Monday, January 30, 2012

Confusion About Circumcision Common Where Program is Most Active

Given the amount of money that has been thrown at male circumcision programs purporting to reduce HIV transmission from females to males, a small study reveals that more women than men have incorrect and dangerous views about the operation. However, it is unlikely to dampen the enthusiasm of the HIV industry, which likes to boast that several hundred thousand men have already been circumcised, out of a target of over 20 million.

But the survey also makes the rather dubious claim that female partners of recently circumcised men found sex more enjoyable. I'm sure I have heard that claim before and I wonder if participants knew that circumcised men are more likely to transmit HIV to women. Many people seem to forget that they will still need to use condoms after circumcision, although promoters of the operation are often so intent on pushing the program they pay a lot less attention to condom use and 'safer' sex practices than they used to.

The survey finds that half of the men and three quarters of the women see HIV as less of a threat and that condoms are less necessary after circumcision. A fifth of women said they would be more likely to have more than one sex partner and nearly a third said they would be more likely to have sex without a condom. The authors of the study say there is a need to involved female partners, but that is hardly the only need. Many of the people being circumcised, according to the (not particularly impartial) reports the media like to brandish, are young, single and not yet sexually active. What the study demonstrates is that some people are seriously misinformed by the HIV industry hype around circumcision. If the proponents had done a bit of research earlier, or listened to some of the critics, they would long ago have seen the need for this kind of survey.

According to someone involved in the massive circumcision program in Nyanza province in Western Kenya, many women already do accompany their partners when they go for pre-circumcision counselling. But then the counselling is clearly not very successful. People seem to think circumcision will 'protect' them, which is what they are told. But why should all those who don't bother using condoms now, or the ones who don't always use them, suddenly start using them just because they are circumcised? Why would they even go for the operation if they will still have to use condoms? Wouldn't it be better just to use condoms? Condoms give the highest level of protection known. And while those who currently use condoms may opt for the operation, they shouldn't be at high risk of being infected with HIV.

If people in Nyanza, who are closest and most exposed to the mass male circumcision program are so misinformed about circumcision, what about the 85% of Kenyan men who are already circumcised? Will they think there is any need for them to use condoms? How about their partners, will they know that circumcision only gives partial 'protection' (at best) and that the optimistic figures bandied about are from carefully controlled trials? The conditions found in such trials will not be found in the real world (which seems to be OK for some researchers and for the HIV industry). Those going for the operation really don't know what the outcome will be for them or for their partners and their partners seem to know even less.

Mass male circumcision programs are something of a black box intervention because it is not yet known if they work, and if they do, how they might work. A lot of less well publicized research suggests that the programs will not work, and some show that they could increase HIV transmission. The figures purporting to show that the operation is cost-effective are based on assumed data, as are the projections of how many infections would be averted if all uncircumcised men received the operation.

Incidentally, the modellers who give us such confident projections about the benefits of circumcision have also come up with the claim that, even if a lot of recently circumcised men face an elevated risk of HIV transmission through resuming sexual intercourse too soon after the operation (from female to male if the man is negative, but also from male to female if the man is positive), the net effect of mass male circumcision programs is beneficial. But the net benefits are highly questionable and to accept them, you would need to buy into the whole HIV industry orthodoxy about HIV almost always being sexually transmitted in African countries. Either way, even the potential gains claimed in this paper may not be realized.

[For more about circumcision related risks for males and females, see the Don't Get Stuck With HIV site and blog.]


Sunday, January 29, 2012

What Has Gates Learned About Development Since Last Year?

Bill Gates' 'Annual Letter' always makes depressing reading. That someone so single minded about making money and controlling as much as possible [good article in the English Guardian on this issue] should understand so little about development is not as surprising  as the fact that, for all his money, he doesn't appear to be able to find advisors who have the balls to stand up to him and get him to at least fake an understanding.

Yet again, to Gates and his cronies, 'innovation' in agriculture in developing countries means wresting the little control left to small farmers out of their hands and putting it in the hands of multinationals, who can squeeze whatever blood is left in the farmers that hasn't already been squeezed out by other means. Technology, as Gates knows, is the preserve of the rich; the rich benefit from it, the poor pay for it. Genetically modified organisms (GMO) and various other technologies that impress Gates so much, and I don't believe he is unaware of this, are not designed to benefit small farmers in developing countries, nor will they ever do so.

In health, also, Gates obsesses about technologies, such as vaccines, single, headline-grabbing diseases such as polio and HIV and issues such as family planning. Yet, over and over again, research shows that it is not just technologies that allow substantial reductions in transmission of common preventable diseases, it is also things like sanitation, water and living conditions. There is no mention in his speech of sanitation and the only mention of water is in relation to GMOs. Polio, which Gates hopes to get credit for 'eradicating', is an example of a disease that will not go away just because everyone is immunized; people need access to clean water and good sanitation. That will help eradicate a whole host of diseases, not just the fashionable ones.

Gates, like a large chunk of the development industry as a whole, thinks that reducing birth rates in developing countries will magically mean that everyone has enough money and enough food. But people need a decent standard of living, gainful employment and food sovereignty. His policies of flying in technologies, whether in health or agriculture, actually increase dependency, poverty and insecurity. If lower birth rates are to occur at all, they will occur as a result of better health, a better economy, better education and the like, not the other way around. And talking of education, Gates is silent on the matter, except for education in the US.

As for HIV, the connection between this disease and enormous profits for Big Pharma is pretty obvious, even to Gates. His foundation has been instrumental in setting up a parallel health infrastructure for this, instead of trying to comprehend how existing conditions in health facilities in high prevalence countries, which are appalling, may have a lot of influence on how the virus spreads. Much of the foundation's money has gone into facilitating the sale of drugs and other technologies and much of the money has never left the US, except to go to US institutions, purpose built in high prevalence countries. Sometimes, the foundation sticks some of the few well qualified health professionals to be found in African countries into a Gates funded institution, just to make the whole thing more African. (For a good example, check out AGRA, the Alliance for a Green Revolution in Africa).

Against the above technocentricity, it's difficult to see why the man should share the HIV industry's obsession with male circumcision. But Gates does mention things like PrePex and the Shang Ring, which will make fat profits for a couple of medical device companies. He seems to think that male circumcision reduces HIV transmission by 'up to 70%', but I think even the most rabid circumcision enthusiasts wouldn't claim that; most would even concede that the up to 60% figure  claimed by the HIV industry is from carefully controlled trial conditions with carefully massaged results (though they might not use the word 'massage').

In addition to advocating male circumcision in countries where conditions in health facilities are dreadful and where there are many far higher priorities, Gates goes on to advocate technologies such as injectible hormonal contraceptives, which have also been associated with increased HIV transmission (male circumcision has been associated with higher HIV transmission in as many countries as it has with lower). Unsurprisingly, genuine improvements in health facilities are not part of the Gates Final Solution. And just to demonstrate his fragile grasp on public health, on the subject of antiretroviral drugs to reduce HIV transmission, he says "In studies where the patients used the tool as they were supposed to, the results were quite good." If people don't 'use the tool as they are supposed to', maybe the problem is with the tool.

And the letter goes on and on, with Gates demonstrating his global imperialist ambitions in every sentence, as well as his ignorance of the lives of the people who will suffer as a result. It seems like every year that passes other institutions with imperialist ambitions, such as the UN, World Bank and WTO, also align themselves with this man. Don't expect too many changes over the next year.


Saturday, January 28, 2012

What Would Be a Legitimate Role for Western Development Workers in Developing Countries?

There's an interview with Yash Tandon on that is well worth reading for people working in development or thinking of doing so. I find it relatively rare to hear what Africans really think of development. My aim in coming to East Africa to work in development was to find out from people working in development here what form development should take. Given that both recipients (as opposed to beneficiaries) of development programs and those working on the programs often agree that things have been going wrong for a long time, how should things be put right?

Tandon criticizes the Paris Declaration on aid effectiveness on the grounds that it was "conceptualized by the donors, and not by the people that were supposed to be assisted". Which is little different from a lot of development decisions, before and after the declaration. Tandon goes on to say that "the so-called development aid never did promote development" and that " The result is that the aid industry has no longer any legitimacy."

It's ironic, considering how often people working in development use the term 'dependency' when referring to recipients of aid, how Tandon turns things around and points out that there are "at least a million people in the Western countries that live off the aid industry". Tandon feels that aid, or whatever term it goes under, was always intended to serve the interests of donor countries. I agree, and Tanzania, with its massive potential for gold, uranium, natural gas, arable land and other resources, is a case in point. The resources remain underdeveloped and underexploited until some wealthy foreign country comes to do the exploiting.

Tandon singles out Oxfam for criticizm as an organization that started out with good intentions but is now part of the very machinery that ensures the smooth operation of aid policies that are intended to benefit Western countries. And he raises a very interesting question: why do we call a lot of 'aid' programming by that name when it is actually just business? The Chinese and the Indians call it business, so why do many Western countries wish to dress it up as philanthropy? It must be a slap in the face to big Western donors to be told that the Chinese do it better when they seem hell-bent on persuading people here that the Chinese are only out for what they can get!

Another couple of sacred cows Tandon slaughters are the imposition of certain 'values', perhaps by church based organizations, which are dressed up as 'solidarity' or some other touchy-feely concept; also the assumption that Western aid agencies have the right to "encourage women who raise their voices against practices that violate their human rights" (for example). Tandon says the latter is not the business of outsiders, that "the initiatives of rural women in Africa against oppression are very strong and very strategic. They know what will work and what will not". I hope his last statement is right; I have not been exposed to initiatives against oppression that are strong and strategic, though I would very much like to be.

These are all perplexing issues for people who wish to work in development without becoming part of the problem, serving as mere instruments of the self-interested Western agenda. Much though I would love to follow Tandon's advice, I have not come across many people who say 'this is what we want and this is how we intend to achieve it'. Rather they tend to say 'how do we get some of this money/assistance/resources'? Perhaps they are now also mere instruments and are currently unable to serve the intersts of those they hope to serve. But how do they change course and set the agenda? If there is an indigenous aid agenda in East Africa, where is it articulated?

I wholeheartedly agree with Tandon's conclusion that "All development is self-development", but I want to work with self-development, with self-developers. I think that the development industry can do a lot more good in developing countries by advocating against certain things, such as land-grabbing, resource theft, imposition of genetically modified organisms and other inappropriate and failed technologies, Western use of cheap labour, exploitation of lax human rights legislation, commodity dumping, unfair trade agreements, etc, something I have called 'Development by Omission' for want of a better phrase. But I wonder if Tandon thinks there is a legitimate role for people who work in development to continue with, as long as they are committed to an agenda set by their adopted country, and if so, what is this role?


Thursday, January 26, 2012

Huge Birth Control Programs Don't Work: Time to Give Education a Chance

I recently moved from a job as grant proposal writer for an NGO working in several different development areas to a similar job in a secondary boarding school for girls, which is being built in a country where many girls don't even finish primary school. So I was comforted to find an article entitled 'Women's Education Slows Population Growth'. That women's education can have such profound and positive consequences is not the issue, that has been recognized for a long time, at least by those working in education. But the priority is so often given to population growth, rather than to education or any other development area.

A shocking proportion of 'development' money and a disturbing number of development related insitutions concentrate almost exclusively on population control, in some form or other. They bang on about an unmet need for contraception as if many women will have depleted health or lives as a result of lacking birth control methods, when they are likely to be in far greater need of better nutrition, healthcare, security, governance, equality, infrastructure and, indeed, education. Shovelling contraceptives into rural communities may be a lot easier than providing people with what they need, but without the education and other development areas being addressed, the only gain will accure to the pharmaceutical companies who produce contraceptives.

Similar remarks apply to a lot of other 'health' programs, which target whatever health issue is currently fashionable and well funded; many of them are also necessary, but they would work a lot better if people had the level of education to capitalize on them. Otherwise, they can just go through the motions of attending numerous courses, often for the per diem they may be paid or the free lunch or other minor benefits on offer. I have met people who have been to various 'training courses' only to attend the same course several more times, sometimes provided by the same NGO as before. Training courses are a great way to spend money and it's easy enough to gather data that allows the donor to pronounce the intervention successful. Some health drives pick out some particular disease, perhaps a water borne disease, without addressing water and sanitation in the area. The current drive to 'eliminate' polio is a cases in point; those who attend immunization drives go home to drink contaminated water and contract something else.

Education itself, as we found in my own country, Ireland, is not enough when there are no jobs to go to. And here in Tanzania, women are not considered to be able to do many jobs that they would in fact be well able to do, if they had the education. Sadly, they are considered to be able to do many jobs that are not particularly appropriate for them when they are too young, too old, pregnant, childraising or breastfeeding, but that's another matter. I always feel a bit dishonest when I tell people about how important education is when there is little guarantee many of them will ever get to use it, especially girls and women.

As if there are not enough obstacles, also, school-going girls who become pregnant are excluded from school. In the rare instances where they are allowed to return to school, most do not. This is to 'set an example', we are told. And it does. It shows that girls who get pregnant will be treated very harshly, whereas the boys or men who make them pregnant, generally, will not. The fact that underage girls being made pregnant by older men is a serious crime doesn't get the girls off the hook. Men don't appear to be prosecuted, boys are generally not excluded from school and the strong prejudice against females appears to be practiced by the very institutions that might be in a position to change things.

According to the article, the average birth rate is less than half in regions where education is valued; as I'm working in one of those regions, I'm hoping that birth rates are lower because education is valued. However, even expensive schools with nice, well-funded buildings and facilities, don't always have especially high educational standards. As a fundraiser, sometimes I can see funds for all sorts of things, but not so many that clearly improve education. There is not so much available for good teachers or other provisions that would make a difference. And many fundraisers are tasked with raising money for the buildings, which is important, but often distracts from the ultimate purpose of these buildings.

So, as the article suggests, it's not the correlation between higher standards of education and lower birth rates that is important; it is the priority that is given to education. Proponents of the population control theory of development, so beloved throughout the last fifty years (and still loved by the Rockefeller Foundation, the Gutmacher Institute, the Gates Foundation, Population Services International, Family health Internationa and many more), never appeared to realize what needed to come first, that with development of education, health, infrastructure and the rest, lower birth rates would follow. Similarly, poverty is pervasive in Tanzania, but lower birth rates does not have much direct effect on poverty; rather, lower poverty rates result in improved health, education and the like.

For education to be of benefit, many other things need to be in place as well. But one thing is for sure; reducing birth rates and hoping that other development areas will benefit accordingly has not worked. The funding these charlatans have received urgently needs to be directed towards people's true needs, which are still education, health, a decent standard of living, security, food security and the rest, just as these are the true needs of all people.


Wednesday, January 25, 2012

Deceived and Misled, HIV Positive People Can Only Speculate About Their Infection

I was intigued by the title of a Kenyan newspaper article: "When a Woman Feels She Is Not 'Rightfully Infected'". I thought that maybe someone was asking how they could have been infected with a virus that is not easy to transmit sexually even though they have never had unsafe sex, very little sex or perhaps no sex at all. Demographic and Health Surveys usually find that a considerable number of people are infected with HIV even though they have no obvious sexual risks. Non-sexual risks are rarely considered and it is usually assumed that people have lied about their sexual behavior.

Anyhow, the article doesn't go that far. A HIV positive woman reflects on the fact that she didn't have enough sex during her marriage to warrent HIV infection. Her husband was working in South Africa and he only came home every six months, which is the only time they had sex. After 22 years of marriage, the woman was diagnosed HIV positive and found that her husband had another wife. Was her husband infected? We are not told. We also don't know if he was infected sexually, whether he infected his wife (the one writing the article) or whether she was even infected sexually.

Leaving aside the fact that the man had another 'wife', in order to establish how someone is infected it is necessary to work out what risks each HIV positive person faces. Even if the man was infected sexually, that does not mean he infected his first wife. She deserves to know how she became infected because if it turns out that her husband is not, and this is commonly the case, it will be implied that she was infected by having sex with someone who was not her husband. This is the HIV orthodoxy: 80-90% of HIV is heterosexually transmitted in medium and high prevalence African countries, though nowhere else. The consequences can be disasterous, with women thrown out of their homes, beaten, dispossessed, even killed.

Far more women than men are infected with HIV in high prevalence countries. Far more men than women engage in 'unsafe' sex. In discordant couples, those where only one partner is infected, it is as often the female partner that is infected as the male; it's approximately 50/50. when genetic typing has been carried out, many couples where both partners are infected are infected with a different subtype of the virus. In other words, one probably didn't infect the other. And even where both have the same subtype, they might not have both been infected sexually. Perhaps neither were infected sexually.

(On the subject of the ratio of male to female prevalence, it's also worth noting that male high HIV prevalence groups are not part of the general population. For example, many men who have sex with men don't have sex with women. Most intravenous drug users are men. Even prison populations, among which prevalence is said to be remarkably high, probably face serious non-sexual risks, such as tattooing, oathing, traditional medicine, intravenous drug use, etc. The actual percentage of HIV positive males who are infected heterosexually is probably a lot lower than the percentage of infected males.)

It may be a long shot, but it's worth checking who infected whom because if it's not the 'obvious' person, it needs to be established how the virus is being transmitted. If someone doesn't often have sex, only has sex with someone who is HIV negative, or has never had sex at all, they should not be infected. There are likely to be non-sexual risks that need to be investigated, particularly healthcare related risks. It's not acceptable to assume that people who are infected with HIV and are African are necessarily liars. But this is generally what happens.

The two women in the article discuss the fact that some people who have little sexual exposure can be infected while those with a lot can remain uninfected. But they seem unaware that some people face substantial non-sexual exposures. They are right that someone could be infected though having sex with a HIV positive person just once; right in theory. But it's highly unlikely. And highly unlikely occurrences like that give rise to few infections. Yet millions of people in some African countries are infected. Something that is highly likely to transmit HIV occurs frequently enough in some countries to give rise to hyperendemic HIV.

So what is it? Unsafe healthcare? Unsafe cosmetic or other skin-piercing procedures? To reduce HIV transmission, we need to know how it is being transmitted. By assuming that it is always sexually transmitted we end up implementing, at best, prevention strategies that may have no influence on non-sexual transmission, whatever influence they have on sexual transmission. At worst, we are just standing by while people become infected and go on to infect others.


Tuesday, January 24, 2012

To Reduce HIV Transmission From Mothers to Children, Reduce Transmission to Women

In the many articles about eliminating (or virtually eliminating) mother to child transmission of HIV (MTCT), the one strategy I haven't heard mentioned seems like it might be the simplest and most effective of all: eliminate, or at least reduce, HIV in mothers. It has been shown that even very high uptake of prevention of MTCT services will still not allow a country such as Zimbabwe to achieve virtual elimination, which would mean reducing the risk to less than 5%. Even an increase in uptake of services from 36% to 56% only resulted in a drop in MTCT from 20.3% to 18%.

The article states that only an estimated 53% of pregnant women globally got any kind of PMTCT treatment in 2009, which resulted in around 400,000 infants being infected, over 90% of which were in sub-Saharan Africa. But the problem with a lot of HIV programs, PMTCT programs being no exception, is that they are instances of 'vertical' healthcare. HIV related healthcare is, effectively, a parallel health service catering for one disease, while other health services, for better or for worse, cater for anything else the country's health system has the capacity to deal with. But this doesn't mean that HIV services are necessarily good, despite all their funding.

As a result, reproductive health services may or may not include HIV services and HIV facilities may or may not include other reproductive health services. While some HIV facilities may be relatively well funded, at least for their intended purposes, other health facilities are unlikely to be very well funded. In a country like Zimbabwe many people have some access to care but the quality of care is not high, unless you can afford private services. So PMTCT services often don't coordinate well with other services that pregnant woman receive; some receive services early in their pregnancy and drop out, others get later services, but still drop out.

The option of improving all health services and making HIV just one disease among many that reproductive health and general health facilities provide has never been popular in the HIV industry, not wishing to share the funding it receives, which often dwarfs what other serious health conditions receive. So quite a number of women are being infected during pregnancy, even late in pregnancy or just after giving birth. And it appears to be assumed that they were infected sexually, probably while already pregnant, though they may have been in the 'window' period when tested earlier, which could explain why they appeared to be HIV negative.

As a Ugandan woman working with safety in health facilities said to me: 'I refuse to believe that young women (the mean age in the Zimbabwean research was 24), finding themselves pregnant, whether for the first or fifth time, have unsafe sex with strange men on a regular basis; or that women who are in the late stages of pregnancy, or even women who have just given birth, have unsafe sex with strangers; or even that pregnant women have lots of sex with their husbands and resume sexual intercourse shortly after giving birth'.

So what is giving rise to this 1% incidence of HIV, the rate of new infections, during and just after pregnancy? Is it all heterosexual intercourse? If so, all the partners of women who seroconvert must also be HIV positive. Yet HIV rates among men are usually lower than among men; it is highly likely that many of the men are not HIV positive. When African women are found to be infected with HIV, even when their partner is negative, it is assumed that they were infected sexually. But is any effort made to find out if they had other HIV risks, such as unsafe healthcare? Some receive a lot of healthcare, and in some countries women who receive reproductive care are far more likely to be HIV positive.

It may not be a popular view, but the rate of new infections among women taking part in this research is very high, higher than it is in Kenya, Uganda or Tanzania; 1% incidence could result in 8% prevalence or more after only 10 years. In Kenya, Uganda and Tanzania, prevalence has remained static at about 6% for much of the last decade. Why are transmission rates so high in this population in Zimbabwe? Those infected clearly face non-sexual risks, but researchers don't seem to want to ask what those risks are, or to investigate them.

It is inconsistant, indeed futile, to aim to reduce HIV transmission from mothers to their children when it is not even known how the mothers are being infected because reducing infection in mothers is far preferable to waiting until they become pregnant and then offering them PMTCT, and may even be more easily achievable.

[There have been many cases of unexplained and/or unexpected HIV transmission among women, men and children in Zimbabwe and further instances in most other sub-Saharan African countries.]


Monday, January 23, 2012

Keep Using Depo Provera For the Next Five Years; It May Not Be Harmful

The issue of whether use of hormonal contraceptives such as Depo Provera may increase risk of HIV transmission in both directions (from male to female and from female to male) has cropped up on this blog a couple of times and several more times on the Don't Get Stuck With HIV blog. Three months ago, when a paper was published suggesting a possible danger of increased HIV transmission, the WHO, UNAIDS and others recommended doing nothing until they held a 'high level consultation' in January. Apparently that consultation is still on the cards, if this podcast is anything to go by (Podcast 4: Hormonal Contraception and HIV).

The podcast goes through the motions of rubbishing the publication that suggested Depo Provera and similar contraceptives may be dangerous, as various factions of the HIV industry did several months ago. However, their pronouncements on the subject seem somewhat disingenuous; the uncertainty about the safety of Depo Provera, both the pills and the injectible form, runs both ways; things may not be as bad as the research suggests, but it may be a whole lot worse. For those previously advised to keep taking the injections or the pills, they might need to make a decision now. Because trials, we are told, could take four to five years.

It remains to be seen whether people using the product will happily keep using it for four to five years in the hope that the research was wrong and they are in no danger, and that all the evidence produced in the past suggesting that hormonal contraceptives are not safe will turn out to be mistaken, or whether they will stop using the product and wait till they get the all clear, even if that happens to be four to five years from now. I would certainly choose the latter!

Yet again, UNAIDS are advising people who are using Depo Provera, oral or injectible, to also use condoms. Somehow, I don't think people are as moronic as these bureaucrats imagine. Condoms will protect people against HIV and other sexually transmitted infections and they will also prevent unplanned pregnancies. Even if there were no questions about the safety of Depo Provera, many would question the need to use two contraceptive methods. But where there are such important questions it would seem unnecessarily risky as well.

There is a good review of the current evidence about Depo Provera and other issues on the Don't Get Stuck With HIV website, for those who wish to practice safe sex and avoid unplanned pregnancies but don't wish to wait four to five years to find out if their contraceptive method is really safe.


Sunday, January 22, 2012

Following Pepin, We Have a Duty to Rethink the HIV Orthodoxy

On page 9 of Pepin's book 'The Origins of AIDS', he writes: "The earliest evidence of HIV in East Africa comes from Nairobi in 1980-1 where 1% of patients with STDs and 5% of sex workers were HIV-1 infected. Just three years later, 82% of Nairobi sex workers were HIV-1 infected." Yet Pepin also spends a lot of effort demonstrating that sexual transmission is too inefficient to start an epidemic. If sexual transmission is inefficient, the percentage of HIV positive sex workers did not go from 5% to 82% in three years as a result of sexual transmission alone. You can't have it both ways and that kind of transmission rate suggests an incredible level of efficiency.

Indeed, Pepin's above two sentences, by their very juxtaposition, could suggest that this is an instance of a HIV epidemic being 'kick-started' through unsafe healthcare. An unrecognized virus has infected a small percentage of people, most of whom are being targeted for STD screening, vaccination and treatment. Nobody at the time had any idea that the process of rounding up sex workers and people with STDs (long-distance truckers, soldiers, etc) to receive healthcare services could at the same time be infecting them with HIV. It would not be inconsistent for Pepin to argue that HIV prevalence doubling every few months could not happen through sexual transmission alone; but he doesn't argue this.

Peter Piot, who spent many years steering UNAIDS away from considering any kind of HIV transmission aside from heterosexual sex in Africa, has piously stated that he agrees with Pepin and, rather outrageously, that he has always been interested in nosocomial infections. But he was the author of the paper published in the 1980s that came up with the above figures about sex workers in Nairobi. While heterosexual HIV transmission was rare in most countries, and that was known when Piot was writing, he seemed convinced that it was the norm in Africa. What should have looked like a massive, though unavoidable, nosocomial outbreak of HIV to someone interested in such outbreaks, became 'evidence' that Africans are not like non-Africans.

Now that Pepin has published his findings and people like Piot have declared themselves to be convinced that non-sexually transmitted HIV must have played a substantial role in creating the most serious epidemics in the world, the least he and the entirely misled HIV industry can do is take another look at how the impossible has happened. Nothing we know about HIV could result in HIV prevalence among sex workers going from 5% to 82% in three years through heterosexual transmission alone. That single paper and that single 'finding' has been cited over and over again. All the more reason for a scientist with integrity to question it in the light of Pepin's findings.

In a way, once it was concluded that HIV was heterosexually transmitted, it was like a self-fulfilling prophecy about African sexual behavior and HIV: those who had been rounded up in the past for their (often assumed) sexual behavior, again became the culprits. All sorts of 'findings' followed, many of which seem questionable now, but continue to be cited; migrants, casual laborers, bar workers, those who spent a lot of time away from home or traveled a lot, partners of all these groups, etc. High HIV prevalence was found in some (but by no means all) of the groups initially thought likely to be infected. But some of those infected would have been infected through earlier unsafe healthcare because they received the very type of healthcare services that Pepin describes, at a time when no one suspected a blood-borne virus had entered the healthcare system.

I follow Dr David Gisselquist, writing on the Don't Get Stuck With HIV blog, in calling for all scientists working with HIV, not just healthcare professionals, to gather up earlier claims (and perhaps more importantly, assumptions) about sexual transmission of HIV and look at them again in the light of Pepin's findings. We no longer need to accept the sort of racist and sexist assumptions about African sexual behavior that have passed as 'knowledge' about HIV. We are now free to rethink the HIV orthodoxy; in fact, we have a duty to do so.


Saturday, January 21, 2012

How Many Dictatorial Bureaucrats Can You Fit in a Five Star Luxury Hotel?

It's discomfiting to hear that Uganda's male circumcision program is being described as 'failing' by a journalist. However, what the journalist actually says about the program is that they really haven't a clue how it is going. Of course, the journalist may know something that is not mentioned in the article. But knowing very little about an expensive, highly politicized 'health' campaign, and one that is concerned (ostensibly) with reducing HIV transmission, is certainly a failure of sorts; think of the publicity.

The Ugandans should take a leaf out of the Kenyans' book and just make up the figures. There's nothing a foreign donor likes more than to hear that everything is going well and few things they hate more than to hear that those involved are indiscreet enough to tell the truth, even if it's an admission that they really don't know how many people have been operated on.

The Ugandans could even just adopt their current strategy on reporting numbers of people on HIV drugs; they don't take too much notice of the substantial percentage that is lost to follow-up every year, those who die or those who develop resistance to the 'cheap' drugs, if they even notice the last issue at all. Many of those being counted could have died or could be getting double counted because they are registered for drugs in several places, which is done because Uganda has never been able to get its drug supply capacity quite right.

The article claims that there is a high demand for circumcisions, which is surprising when the same sentence also says it's not known how many men are receiving the operation. Apparently "most of the institutions carrying out circumcision don't share their data with the ministry of Health". So the journalist and those interviewed are, effectively, just guessing. Which is not really a problem, after all, as those publishing 'figures' purporting to show that male circumcision has any appreciable impact on HIV transmission are entirely unable to say why such an operation should work in the way they say it does, nor why it only seems to work as often as it clearly doesn't work. They too are just guessing.

As for various health facilities not sharing data, I guess that's no more horrifying than the admission that data is not always even shared with people taking part in some of these studies. HIV positive people are not always told they are HIV positive, their partners are not always warned, etc. This wouldn't happen in the countries from where the money emanates for this research, but it appears that ethical standards paid for by big donors, such as Gates and whoever he fronts for, don't apply to Africans. Like Tuskegee (which is so often mentioned in these contexts), it may come out in a few decades time, but for now, people who are known by medical professionals to be HIV positive are allowed to leave health facilities and infect their partner or partners, and no parties need be informed.

The commissioner for National Disease Control, Dr Alex Opio, does "not have a single figure on the great work being done": so how does he know how great it is? I'm glad he has spotted that there is a need to "address this immediately", but shouldn't he wait till he knows what is going on before commenting so liberally? Aren't there laws about telling the truth to journalists when there are important international donors involved?

In a sense the commissioner is right: such 'data' is being used for 'evidence-based medicine'; the whole circumcision (for Africans) program is based on such questionable evidence. Despite citing the rather far-fetched figures ("4.2 million adult/adolescent men need to be circumcised in five years to avert 340,000 new HIV infections by 2025"), the commissioner does realize that a lot of foreign money is pulling out. But enthusiasm for circumcision still seems to be as keen as ever. Other figures cited are equally disturbing, such as the 20.3 million Africans that 'need' to be circumcised, which we are assured will 'prevent' several million infections and save 16.5 billion dollars in treatment costs.

In stark contrast to all the rhetoric about democracy, good governance, accountability and the like that we hear from some of the more pompous and sanctimonious representatives of the HIV industry, some of the least accountable and most undemocratic institutions the world has ever known (as for governance, we don't know, they are unaccountable) have developed a framework 'in consultation' with national ministries of health.

Institutions listed include "the World Health Organization, the Joint United National Programme on HIV/AIDS (UNAIDS), the US President's Emergency Plan for AIDS Relief (PEPFAR), the Bill & Melinda Gates Foundation and the World Bank". While we have little idea how many Ugandan men have been circumcised under the current program, we can gain some idea of how much of the HIV industry funding will be spent, given that particular bunch of overpaid bureaucrats.

[For more about non-sexual HIV transmission, such as through unsafe healthcare and cosmetic services, see the Don't Get Stuck With HIV site and blog.]


Thursday, January 19, 2012

Is it Already Too Late For People to Reconsider this Circumcision Farce in Africa?

According to an article on IRIN's PlusNews there is 'good progress' being made in the male circumcision program in Tanzania, which presumably means that they are going to get away with performing hundreds of thousands, perhaps millions of operations, knowing that the overall positive result will be small at best and there will be a lot of adverse events, perhaps even serious ones. It's clear that people pushing for these programs are not in the least bit worried that they will have to bear the costs of any adverse events. Who knows, perhaps they'll even profit from them.

But it's not unusual for circumcision 'experts' to make light of the subject. It is also claimed that the goal is to circumcise 2.8 million men by 2015 in a country where many people die of cheaply and easily preventable and treatable conditions every day. Many tens of circumcisions will need to be carried out just to prevent a single HIV infection, if the figures we are constantly blasted with are right. Where prevalence is particlularly low, hundreds of circumcisions will need to be carried out to prevent a single infection.

The program is being rolled out in Iringa at the moment, where HIV prevalence is much higher than anywhere else in the country. Yet it's certainly not the only area where circumcision rates are low. There are many areas within high HIV prevalence countries where circumcision and HIV are positively correlated, as well as areas where they are negatively correlated. In other words, we don't know what the connection is between HIV and circumcision and we certainly don't know why so many people are becoming infected in just some areas.

Are we supposed to believe that people in Iringa have amazing amounts of sex, unlike, say, the people in Arusha, Moshi or Kigoma, where HIV prevalence is far lower than the national average? Or perhaps we are supposed to believe that HIV prevalence in cities, particularly Dar es Salaam, are high just because of love levels of circumcision. In some places where birth rates are very high, such as the Northeastern province in Kenya, HIV prevalence is less than one percent. People there are clearly having sex, unless there has been a sustained outbreak of virgin births in the area. But the claim that there has been such an outbreak is no less ludicrous than the claim that HIV prevalence is high in some countries purely because of sexual behavior or, even worse, because some of the men are not circumcised. Circumcision rates are very high in Northeastern province, but they are also high in Western Kenya, where HIV rates are high too.

There is some evidence of mission creep in this program: originally these crazy claims were about adult male circumcision. Now, some articles mention infant circumcision and this one about Tanzania says that the 2.8 million people includes men from 10 years old to 34 years old. The cost of all this is estimated at between 28 and 47 million dollars, which would probably be enough to completely eradicate far more serious conditions, such as obstetric fistula, and still leave some change to train some much needed health professionals. By the way, nurses have been trained to do the operation in Tanzania and elsewhere, as there are not enough doctors.

It's worth bearing in mind that circumcisions are more common in urban areas, where HIV is less common. But that might change. Earlier circumcision programs suggested that some men could have been infected with HIV as a result of unsafe healthcare they received. This was very inconvenient and the embarrassing results were not published for journalists and other commentators to rant about, but I wonder if they would even have bothered. It's too late for the hundreds of thousands of Kenyans claimed to have already had the operation, probably unnecessarily, and the tens of thousands of people in other African countries. But there is still time for some African countries, or African people, to get some impartial advice about this subject, which is now top heavy with industry lies.


Wednesday, January 18, 2012

Doubts About Male Circumcision and the HIV Industry's View of African Epidemics

Even the title, 'Not a Surgical Vaccine', flatly contradicts the claims of circumcision enthusiasts; the term 'surgical vaccine' is rejected for being entirely unscientific. But it's in good company with many of their other claims. Authors Robert Darby and Robert van Howe look in particular at the issue of infant circumcision in Australia which aims to reduce heterosexual HIV transmission. They find there is no case for this intervention.

The authors question the 'robustness' of the three African trials constantly cited in favor of mass male circumcision and find that possible risks of such an intervention are being ignored. They also raise questions about the ethical and human rights implications of such programs, which are already well underway in a number of African countries. The authors recommend that Australia continues to discourage infant circumcision.

However, many of the reasons for finding the pro-circumcision arguments unconvincing are also relevant to African countries; they are also relevant to adult male circumcision. The authors ask if the incidence of heterosexually transmitted HIV is rising to a dangerous level and whether circumcision is the only effective way of countering this challenge. In high prevalence African countries it would be better to demonstrate how heterosexual HIV transmission is so much more common than elsewhere. As for the question of whether circumcision is the only effective way of countering HIV transmission, it is not particularly effective; but there are effective ways.

For example, condoms are very effective at reducing HIV transmission. But also, male circumcision only reduces transmission among men who also use condoms all the time. In other words, it is pointless unless men are going to use condoms on all occasions where they are not aiming for conception. The condoms won't just prevent conception and HIV, they will also substantially reduce the risk of transmission of all sexually transmitted infections (STI).

The authors list six reasons for disputing the proposal that all infant males be circumcised in Australia but with the exception of number two, they all cast doubt on the circumcision programs in African countries, whether for infants or for adults:

1 [The proposal] ignores doubts about the African evidence on which it relies and passes over numerous critiques of the clinical trials and the manner in which the WHO recommendations arising from them have been implemented.
2 It is irrelevant to the Australian situation and the specifics of Australia's HIV problem.
3 It departs from the principles of evidence-based medicine.
4 It underplays the harm and risks of circumcision.
5 It violates accepted standards of medical ethics and human rights.
6 It is marred by unscientific thinking and hyperbolic language, such as the description of circumcision as a ‘surgical vaccine’.

In addition to a whole host of criticisms of the randomized controlled trials, the authors say "Perhaps the most crucial flaw in these three studies is that the researchers assumed that all the men who became HIV positive during the course of the trials were infected through sexual contact." But that flaw can be found in many trials of HIV prevention interventions, perhaps most. The authors suggest that as much as half of the infections were acquired non-sexually. And the authors also note the lack of a convincing biological explanation as to how circumcision is supposed to protect against HIV and other STIs.

It's interesting that the authors combine scepticism about mass male circumcision campaigns with less than whole-hearted acceptance of the HIV industry view that serious HIV epidemics found in African countries are a result of high levels of sexual activity. They suggest that "It is also probable that a significant proportion of HIV infections are the result of non-sexual transmission, such as non-sterile medical procedures." I hope these researchers' findings are applied, as they should be, to countries other than Australia, where HIV rates are extremely high. Their findings have implications for the entire HIV industry view of HIV in African countries, not just the doctrinaire decision to fund mass male circumcision campaigns.

[For more about healthcare associated HIV infections, see the Don't Get Stuck With HIV site and blog.]


Tuesday, January 17, 2012

Sex Workers Face Sexual and Non-Sexual HIV Risks

A survey into HIV/AIDS among female sex workers (FSW), injecting drug users (IDU) and men who have sex with men (MSM) in Lebanon has found that prevalence was 3.7% among MSM but that no members of the other two groups were HIV positive. Whatever about IDUs, it is not too surprising that no FSWs were infected. In many countries where HIV prevalence has been monitored over a long period of time, prevalence among FSWs has been found to be low, even zero, unless they also face other risks such as injecting drugs.

This is what makes it so surprising that HIV prevalence can be extremely high among sex workers in some African countries. It has been claimed that prevalence reached over 80% among sex workers in Nairobi in the 1980s and over 70% in one region in Tanzania in the 1990s. It is often said that high rates of sexually transmitted infections STI make sex workers more susceptible to HIV. This is undoubtedly true, but rates of some STIs, which are an indication that those infected could have been engaging in unsafe sex, don't seem to correlate with HIV rates.

Programs that aimed to reduce STI rates have often been successful, but they have not usually resulted in any reduction in HIV incidence. Indeed, long before HIV was identified, STI prevalence among the entire male population of Leopoldville in the former Zaire in the late 1950s was extremely low. And it was in the years following this that HIV transmission rates were said to have increased as a result of extraordinary levels of 'unsafe' sexual behavior. What seems more plausible is that FSWs in Kenya and Tanzania were rounded up, perhaps routinely, to receive sexual healthcare that may not have been too sterile.

Sex workers everywhere can engage in high levels of 'unsafe' sex, but only in a few countries have sex workers been found to have such massive rates of HIV infection. And only in a few countries have up to 50% of the female heterosexual population in certain age groups been infected with a virus that can be transmitted sexually, but is far more efficiently transmitted through unsafe healthcare. Why should high levels of 'risky' sexual behavior among Lebanese sex workers result in no HIV infections when relatively low levels in some African countries result in high rates of HIV infection?


Monday, January 16, 2012

Pandemic HIV: Not as Perfect a Storm as we Have Been Led to Believe

In his review of Jacques Pepin's 'The Origins of AIDS', Peter Piot (Science 334 (6063):1642-1643, 2011) claims to have been "fascinated by the sometimes devastating consequences of medical injections" since the mid 1970s, following the Ebola virus outbreak in the Democratic Republic of Congo. That's strange, because I've never been able to detect that fascination in his papers. Perhaps his fascination is dormant, a bit like one of the HIV virus strains Pepin describes, which never get beyond infecting one or a handful of people.

Anyhow, now that Pepin has described the role of healthcare in spreading HIV, especially in the decades before the virus was recognized, maybe Piot will develop all those thoughts which never quite became papers. Perhaps his ideas will 'go viral', mobilize UNAIDS and the entire AIDS industry to relinquish their more evident fascination with the sexual behavior of Africans, and perhaps result in thorough investigations of the many suspected cases of healthcare transmission of HIV that have been ignored for so long.

But like Pepin himself, Piot jumps from high rates of HIV transmission as a result of unsafe healthcare to high rates of HIV transmission as a result of 'unsafe' sexual behavior, as if unsafe healthcare completely died out in the 1980s and ceased to play any significant role over the last twenty years or so. HIV transmission from unsafe healthcare did begin to reduce shortly after it was recognized as playing a part in spreading the virus. And in countries where healthcare practices were modified to avoid HIV transmission, HIV incidence, and eventually prevalence, began to drop.

But the massive increase in unsafe sexual behavior that was said to follow urbanization and various other (often rather vaguely described) changes in the 1970s and 1980s may never have happened, or may never have played as big a role in HIV transmission as the industry claims. Of course, sexual transmission of HIV occurred, and still occurs. But with healthcare producing large enough populations of HIV positive people, relatively normal (for human beings) levels of sexual behavior would have resulted in additional infections, much as sexual behavior continues to contribute to epidemics now, albeit far more modestly than is sometimes claimed.

The idea that healthcare related infections no longer occur, or hardly ever occur, is a matter for investigation. Piot and Pepin may be right, or even somewhat right; but there is a lot of empirical work to be done. The need for empirical enquiry into the possible extent of healthcare transmission has been obvious for many years, many people have called for the work to be done. But all that people like Piot have done is supported UNAIDS and the industry in denying a role for anything except sex.

Glass syringes are no longer used and disposable syringes, presumably, are not reused (very often). But how does the industry feel so confident that there are no practices in healthcare facilities which, if carried out without proper care, risk transmitting HIV and other bloodborne diseases? The 'perfect storm' metaphor that Pepin mentions and Piot echoes, one that is currently so beloved by journalists and other commentators, doesn't appear to be appropriate here. They both refer to a series of events that gave rise to the HIV pandemic, rather than concurrent events.


Sunday, January 15, 2012

Pepin's Spectacular 'Origins of Aids'; Looking Forward to Part II

I have been reading Jacques Pepin's recently published book 'The Origins of Aids'. He has produced a huge amount of research and thinking on the issue of where HIV came from and how it spread all over Africa and beyond in a relatively short space of time. He also considers some competing theories and proto-hypotheses and effectively shows why they do not provide an adequate or comprehensive explanation, either because they are not borne out by evidence or because they don't show what they purport to show.

Few would disagree with Pepin's conclusions that unsafe medical practices 'kick started' what became the current HIV pandemic, a process that was required for a virus that was difficult to transmit sexually to eventually infect people who were not sexually active, or not particularly so. Also very clear is one of Pepin's lessons learned: that profound social changes resulting from colonization, urbanization and the like, were highly significant.

But this is where I start to feel less convinced by Pepin's further remarks on what 'profound social changes' is usually taken to mean for HIV: sexual behavior. Pepin speculates about how 'unsafe' sexual behavior could have reached levels that explain later explosions in HIV transmission, but he never shows that enough people actually engaged in the requisite quantities and types of this behavior to account for some of the very high, or even medium prevalence epidemics.

In fact, since detailed figures have been collected, the connection between sexual behavior, unsafe or otherwise, has never been very strong. This is not to say that sexual transmission of HIV has never occurred, just that it has never been shown how it could reach a creshendo and then, as if spontantously, reduce and drop to a very low and steady rate, at least in some countries. But the drop in incidence (and/or the drop in 'unsafe' sexual behavior) does 'appear' to have been spontaneous in some countries, occurring long before any serious HIV reduction programs took place.

Vulnerable groups, such as sex workers, are small. If they face very high risks, their clients face higher risks than they would if they stuck with a single regular partner; but they face lower risks than the sex worker. And partners of sex workers' clients face lower risks still. Prevalence in the general population in some countries, people who did not belong to any high risk group, has often been higher than prevalence in extremely high risk groups in non-African countries; how do extreme levels of transmission among those who face the highest risks also arise in those who don't face the highest risks? I've never been convinced by talk of 'bridging populations', people who have sex with high risk groups and spread the virus among low risk populations.

For example, HIV prevalence among sex workers in India is less than 10%, often a lot less. But HIV prevalence in one whole region in Tanzania and among one large tribe in Kenya is two or three times higher. In some countries, such as South Africa, Swaziland, Lesotho, Botswana, Zambia, Zimbabwe and others, prevalence in the general population is many times higher. In some African countries, ordinary people doing ordinary things are infected with a virus that is difficult to transmit sexually and it is assumed that most of them were infected sexually. Is this not illogical? Even UNAIDS produce figures showing that the majority of HIV transmissions in many African countries result among people who have no obvious sexual or other risks.

Pepin seems to go beyond his own evidence in concluding that although unsafe healthcare played the major part in the spread of HIV at one time, that it no longer plays a particularly significant role. He may be right, but I don't see how this conclusion is borne out by evidence. In fact, just as there is still a serious lack of convincing research into sexual behavior in African countries, there is an even more glaring lack of investigation into instances where HIV has clearly been transmitted in healthcare facilities and in contexts where sexual behavior is unlikely to have played a part.

Over thirty years, it has become quite evident that sexual behavior doesn't miraculously change because of some perceived threat, such as HIV. For several decades before HIV was identified, the bulk of health development spending was thrown at persuading African women, and the donor community, that birth control would solve all their development problems, poor health, poverty, malnutrition, drought, famine, flooding, etc; if only people would just have fewer children. Many still believe it, Bill Gates being no exception in that respect.

What can change very quickly is practices in health facilities, if the right training and other resources are available. The spontaneous event that resulted in a sharp reduction in HIV incidence early on in various African country epidemics (and elsewhere) is unlikely to have been related to sexual behavior; but changes in healthcare practices took place very early on, especially in countries where such changes were affordable. Even in Western countries, some of the largest groups infected were haemophilics and others who regularly needed various forms of skin-piercing healthcare.

I wonder why Pepin didn't answer the often asked question: 'What happened in Uganda'. He had the answer at his fingertips. Uganda reacted to advice that was still given to developing countries in the 1980s, but is considered unmentionable now: HIV can be transmitted most efficiently through contaminated blood. Pepin shows us how amazingly common non-sexual transmission was in the past but he doesn't appear to have looked into how common this mode of transmission might have continued to be for the last twenty years or so, or how common it is now.

[I have also written about Pepin on the Don't Get Stuck With HIV website and blog, where we are trying to collect together cases of nosocomial (hospital acquired) HIV outbreaks, unexpected HIV infections and investigations that have taken place around the world.]


Monday, January 9, 2012

Branding Duesberg is Easy But Refutation Seems to Elude HIV Industry

Nature notes the publication of Peter Duesberg's controversial article in an Italian journal, where it is claimed that there is no proof that HIV causes AIDS. The article was previously published and then withdrawn, but the publishers, Elsevier, still make it available for a fat fee.

Anyhow, Duesberg's claim is no stronger now than it was when he first made it. His arguments are partly based on data which he himself points out is often not available. But, instead of supplying the data on which, presumably, the contrary arguments are based, all we get is a few protests that Duesberg's article was published at all, and the predictable rantings of the HIV industry sponsored comment junkies.

The publicity conscious HIV industry should be well aware of how they are drawing attention to Duesberg's views, while failing to deal with them satisfactorily. But the industry is really not good at producing well-rounded data, which would allow convincing opposition to Duesberg and allow the industry itself to put together a coherent argument for their own position (or positions).

Apparently, one of the reasons for withdrawing the original publication of the article was that it contained opinions that "could potentially be damaging to public health". But that's not a reason for refusing to publish them in a journal that hardly anyone reads. In what way would public health be served by not publishing the article? At the very least, Duesberg has pointed to serious failures on the part of WHO and other institutions to collect and publish data that is vital to public health.

If public health is really the issue, evaluate the paper properly, publish the evaluation and get on with something more important. Otherwise you are just recruiting for Duesberg and the whole issue becomes a mere exercise in protecting various theoretical pitches.


Wednesday, January 4, 2012

How Low Would An NGO Go For the Sake of Money, Even Spite?

The first time I came to East Africa, in mid-2002, I wondered how I could be part of 'development', part of the efforts to change things for the better (despite knowing that some things that go under the name 'development' make things worse, often by design). The changes may be small, but they would make a big difference to some. Etc.

Like anyone else who had similar wishes, I needed to find out what was going on, what was so bad that it needed changing, how to bring about such change, why this sort of change was not already occurring, or if it was, how to do more of that and less of anything that was inimical to development...

I wanted to meet people involved in development, people from East Africa, people not from East Africa, whatever it took. I went back to Europe to save enough money to return and, at the same time, study for a Master's degree that included development, and perhaps some other areas, so I would have some kind of perspective, maybe even some useful skills.

That may all sound very naive, but in some ways I haven't changed that much. Since I've come back I've been working with individuals, community based organizations (CBO), non-governmental organizations (NGO) and the like, hoping to find that some were doing the right thing so I could learn about where I could fit in. Because, as I spend time trying to find out where I fit in, I have to do something. So I do many things, and I hope that continues.

But what do NGOs and others in the developing world do? Well most people know something about some NGO, what might have once been referred to as 'charity'. They do relief work following emergencies, education of various kinds, healthcare work, poverty reduction work and much else. Nominally, they do all the kinds of things that someone 'with a heart' would wish to do, or wish to know that others do or to support, financially and in other ways.

Well, some people do things because they 'have a heart', but not all do. Some make a living out of their work, some make a very good living, some make a fortune, etc. But one expects NGOs themselves to be run, driven perhaps, by 'a heart', whether it's the heart of a person, several people or some kind of community, perhaps a church.

Many organizations in East Africa doing development work are, to a greater or lesser extent, church-based. Now, we all know from experience that being church-based does not guarantee that the work is always well intentioned. Unless the people driving the organization have good intentions, the work will be of little benefit to people who are in need of, say, education, poverty reduction, healthcare, and the like. As I've said, some 'development' work is harmful, and the ideal of 'making things better', however naive-sounding, was never part of the plan.

Perhaps I'm rambling a bit; that is partly my want, but partly my intention, for the moment. But you do come across organizations who say all the right things, tick all the right boxes and go through all the motions, and all that just to survive as an organization. There is nothing else they can do but survive. They look for calls for proposals, find ones they think they can do or ones they can persuade the donor they can do, and apply. If they get money, they do the job, somehow or other, if not they collapse.

So take an organization I shall call; they are a church-based organization, they do all of the above and everyone says that they are very good proponents of their church's teachings. They 'help' poor people, sick people, vulnerable and abandoned people, people with disabilities, people who are in some way stigmatized, they care for them and look after them, up to a certain point; they are unlikely to do so for the duration of those people's lives, unless those lives are short (and many are); projects are usually a few years and no more.

But that's something, because they are doing what they say they are doing, donors love them, they give them money and every few years, when a project ends, they can apply for more money and say 'look at these children and old people and orphans and vulnerable children and disabled people and stigmatized people, this is what we have been doing, if you give us more money we will keep doing it and even find some more beneficiaries'.

But when it comes down to it, the organization is just part of a bigger community, which is part of an even bigger congregation, which is part of a whole lot of congregations and overlapping groups. And it happens that has a neighbour, which's church was able to help out with some land, so that this neighbour could build another NGO, specializing in some of the above needy groups; let's call the neighbour, as an organization, do very well. So well that the church sees the beautiful buildings and, maybe, they  'covet' them. may well tick all the right boxes when it comes to applying for grants and, eventually, reassuring donors that they have spent the money well (and asking for more, of course), but they covet the assets of so much that they ignore the vulnerable, poor, disabled, abandoned, stigmatized beneficiaries of; they threaten to evict their neighbours, to whom they were once so sympathetic.

For me, the question is, if is so concerned about all needy people, some of whom is benefitting, how could they do something that would compromise every single beneficiary? And just for the sake of some assets (plus a fair amount of spite, jealousy, bloody-mindedness, prejudice or anything else that drives such maneuvers)? Shouldn't their donors say 'hey, why do you take our money but continue to impoverish the poor, stigmatize the stigmatized, abandoned again those who have been abandoned?'

If donors don't do that, they are simply accepting that development is just an exercise in identifying some projects that can tick the right boxes, and getting on with the job. So is that all development is? As a person still trying to figure out what development is, I certainly don't accept that it is, effectively, an administrative and PR effort entirely motivated by political and/or commercial interests, with no intentions worthy of a human being as a human being. If development is just another business, and just as unscrupulous as it needs to be, I think many people working in the field will be looking for another way of fulfilling their original intentions.

I'll return to this theme soon and I hope to be clearer about; are their intentions honorable, or is all the 'we're a church-based organization and we follow the teachings of the bible' just posturing, just a way of keeping the donor funds flowing. Because I've heard many claims about 'following the teachings of the bible' and (sharp intake of breath), some of them sounded quite hollow. But that's just my view.