Wednesday, September 15, 2010

Concentration Clinics for the Usual Suspects

The WHO have just finished a forum on medical devices and they note the lack of access to such equipment in developing countries. However, developing countries have a far bigger problem than that. There are also too few medical facilities, too few trained personnel and too few drugs. As a result, in many developing countries the majority have little access to health care. And in some countries, access to health care is relatively high but the quality of the health care is very low.

Anyhow, the WHO does conclude that up to 40% of injections are unsafe in developing countries, probably around 6 billion or more injections. This is a particularly interesting figure for a country like Kenya, where UNAIDS insists that HIV transmission through unsafe injections only accounts for between 0.6 and 2% of all transmission. If you thought that 40% of injections were unsafe, you might avoid health facilities altogether, as UN employees are advised to do. But if it's the only health care available, many will probably risk it, especially when the alternative is far worse.

But there is a difference between UN employees and Kenyans (and most other Africans). Not only is there no alternative to poor quality care in most African countries but Kenyans and other Africans are generally not aware about the risks they face when they visit a doctor, dentist or other health care practitioner. Even among health professionals there appears to be little awareness of the risks. Therefore, neither health professionals nor patients will take any of the relatively straightforward steps required to reduce the risks.

Making health facilities safe could significantly improve overall health in countries like Kenya. HIV transmission through unsafe health care could be avoided, probably entirely. But also, transmission of hepatitis C and B (HCV and HBV), which are very commonly transmitted in health care facilities, could also be reduced. Kenya's health services are not going to become top class over night, not after decades of neglect, but they could become safer.

But at the rate things are going, even safety is not considered a priority. The percentage of spending allocated to injection safety in Kenya's latest National Aids Strategic Plan is small, less than one percent. And there is an even bigger question mark over where, exactly, this money will be spent. The country doesn't have a very big health infrastructure. More than half of the health providers sampled (supposedly a representative sample) in Kenya are either private pharmacies or otherwise limited to a handful of services.

Kenya's Service Provision Assessment Survey looks at what is available at 440 facilities and reports data on, among other things, 'elements for preventing nosocomial infections', that's infections that are due to unsafe health care. Included are running water, soap, latex gloves and facilities for disposing of 'sharps' (needles and the like). The majority of facilities, about 90%, don't provide all of these basic facilities. More than half the hospitals don't have running water. Similarly shocking figures apply to stocks of things like disinfectant, needles, syringes and latex gloves. In fact, only 3% of hospitals have all three. Most providers don't even have guidelines for infection prevention or sterilization.

The Kenya Modes of Transmission Analysis rather confidently states "It is unlikely that there is much medical injection transmission these days, given the raised awareness (both amongst health professionals and the general public) of the importance of clean needles." The confidence seems particularly unwarranted when they say, much later in the document, "[there is v]ery little information on injections safety - [it is]...hard to get baselines". That's a contradiction that even UNAIDS would be proud of.

Putting the various documentation together, sketchy as it is, the picture of health services in Kenya and other African countries is that they pose a lot of risks for blood-borne infections. Research earlier this decade showed that over 32% of HCV and over 40% of HBV were being transmitted through unsafe injections. In clinics where many of the clients are infected with some blood-borne virus, the probability of nosocomial HIV or other blood-borne infection would be even higher.

Consider, for example, clinics that deal primarily with sex workers and intravenous drug users, even clinics for pregnant women. Current HIV strategies herd together those most likely to be infected with HIV and play a barbaric form of Russian roulette with them and all their other less 'high risk' clients. It's no wonder that HIV is unbelievably high in STI (sexually transmitted infection) and ante-natal care clinics. These clinics are probably the source of much of the prevalence in countries with such deplorable health services.

Some evidence may point to sexual transmission of HIV. But some evidence points to nosocomial transmission, too. Without investigating the considerable evidence for nosocomial HIV transmission, targeting sexual behavior and not bothering about unsafe health care is condemning an unknown number of people to disease, stigma and early death. Given the weight of evidence, it's becoming more and more difficult to understand why UNAIDS and the HIV/AIDS industry continues to insist that, in African countries, HIV is almost always transmitted sexually.


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