe sex, as well as sex, occurs in every country in the world. But hyperendemic HIV doesn’t.

Non-consensual sex should never be tolerated and should also be punishable by law. But this is so regardless of whether HIV transmission is involved. Being sexually assaulted and being infected with HIV, or any STI, and/or being made pregnant, is worse still. But transmission of HIV needn't be involved for non-concensual sex to be abhorred. And one can have a moral objection to non-concensual sex without that moral objection even being a religious conviction. It is, or should be, a crime, punishable by the law.

All this may seem obvious to some people. But other people's reaction to what they see as immoral behavior seems, to me at least, to be downright immoral. These people would justify sexual assault on the grounds that they were preventing the transmission of HIV. They made a young woman strip because she was 'dressed indecently' and 'in an alluring way with the intention of passing on the HIV virus'. I don’t think I need dwell further on how ludicrous this argument is. They didn't even know if the young woman was HIV positive, they just felt, by making her take off her clothes, that they were upholding morality. This may seem like an isolated incident but it has happened on other occasions and, according to onlookers, many people took photographs.

People can make up their own minds as to who was 'upholding morality' and who was doing the opposite. My intention is to raise the question of why HIV, a disease, has been turned into an excuse for discriminating against people, whether by ‘moral’ vigilantes or leaders in the HIV industry. Viruses are not moral entities, but people are. Why are people being punished because they have been infected by this particular virus? Because this particular virus is said to be a consequence of immoral behavior. In Africa, that immoral behavior takes the form of heterosexual sex.

Immoral behavior should be treated as societies see fit; but surely that doesn't involve those considered to be immoral being made the victims of equally immoral, criminal behavior? Punishing a person for having a virus will not do them, or anyone else, any good. And having the virus is not, in itself, immoral. Failing to tell your partner that you are HIV positive or deliberately spreading a virus is wrong. But deliberately harming someone in any way is wrong.

One of the few things that the HIV industry is right about is that people should know their HIV status. But what the industry doesn't seem to want people to establish is how they became infected. The industry only seems to want sexually active people to know their status. Yet many are infected with HIV but are not sexually active; or they are sexually active but were not infected sexually. Everyone needs to know how HIV is spread, whether they are HIV positive or HIV negative because everyone needs to know how to prevent the spread of the virus and to put themselves in a position to do so.

If people don't know how they became infected it will not be possible to eradicate HIV infection. Somehow, millions of Africans are HIV positive and millions more are destined to become infected and the HIV industry doesn't want to do anything about it. I can't say why a large group of well educated people are more interested in propping up their industry than establishing exactly how HIV is spreading in countries like Swaziland. All I know is that they want people to believe that HIV is almost all about sex in Africa.

Even where HIV is sexually transmitted, reducing transmission is not a simple matter of legislating about who can have sex, with whom, when, where and what forms that sexual interaction can take. That hasn't worked anywhere and will never work anywhere. People may well need education about sexual risk taking and the like. But they need education about all sorts of things. A few sex education programs that skate over anything important is not going make up for a lack of education. And programs that fail to mention non-sexual HIV transmission, through unsafe medical or cosmetic procedures, for example, will have little effect on any HIV epidemic in Africa.

By making people fear the stigma and discrimination associated with being HIV positive more than the virus itself, the HIV industry has ensured that many people will never want to know their status. And many who do know will not wish to find out how they became infected. But people really should know how they became infected; otherwise how will uninfected people know how to protect themselves?

The HIV industry simply assumes, and wants others to assume, that people became infected through unsafe sex, at least, if they are African. The most frightening thing about HIV is the refusal of the HIV industry to address HIV transmission in all its forms, how they don't seem interested in anything but sexual transmission, which they have been completely unable to influence in any way, how they appear happy to see HIV continue to spread while they work their way through obscene sums of money that could be used to eradicate the disease. HIV itself is amoral, but that kind of industry is run by people whose morality needs serious attention.

HIV is a virus. It is not a weapon or a punishment. Yet the HIV industry and various other parties use it as a stick to beat HIV positive and HIV negative people. Some beat women, some beat men, some beat Africans, men who have sex with men, commercial sex workers, intravenous drug users or anyone who can be deemed to be 'immoral' in some way. It's always someone else who spreads HIV and they are always bad people, according to the orthodox view. But viruses are spread by infected people. And you won't cure a virus with a stick.


Wednesday, August 18, 2010

The Wrong End of a One Ended Stick

According to the South African Independent, a member of the Swazi royal family has dismissed the severity of the HIV epidemic in Swaziland, where prevalence is the highest in the world. He thinks the HIV industry is exaggerating the number of people infected in order to make money. The royal is sadly mistaken. The HIV industry will do anything to make money but they are not exaggerating. The healthcare industries make enormous amounts of money out of disease and the threat of disease but they don't need to make up the figures.

The deluded personage may also be right in saying that circumcision won't achieve much more than soap and water. But he appears unaware that clean water and adequate sanitation are not available to many Swazis. And he is also right, but for the wrong reasons, if he thinks that abstinence, being faithful and even using condoms will not eliminate HIV transmission. They may reduce sexually transmitted HIV but they will not reduce HIV transmitted through unsafe medical or cosmetic practices.

The thing that the Swazi royal, along with the entire HIV industry, fails to appreciate is that HIV prevalence in Swaziland is 86 times that of, say, India. That's just as well because the population of India is about 1000 times that of Swaziland. So if the ever-hungry HIV industry really wanted to exaggerate the number of people infected with HIV, India would be the place to do it, not Swaziland. But how could the sexual behavior of so many Swazis be so different from that of the rest of humanity, including that of India? Only a handful of countries, all African, come anywhere close to Swaziland's HIV prevalence figure.

Royals, members of the HIV industry and journalists should be able to work out that Indians have sex, quite a lot of it, with much of it being unprotected. And the number of HIV positive people in India is twice the population of Swaziland. But if rampant sexual behavior is enough to explain high HIV prevalence among the Swazis, substantially less rampant sexual behavior among Indians should give rise to a lot more infections, shouldn't it, given the multiple? But even among Indian sex workers, who the same royals, industry members and journalists will agree, must engage in a fair amount of sex, HIV prevalence is less than 5% and declining. That's lower than national prevalence in about 20 other countries, including Kenya, Tanzania and Uganda.

Nearly one fifth of all HIV positive people, about 8 million people, live in five African countries with a combined population of less than 70 million. India and China together, with about one third of the world's population, have about three million HIV positive people. If there were something so extraordinary about the sexual behavior of people in those five African countries, I think it would stand out, somewhat. And it would explain why ABC doesn't work: people are simply too busy to listen to the advice. If they stopped to listen and put on a condom, they wouldn't get enough sex in for that day.

But there is no evidence that sexually active people in countries such as Swaziland, Botswana, Lesotho, Zimbabwe and South Africa have four or five times as much sex as Indian sex workers. Nor is there any evidence that people in those countries take four or five times more sexual risks. Levels of sexual behavior in these and other African countries is similar to those found in countries with far lower HIV prevalence. The behavioral paradigm, which suggests that high HIV prevalence in African countries is mainly due to heterosexual sex, can not possibly be correct.

Despite the obvious falsity of the behavioral paradigm, it still shapes most HIV prevention programs and most national HIV strategies. The one thing the HIV industry refuses to do is establish exactly where HIV infections are coming from. The figures in 'modes of transmission' surveys are mostly guesswork, skewed by the very paradigm that is in question. The Swazi prince is wrong, Aids is not a scam. But the HIV industry's explanation of HIV transmission is a scam. Perhaps his high and mightiness will look into the matter, given the eagerness of the world's press to make his views so widely known.


Tuesday, August 17, 2010

Swaziland Takes Half a Step Towards Eradicating HIV

According to IRIN's PlusNews, Swaziland is to dump its ABC approach HIV prevention (Abstain, Be faithful and use a Condom). Swaziland has the highest prevalence of HIV in the world. The article states: "experts are still at a loss as to why Swazis have resisted all attempts to change the behaviours that put them at risk from the virus." But they needn't be puzzled. ABC hasn't worked anywhere. It's just that Swaziland is the first country to publicly admit it.

Don't be fooled by all the articles about Uganda working magic in the 1990s using ABC to reduce HIV prevalence. The approach didn't exist in Uganda in the 1990s and HIV prevalence was never even as high in Uganda as most of these articles say. Prevalence did reach very high levels in the country and they are low now, that's true. But many strategies were employed to reduce HIV transmission and the main reason why prevalence dropped so quickly in the 1990s is because death rates were very high. A similar pattern occurred in Kenya somewhat later, which took the Kenyan government by surprise as they hadn't even got around to admitting that there was a HIV epidemic in the country.

While recognizing that ABC is not working in Swaziland, Dr Derek von Wissell, director of the National Emergency Response Council on HIV/AIDS is still convinced that "behaviour is what has to change". He then turns his attention to men, pointing out that 70% of men are "free agents", to whom being faithful does not apply. This is supposed to explain why HIV prevalence is 38% among girls in the 20-24 age group?

There is something very unconvincing about this explanation. Unless the majority of sexually active women are having a lot of unprotected sex with a small number of men, we really don't have any idea where all these infections are coming from. In order to infect someone with HIV, a man needs to be HIV positive. In fact, he also needs to have sex with each woman quite a number of times, statistically. If Dr von Wissell is thinking straight, there is a small number of men who need to be identified and given some good advice, quickly. Never mind targeting sexually active women.

But I don't think the man is thinking straight. His thinking, like that of most thinking throughout the HIV industry, is skewed by the 'behavioral paradigm', the belief that almost all HIV is transmitted through heterosexual sex in African countries. To hold this belief, you need to think that, sexually, Africans are different from people from other continents. They have a lot more unsafe sex with far more partners than those in other continents. Also, the women are particularly prone to having unsafe sex, lots of it, with a certain group of highly sexually active, HIV positive men.

Of course, these beliefs are just prejudices, there is no evidence for them. On the contrary, there is plenty of evidence that some people in all countries have lots of sex, even unsafe sex. But most people don't. Yet, in some African countries, HIV prevalence is so high that almost every sexually active woman can be considered lucky to remain uninfected. Swaziland, in particular. If you stick fast to your prejudices, you might wonder who these evil men are, you might even wonder about why the majority of women take such stupid risks. But if your approach to reducing HIV transmission is so influenced by prejudice, you may not be bothered by any glaring irregularities.

The lessons that the HIV industry steadfastly refuse to learn are that, one, you can't just legislate for (or against) certain kinds of sexual behavior, despite decades of evidence of this from the population control brigade. And two, not all HIV is transmitted sexually. If von Wissell wants to "challenge conventional thinking" and to avoid slavishly following what went before, he would want to go a little further than uttering soundbites about needing to find new ways to prevent infections. He could start by looking at how HIV is being transmitted, how it is actually being transmitted, not how the HIV industry says (and really wants to believe) it is being transmitted.

Even allowing a very high probability of HIV transmission per sex act, you would have to believe that Swazi women have a lot of sex with a lot of different partners to explain current prevalence rates. Coupled with that, you would have to believe in that small bunch of HIV positive men, who get to have sex with far more than their fair share of women. In days gone by, all sorts of myths were dreamed up to explain pregnancies that shouldn't have occurred, such as seals appearing as men and then disappearing again. But we don't need to resort to such myths any more. It's time for the HIV industry to wake up. It's time to admit that non-sexual HIV transmission plays a part in hyperendemic countries such as Swaziland and to investigate modes of transmission properly.

ABC doesn't work; it has never worked; it will never work. Good sex education, as opposed to obscure platitudes and moral cant that is completely ungrounded in any reality, would be welcome. Children in African countries are in bad need of any kind of education; but general education is a prerequisite to sex education. Education about and access to condoms would also be helpful, in many ways. But no approach to HIV prevention that assumes the truth of the behavioral paradigm will eradicate HIV. Swaziland has made the first half step. Let's hope the HIV industry doesn't interfere this time.


Monday, August 16, 2010

Measurement of Success is the Measure of Our Failure

Out of the top ten killer diseases listed by AlertNet, most relate to a lack of something very basic:

Number one, lower respiratory infections are closely related to poor environmental and living conditions; 2, HIV/AIDS is related to many things, including healthcare, education, infrastructure, labor practices, legal issues, equality and others; 3, malaria is to a large extent related to environment and living conditions; 4, diarrhea is mostly related to poor water and sanitation; 5, TB, environment and living conditions.

It's not until you get to numbers 6 to 9, measles, whooping cough, tetanus and meningitis that you find diseases that are generally controlled with a vaccine. And controlling these diseases still requires adequate health systems, education and infrastructure. Number 10, syphilis, can also be controlled by good sexual healthcare, sex education and drugs.

But the point is that medical treatment is not health. Medical treatment is for people who are sick. In order to avoid numbers one to five, the majority of people need things like good housing and domestic facilities, water and sanitation, access to nutritious food, education and the protection of the law against discrimination, exploitation and inequality. If these basic needs are not met, medical treatment alone is unlikely to be of any use. These top ten killers kill millions of people because of the absence of things other than medical treatment and supplying endless amounts of medicine will not prevent illness and death.

The AlertNet article is perverse in that it doesn't mention that the biggest killer, lower respiratory infections, are spread by poor living conditions and that, therefore, deaths could be significantly reduced by concentrating on improving these conditions. One of the Millennium Development Goals includes reduction in child mortality as an indicator of progress. But that doesn't necessarily translate into improving living conditions. Children are especially susceptible to respiratory infections and much of the mortality from these causes occurs in children and infants. But providing lots of treatment is not a substitute for better conditions.

Similar remarks apply to malaria. It can be better controlled if people live in decent housing. When they live in villages, towns and cities, especially, the environment also needs to be such that malaria carrying mosquitoes can be controlled. But a large percentage of people live in semi-permanent housing that doesn't protect them from mosquitoes and other threats. Mosquito nets are good if people have enough space and enough beds to make them effective, yet many live in cramped conditions where mosquito nets are less effective. Technical solutions need the right conditions and have sometimes proven to be a waste of money.

One often hears calls for vaccines against diarrheal diseases and big donors are especially fond of such vaccines.  But what these big funders don't seem to want to ask is why are people drinking water contaminated with their own feces? These vaccines may have some impact at first, but if people don't have access to clean water and good sanitation, they will continue to be infected with other water borne diseases. Is it even logical to give some medicine to people who then continue to drink contaminated water? Vaccines may be a good supplement to eradicating some of the big killer diseases but without ensuring safe water and sanitation, they will have little effect. The same applies to pneumonia vaccines.

Providing people with decent living conditions, water and sanitation and the like are expensive. But billions of dollars are spent on vaccines, much of the money going to rich and powerful multinationals. There isn't a lack of money, just a lack of equity. Most of the money is being spent on subsidizing the rich; pharmaceutical giants, agriculture and the like. It's true that most people in developing countries don't die for lack of food, and malnutrition doesn't usually kill people either. But these both leave people weaker, more susceptible to disease and more likely to die of preventable and treatable diseases.

Sometimes it appears that development misses the point: yes, people are poor, undereducated, unhealthy, isolated and otherwise deprived. But a handful of indicators is not a measurement of development. The aim of development is not to produce a few Olympic runners, jumpers and throwers and then claim some gold medals. The aim is that everyone can enjoy healthy and fulfilled lives. Achieving some goal such as immunizing all (or most, or 80%) of children against a couple of waterborne diseases is a failure if they still die from some other waterborne disease; it's a failure if they don't have access to clean water and good sanitation. Immunization, like much medication, can be a necessary condition to ensure health, but it is not sufficient.

Of course, development experts are not advocating that everyone be supplied with medication and ignoring other conditions. But the money is mainly going towards the technical solutions and not going towards supplying basic needs. In developing countries, many people spend more money on healthcare and health care products than they do on more basic things. And where they don't have the money to spend, a lot of development money is spent on these services and products. Basic needs are prior, in the sense that they must be supplied first. In highlighting how basic some of the top ten killer diseases are, AlertNet takes the first step towards refocusing attention. But it fails to say why so many people in developing countries are dying needlessly or what can be done about it.


Saturday, August 14, 2010

It’s Undermined Itself; Will the HIV Industry Now Abolish Itself?

There are many myths and confusions about HIV/Aids and Wikipedia lists and debunks many of them. But one of the most dangerous myths arises, not so much because of what is said, as because of what is not said. The view of the HIV industry is that most HIV in African countries is spread by heterosexual sex. According to the industry, unsafe healthcare probably only accounts for about 2.5% of HIV transmission.

There are two major consequences arising from the HIV industry's view, which is widely accepted as being based on the most up to date and reliable information: firstly, people in African countries are left unaware of what could be a significant source of HIV infections and, therefore, of how to protect themselves; and secondly, it is generally assumed that people who are HIV positive have engaged in unsafe sex and many become the victims of stigma and discrimination as a result of this association.

Unfortunately, this is one of the myths that Wikipedia does not deal with. They do deal with a closely related myth, that 'HIV survives for only a short time outside the body' but they simply replace that myth with a weaker version. Similarly, the article mentions the danger of sharing hypodermic needles among intravenous drug users, but they don't point out that sharing syringes also carries a serious risk.

There's a recent article by Dr Devon Brewer in the Swaziland Times on myths about HIV and other viruses only surviving for short periods outside the body. Small amounts of contaminated bodily fluids can stay infectious for a week or more, whether wet or dry. As this has been known for over 20 years, it's a bit of a mystery that so many influential people and institutions still appear to think otherwise. Interestingly, healthcare workers in developing countries are taught the myths while those in developed countries are taught to see all potentially contaminated blood and bodily fluids as dangerous.

More detailed information about non-sexual HIV transmission can be found in a book, published free of charge online, by Dr David Gisselquist, entitled 'Points to Consider'. The extent to which non-sexual HIV transmission has been underestimated, even denied by the HIV industry is shocking, but also very difficult to understand. Once the industry wakes up it will be a big job to disabuse people of the inaccurate and incomplete information they have been fed for so long. But sooner or later, it will have to be done.

Despite recognising the risk of transmitting HIV and other viruses through sharing injecting and other potentially contaminated equipment, the Wikipedia article fails to acknowledge that the same risks occur when potentially contaminated equipment is shared in healthcare contexts or even during cosmetic procedures. This failure seems illogical, but they are in good company, given that UNAIDS and the rest of the HIV industry go to a lot of effort to downplay such risks.

The reason why this set of risks is so much more important than the various other myths discussed in Wikipedia and elsewhere is that people could easily protect themselves if the existence of the risks was not denied by the industry. The HIV industry does attempt to defuse some myths. But their adherence to the 'behavioral paradigm', the view that most HIV is transmitted through heterosexual sex and that transmission can be reduced by influencing sexual behavior, means that people are not warned about non-sexual risks. And the HIV industry has not even investigated many instances of non-sexually transmitted HIV, so they don't have any idea of the extent of such transmission.

Healthcare for most people living in Sub-Saharan African countries is appalling. Many people with treatable and preventable conditions are unable to afford even the most basic medical care. They have no option but to put up with these conditions until they recover or until they die. Foreign donors are very keen to promote certain kinds of healthcare, such as childhood immunizations. Well run immunization programs can save the lives of many children. But badly run programs can result in healthcare related infections and other risks. Even in developed countries, those working in healthcare facilities need to observe very strict guidelines about sterility. When they fail to do so, the consequences can be dire.

Gulu district in Uganda is proposing that they force parents to be immunized and to have their children immunized against a number of diseases. Yet, one of the officials advocating such measures admits that they don’t have enough drugs and that often, drugs are stolen. But not only are drugs stolen or in short supply in government run clinics, other equipment is also affected. Often, there is not enough sterile equipment that should only be used once and this can result in the same equipment being reused. In populations with high prevalence of HIV and other diseases that can be spread by contaminated equipment, such conditions could easily lead to far more than the 2.5% figure estimated by UNAIDS.

Prevalence of HIV and other viruses shouldn’t be very high among young children and infants, so the risk of being infected through unsafe healthcare may be lower than in other scenarios. But pregnant mothers are routinely given injections, as are women visiting family planning and sexually transmitted infection clinics. Those involved in commercial sex work would be particularly at risk from unsafe healthcare as they regularly visit clinics for both vaccinations, treatment and injected contraception. It’s no wonder that HIV prevalence among sex workers in Zimbabwe is currently said to stand at around 80%. Heterosexual transmission risks are very low compared to the risks people face in healthcare facilities that work with high HIV prevalence populations, especially where equipment is in short supply and the risks are not widely recognised.

The most pernicious aspect of the myth that most HIV transmission in African countries results from unsafe sex and that very little results from unsafe healthcare is that it is propagated by the very industry that has built itself up around promises to reduce transmission and eventually eradicate the disease. Far from reducing transmission, the industry is more likely to be responsible for a significant percentage of transmission and for continuing to fail to prevent transmission by implementing adequate levels of safe healthcare. To make matters worse, the industry has stigmatized the victims of the sort of institutionalized racism and sexism that arises from blind adherence to the behavioural paradigm.

A sympathetic analysis of the HIV industry’s refusal to deal with non-sexual HIV transmission might point to the consequences of people losing faith in their health services. But people in African countries have already lost faith. This is one (only one) of the reasons that the HIV industry’s efforts to treat and prevent HIV have been so futile. If people are not engaging in risky sex, they will not listen to those who insist that they are. Even those who are engaging in risky sex will not wish to be stigmatized. And they too face the same, perhaps even greater, non-sexual HIV risks. The HIV industry has been founded on a myth, but one that undermines their utility. Will they go or will they have to be pushed?


Thursday, August 12, 2010

A Threat to the Behavioral Paradigm

An article entitled 'Could HIV be a matter of biology?' may surprise some people, who would think that all diseases must have some connection with biology. But there is a large group of people, comprising the bulk of the HIV industry, who think biology is of little relevance, perhaps of no relevance at all.

The article says "Africa's HIV epidemic may not be driven by behaviour alone according to a new study suggesting that Kenyan women are more biologically susceptible to the virus." This is not just the claim that women are more susceptible but that women in countries where there is a high disease burden are more susceptible than women in countries where disease burden is low.

The HIV industry, led by UNAIDS and big HIV donors, is quite explicit on the matter: most HIV transmission in African countries is through heterosexual behavior. Most of the industry's 'prevention' programs and resources are aimed at influencing sexual behavior. Little or none of their programs or resources are aimed at influencing the conditions in which people live, even though these may have a lot of impact on sexual behavior and on HIV transmission.

The hypothesis that HIV could be, at least partly, a matter of biology, is not particularly new. There are several researchers who have long objected to the 'behavioral paradigm', the view that massive HIV epidemics in some African countries are mainly a result of African sexual behavior. African sexual behavior, the paradigm says, is substantially different from the sexual behavior of people in other continents, where HIV transmission is mostly related to men having sex with men, intravenous drug use and perhaps commercial sex work.

But the hypothesis that those living in countries with high disease burdens are more susceptible to HIV, for example, endemic malaria, intestinal parasites and various forms of malnutrition, is not new. Eileen Stillwaggon, and possibly others, have been expounding such a hypothesis for many years. Indeed, the knowledge that HIV attacks the very cells that are produced in large quantities when people's immune systems are attacked should alert researchers to the possible role of co-infections in susceptibility to HIV.

Just when people are (biologically) least protected from HIV infection, they are most susceptible. So the authors of this study hope that their findings will 'revolutionize prevention efforts'. Let's hope so. Lecturing people about who to have sex with, how, when and where has not worked. There may be many reasons why this approach has not worked. But approaches to HIV prevention that do not assume the truth of the behavioral paradigm are long overdue.

It would be good if any Damascan convertion that may take place were not limited to a search for non-behavioral responses to HIV. After all, some effort to reduce levels of malaria, intestinal parasite infestation, malnutrition and many other conditions are also long overdue. They seem to have become isolated from funding, except to the extent that they may have something to do with HIV transmission. They are all in need of the sort of effort that has gone into reducing HIV transmission, but hopefully with better results.

It would also be encouraging if those holding the purse were to take note that health is not just a matter of disease or disease reduction. Malaria and parasites are intimately connected with environmental factors. Two of the top killers of infants and children, diarrhoea and respiratory infections, are similarly connected with the environments in which people are forced to live. It would be stupid beyond belief to treat all these diseases without also improving the conditions in which people live. Stupid beyond measure, but sadly, the approach favored by UNAIDS, the HIV industry and healthcare development as a whole up till now.

Towards the end of the article, the issue of stigma is raised. Because of widespread adherence to the behavioral paradigm, those infected by HIV and those thought to be at risk of being infected and of transmitting the disease, are associated with sex, illicit sex, specifically. If the HIV industry could be persuaded to accept that HIV is not just a matter of behavior, they might relax their adherence to the childishly naive paradigm. Instead of blaming people, while at the same time saying they don't blame them, they might come to realise that HIV positive people really are not to blame for becoming infected.

We should not expect the HIV industry to be influenced to any significant extent by scientific research; they have remained almost hermetically sealed from such influence so far. But those who have long opposed the behavioral paradigm and who advocate for genuine improvements in the conditions in which people live may soon be joined by other reasonable people. There would be little point in eradicating one virus and leaving people to die of other, more easily preventable and curable diseases. HIV is not just about sexual behavior and health is not just about disease.


Tuesday, August 10, 2010

Manufacturing Markets for Big Pharma

There’s a distinct tension between two articles I came across recently on generic antiretroviral drugs (ARV). The first, entitled ‘PEPFAR success critically dependent on use of generic ARVs, study shows’, claims that use of generic ARVs have allowed PEPFAR (the US President’s Emergency Plan for Aids Relief) to reach its target of getting 2 million people on treatment in low and middle-income countries. The article describes how use of generics has overcome various objections from some US politicians, who were well lobbied by the pharmaceutical industry and its cronies.

I would guess that what pharmaceutical companies settled for was to be in control of generics, rather than wishing their use to be banned. They would have wanted to control who produced generics, where and at what price. There’s no reason to lobby against them if they bring in a healthy profit. We are told that PEPFAR saved around 323 billion dollars by using generics. Regardless of whether they would really have spent that much money on overpriced pharmaceutical products, pharmaceutical companies still took in hundreds of millions of dollars. Anyone with shares in the industry need have no worries about that.

The article concludes that “Drugs are no longer the main driver of treatment costs”, which is good to hear. But it is interesting to note that drugs for sick people are potentially just a small part of the ARV market. A much hyped microbicide, a gel containing the ARV Tenofovir, is aimed at women who are HIV negative. And the same Tenofovir is behind the current pre-exposure prophylaxis trials (or ‘PrEP’, the process of taking antiretrovirals to reduce the likelihood of being infected with HIV), amply supported by Bill Gates’s Foundation. PrEP could potentially be used by any HIV negative person, though it may be targeted especially at men who have sex with men and perhaps commercial sex workers.

Current estimates are that in excess of 30, perhaps nearly 40 million people are HIV positive. That sounds like a vast market for ARVs when you consider that people will have to take them for the rest of their lives. But this is nothing compared to the number of people who could be customers for microbicides, PrEP and any other ways of selling ARVs that the pharmaceutical industry dream up. In Africa alone, the potential market could run into hundreds of millions of people. It is to be wondered if PEPFAR will still have the stomach for that. Gates needn’t worry, the Foundation stands to gain if microbicides and PrEP get off the ground.

In case hundreds of millions of customers doesn’t satisfy Big Pharma, and it won’t keep them happy for long, newer versions of ARVs are constantly being produced with improvements or claimed improvements. These are gradually replacing older versions. And those on ARVs, sooner or later, develop resistance to first line drugs. Second line drugs can cost many times more, but without them people will die. Third line drugs are still beyond the reach of developing countries, despite all the donor money available for treatment. It’s not clear where all the money will come from as it will exceed PEPFAR, the World Bank’s Global Fund and Bill Gate’s savings many times over. But things are going well for Big Pharma so far.

The second article is entitled ‘HIV generics under threat from tighter patenting rules’. This is about the pharmaceutical industry lobbying that is still going on to persuade governments, and anyone else who will listen, to create intellectual property laws that prevent generics from being produced. The US and the EU are the main culprits, as usual. Although generics can be produced once a ‘voluntary licence’ has been obtained, the original patent holder still gets a big say in how the drugs can be distributed, how they are priced and where they are sold.

Some object to this on the grounds that it leaves too much power in the hands of the patent holders. As I suggested above, the pharmaceutical industry likes to be able to control things and it seems unlikely that they would have conceded anything without getting their pound of flesh. Far from trying to relax intellectual property laws so that poor countries with high HIV prevalence can benefit, the US and the EU have been trying for some time to make it more difficult for countries like India, the biggest producer of generic ARVs, to produce these drugs. And there have been efforts, some of them successful, to prevent other countries from buying them. An example is Kenya, and other African countries are now trying to create similar laws.

Given the weight behind increasing the cost of ARVs, it seems very odd that PEPFAR should be fighting to reduce them. Are we supposed to believe that PEPFAR is in conflict with the government that allowed it so many billions of dollars? Could PEPFAR be a champion of fair intellectual property and trade laws that benefit poor people in poor countries? This is difficult to accept. The PEPFAR billions were unlikely to have been forthcoming in the first place unless they stood to benefit the US industry as a whole and Big Pharma in particular.

The World Trade Organization (WTO) has talked the talk of allowing developing countries access to ARVs by giving them a nominal right to produce generic ARVs under a compulsory licence. But this has had little impact in practice. And in case it should ever any impact, the US and EU are busy trying to get developing countries to sign up to Free Trade Agreements and Economic Partnership Agreements so that whatever the WTO has done is irrelevant.

Big Pharma seems to have used a classic bargaining trick; they have started the bidding at a price many times higher than would be reasonable. They have then been in a good position to accept a price a few times lower, probably set by parties who had an interest in maximizing pharmaceutical company profits. Giving the industry so much control means that they can add in the pretence that there is some level of competition, though there is unlikely to be any. A spokesperson for UNITAID, Ellen ‘t Hoen, said that “financing for HIV had to remain strong, as even the lowest-cost drugs needed an assured market”. So that’s the level of competition!

The pretence that the global pharmaceutical industry is just trying to make its way in a competitive business is sickening enough, when you consider how much effort goes into stacking the odds in their favour. But the expansion of the ARV market to include those thought to be at risk of being infected with HIV is outrageous. UNAIDS and various other commercial interests, academic institutions and the like, view almost all Africans as being at risk of infection with HIV. Yet this same group has failed adequately to describe serious HIV epidemics to the extent that they are in any position to make a useful assessment of risk.

Not only is the carefully crafted market for ARVs huge and expanding, it also enjoys the full protection of ‘global’ trade laws. And judging by the emphasis on microbicides and PrEP at the recent Vienna Aids Conference, the HIV industry appears to see its primary role as helping Big Pharma expand. The right to health has shrunk to a ‘right to treatment’ and those providing ‘the treatment’ have moved in to supply it to the healthy and the unhealthy alike. As for the HIV pandemic, Big Pharma says ‘don’t worry, we have the treatment’. But if health has been reduced to treatment, will there be any resources to ensure that healthy people stay healthy, even to reduce the spread of HIV and perhaps eventually eradicate it? Already, the HIV pandemic seems far too valuable to risk destroying.

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


Sunday, August 8, 2010

In the Absence of Evidence, Use a Shoehorn

According to an article entitled ‘Moulding Men You Can Count On’, “Research shows that men are the main drivers of the HIV epidemic. Men transmit HIV to women, who, in turn, can infect their babies if they fall pregnant.” But this is not something demonstrated by research. It is an interpretation of research that often purports to be well supported. While some men transmit HIV to women, the majority of HIV positive people in African countries are women. There is no evidence that there is a relatively small group of men who sleep with a relatively large group of women.

Of course, there are some men who sleep with a lot of women and some women who sleep with a lot of men. But that’s also the case in non-African countries, where HIV rates are very low. And women also transmit HIV to men. And men transmit HIV to men. The majority of new HIV infections in a country like Uganda are among monogamous and often married people. Also, many HIV positive people have a HIV negative partner.

Various shoehorning arguments have been advanced about men who have sex with men (MSM) also having sex with women. But the percentage of MSM in African countries is unlikely to be much larger than in non-African countries. And women are said to be more vulnerable for structural reasons, such as their relative inequality in society and in marriage. This may be true, but again, most new infections are in monogamous couples and the male partner is often not infected. Women do not become infected by having sex with uninfected men.

The shoehorning becomes more obtuse, racist and sexist. But in the end, the sort of rapid transmission of a virus that is difficult to transmit sexually, found in some African countries, is not explained unless unbelievable levels of unsafe sexual practices are hypothesized. Such levels are not borne out by evidence, but they seem to be believed by the HIV industry. As a result, sexual behaviour in African countries is targeted by almost all HIV ‘prevention’ programs. This has not worked, but the industry is wealthy and powerful enough to continue its deceit. And most academics in the field seem happy to go along with that.

So, not only would this assumed small group of men, who drive HIV epidemics, have to have sex with a lot of women to explain the number of women who are HIV positive, those men must also have had sex with an even greater number of women who were not infected. After all, the probability of infecting someone is lower than 1, thankfully. This is not to deny that there are many social problems, some of which may increase the transmission of HIV. All social problems should be targeted. But let’s not pretend that some of them are driving HIV epidemics when this is clearly not true.

The article correctly points out that no one, male or female, can assume that their partner’s status is the same as their own. But similar remarks apply to children. The mother’s status is not a reliable indicator of their children’s status. Nor is the children’s status a reliable indicator of their mother’s. There have been enough instances identified of discordant couples (where one member is HIV positive and the other is HIV negative). And there have been enough instances of infants and children being found to be HIV positive when their mothers are not.

There’s no great mystery about this. People can be infected with HIV through sexual intercourse with someone who is HIV positive; infants can be infected by their mother. But people can also be infected by unsafe medical, cosmetic or certain traditional rituals. People of all ages can undergo any of these, perhaps all of them. And, while sexual transmission of HIV is not very efficient, transmission through contaminated blood or through other bodily fluids can be very efficient.

The article is about targeting men, because many HIV programs don’t do this, or don’t do it very well. It is very worthwhile targeting men, but it would be far better if they were being supplied with correct and complete information. Men may react a lot better if they are not being accused or implicated in ‘driving HIV epidemics’. Some men engage in unsafe sexual behaviour, as do some women, all over the world. But these same people are entitled to know about other unsafe practices in order to be able to avoid both infection and transmission of HIV and other blood borne diseases. Equally, those who do not engage in unsafe sexual behaviour are entitled to know how to protect themselves, if they are HIV negative. And they are entitled to know how they may have become infected if they are HIV positive.

This program targeting men, and any other program that aims to reduce HIV transmission, needs to make it clear how HIV can be transmitted. People need to know how to protect themselves, completely. There is no point in telling them to reduce their number of sexual partners, have sex less, be faithful to their partner, use condoms and take any other precautions, while neglecting to tell them about non-sexual modes of transmission. Even people whose sexual behaviour is deemed to be risky also face non-sexual risks. Men who have sex with men and commercial sex workers, often thought to be at highest risk of sexual transmission of HIV, also risk being infected and infecting others non-sexually.

There is a lot of talk about ‘knowing your status’ but that’s not enough on its own. You also need to know how you became infected. Especially if your partner is not infected, because then you might have some explaining to do. The assumption that most HIV is transmitted sexually in African countries is one of the main sources of stigma. Men who are being targeted for HIV awareness training also need to know that being HIV positive does not mean you have been engaging in unsafe sex. Then, if their partner is found to be HIV positive, it is less likely that they will react violently. If people don’t know about non-sexual risks and hear about nothing but sexual risks, it’s hard to change the message later. It’s not surprising that people think all sorts of terrible things about a partner who has just been diagnosed as HIV positive when they themselves are HIV negative.

People need and are entitled to correct information, but also, complete information. Allowing them to assume that they are safe from HIV by taking all the recommended measures to avoid sexual transmission does not protect them from non-sexual modes of transmission. Failing to inform people about non-sexual risks is, effectively, luring them into a false sense of security. People will not take precautions against risks they don’t know about. Involving men is vital and the program in question must be applauded for that, but it must include information about non-sexual HIV transmission for two main reasons; to reduce transmission and to reduce stigma. Otherwise the program is as pointless as most of the others approved of by UNAIDS and the HIV industry.


Friday, August 6, 2010

Deal With Your Anger Wisely, Obama

Obama is 'angry' over the spread of HIV/Aids. It appears he's angry with African governments for not doing anything about the epidemic and perhaps with Africans for doing the spreading. That seems to be the direction his thinking takes. He says "treating patients while others are catching the virus is untenable."

"We are never going to have enough money to simply treat people who are constantly getting infected," he said. "We've got to have a mechanism to stop the transmission rate."

I couldn't agree more. That's why I believe some of the main actors in the HIV industry should find out why HIV transmission is so high in some African countries and in some sectors in some African countries, yet it is low in other countries and other sectors. These actors include UNAIDS, the WHO, the UN as a whole, the US Center for Disease Control, universities such as Johns Hopkins and various other extremely well funded institutions. I assume Obama has some influence with them. (That he has influence in Africa is not in question but how that influence works or how legitimate it is are less clear.)

And while we're on the subject of money, my guess is that the amount of money made out of HIV dwarfs the amount spent on it, it's a good investment. Institutions like the ones mentioned, various commercial interests and other big NGOs have done very well out of funding over the years. So let's not pretend that money is leaking out of the US and the country gets nothing in return. And the absolute amount of HIV money coming from the US may be high, as Obama claims, but as a percentage of GDP, the US is nowhere near the highest contributor.

The “retrogressive culture that makes females satisfy the pleasure of men” that Obama says is responsible for the “upswing in new HIV/Aids infections in Africa” is, presumably, the same culture that gave rise to a Black American politician who won the last US presidential elections. Has he anything to say about the retrogressive culture that allows billions of dollars to be spent enriching rich people and institutions while Africans die?

"In Africa, empowering women is going to be critical to reducing the transmission rate because so often women, not having any control over sexual practices and their own body, end up having extremely high transmission rates”.

Women all over the world have little control over sexual practices and their own body but nowhere in the world are HIV rates as high as they are in some Southern African countries. The entire cash-rich industry has failed to explain what is behind the source of their wealth and power: HIV epidemics in certain African countries.

It's great to hear that the "US has a huge interest in public health systems in Africa" because health systems have been ignored for several decades, with all the attention being concentrated on a handful of diseases considered newsworthy enough to attract funding. Let’s get on with it.

It's hard to believe that such statements as the ones found in this article could really emanate from one of the most powerful politicians in the world. Doesn't he have anyone to do his publicity or to provide him with up to date information? It is not true that in Uganda "infection rate was about 30 per cent in the late 1980s". Prevalence in certain sectors of the population may have reached that level but there was never a time when 30% of sexually active people in Uganda were HIV positive. HIV prevalence did reach such levels some time later, but not in Uganda.

There was no "politically-led three-themed campaign - for Abstinence, Being faithful and Condom use or ABC model - [that] helped drive down the rate to an average six per cent." ABC didn't exist till the late 1990s and it was not dreamed up in Uganda. The abstinence only campaigns imposed by his predecessor on Africa in the early 2000s have had little or no effect in Uganda, just as they had little or no effect in the US. They may have been confusing but most behavior change programs failed, so any damage they could have done may have been similarly limited.

If Obama wants to "explore workable preventive programmes" he needs to challenge the behavioral paradigm, the view that most HIV is transmitted sexually in African countries. He needs to question the view that Africans have unbelievable amounts of ('unsafe')sex with incredible numbers of partners.

If he wants to "build greater public health infrastructure", he needs to be informed about basic distinctions between vertical approaches to health, which target individual diseases and horizontal approaches, which concentrate more on primary healthcare. And he shouldn't be distracted by nice distinctions like 'diagonal' approaches, which claim to be some kind of 'third way'.

And if he wants to "institutionalise country-specific interventions", he needs to campaign for the abolition of UNAIDS and perhaps other big players in the HIV industry. Their programs to date have painted whole continents with the same brush, failing to identify all the ways that HIV is being transmitted and ignoring some of the most vulnerable groups. Buzzwords like 'global health' seem to lead, inexorably, to this sort of broad brush policy.

Massive rates of HIV transmission in African countries can not be explained by resort to myths about the great sexual appetite Africans have. And no research has yet demonstrated that Africans have more appetite for sex than people who live in other continents.

Rapid rates of HIV transmission can partly be explained by very low standards of healthcare, where the majority of injections given in healthcare settings are not necessary and are unsafe, very likely to transmit HIV, hepatitis and various other infections. The extent to which unsafe healthcare could explain high rates of HIV transmission in African countries is unclear, because the HIV industry, in all its splendor, wealth, power and wisdom, has never seen fit to investigate.

Please Mr Obama, before you consider punishing anyone, try to establish what wrong has been perpetrated and who has perpetrated it. The important thing is to reduce HIV transmission, not to apportion blame, despite what the Christian Right may tell you. But unless we are clear about how HIV is being transmitted, and you seem very unclear, we will never reduce transmission enough to eradicate the disease.