Saturday, March 12, 2011

Why Poor Access to Health Facilities May Save Lives in Africa

"Hospital Births Still Unpopular" in Ethiopia, writes IRIN, the UN development news agency. But is this a good or bad thing? Ethiopia has never managed to provide the majority of its inhabitants with health services. Yet HIV prevalence, like in many other countries with low health service usage, is relatively low, at just over 2%.

In South Africa (and several other Southern African countries with high health service usage), HIV prevalence is staggeringly high. These are not just two countries where HIV prevalence and health service usage happen to be negatively correlated, there are many others. Zimbabwe has had high health service usage at times in its history, as have Swaziland, Botswana and Zambia, all in the top ten for HIV prevalence.

Where health services are of high quality, things are quite different. Take Cuba, for example, which has some of the best health indicators in the world and the lowest HIV prevalence in the Carribean. Similar remarks apply to many other Western countries and even a few developing countries.

Even the US has good health services for those who can afford them. But sadly, those who can't afford the best experience the highest HIV rates in the country. Most of them also happen to be non-white. And before you ask, yes, HIV and other viruses can be transmitted in US health services too. Do you think that doctor specializing in late abortions had any more respect for adults than for children?

To conclude that countries need fewer health services would be crazy, though it is the direct aim of the World Bank and the International Monetary Fund, through their structural adjustment programs, or whatever they call them now. And it is the indirect aim of the WHO and UNAIDS, through their insistence that grossly disproportionate amounts of health spending goes to HIV.

Despite the barbaric health agenda of global economic health institutions, African countries, like all countries, need good health services. They also need decent levels of education, good infrastructure, economic and employment opportunities, in other words, a future. But that is what they have been denied for many decades. Human rights that have been denied many countries for so long don't appear to be any more forthcoming now that they were in the past, either.

The argument that HIV spending puts all other health spending in the shade is not even the most important issue here. The most important issue is that the billions of dollars that have gone into HIV so far have done little to reduce transmission enough to see the virus being eradicated any time soon.

Not that much of the money has been spent on prevention anyway, and what has been spent was frittered away on pointless exercises, which will probably continue for some time, because the 'experts' simply don't have any idea what else to do. They don't know how to reduce HIV transmission, or they don't wish to suggest that the health industry itself may be part of the problem.

You could argue that the multi-billion dollar per annum global HIV industry is run by a bunch of buffoons and you'd probably have some supporters. Like any professional group, there are buffoons. But there are also people who are the best in their field. And then it sounds as if things get done or remain undone because that's what the whole lot of them, buffoon or otherwise, want.

For example, a bunch of people of some description found that 'only' 1.4% of HIV positive children had HIV negative mothers. They speculated about these children being infected by contaminated breast milk, which is a possible explanation. But they hesitate to conclude that infants and mothers may be at risk of infection through unsafe health care practices.

This is surprising because the same researchers found that 47% of instruments were contaminated with blood, many of these instruments being used for invasive procedures. They also found that many of the HIV positive children with HIV negative mothers were breastfed by a non-biological mother. So there are several possible sources of non-sexual HIV transmission, but this research is just scratching the surface.

HIV negative mothers can be infected by their babies if their babies are infected nosocomially. This has been demonstrated many times, especially in Romania, which experienced a massive outbreak of nosocomially transmitted HIV, one of the biggest ever brought to light.

Also, both mothers and babies can be independently infected, though various routes. The fact that many mother and baby pairs were both infected does not tell you how either of them became infected. Researchers might need to do a bit of work to establish that.

As for the HIV positive women, with or without HIV positive babies, how were they infected? Were their partners tested? Partners tend not to be routinely contacted and tested and it seems they were not in this instance, or perhaps the authors didn't think it important enough to comment on. Half of all HIV positive women in African countries have HIV negative partners. How did they become infected?

But one of the most striking aspects of HIV testing in pregnant women is how many of them seroconvert very late during pregnancy or even in the months after giving birth. This suggests that many of them were also infected after they would have known they were pregnant or even just after they had given birth.

I'm not an expert in these matters but many women have told me they do not tend to have that much sexual activity during late pregnancy or in the months just after giving birth. And they certainly don't see this as a good time to engage in unprotected sex with people who are not their main partner. Why not cast the net a little wider and look at the most likely modes of transmission, non-sexual modes, rather than the least likely mode, heterosexual transmission?

I'm looking for what researchers don't talk about, what they don't find, usually because they are not looking. Why are researchers not contacting and testing partners as a matter of routine? Why are they not following up HIV seroconversions which are very unlikely to have resulted from sexual transmission? They need to put their anti-African and anti-woman prejudices aside and start investigating. African hospitals are clearly dangerous places.


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