Sunday, March 25, 2012

Public Health and Education; You Can't Have One Without the Other

It's shocking to hear that, after so many years and so many hundreds of millions of dollars spent, half of all Ugandans think HIV can be spread by mosquitoes. This is 'because they [Ugandans] are illiterate', according to this YouTube video. But how do we know which of them were answering the question, rather than just guessing? If, after this many years of AIDS awareness publicity, education, politics, programming and the rest, people still have to be asked such questions, there is something very wrong with the education system in Uganda and other high HIV prevalence countries. Of course, problems with education long predates the discovery of HIV.

Uganda was probably the first African country to receive aid money for HIV programs, for all the good it has done. The 'comprehensive knowledge' people are said to require is mainly about heterosexual HIV transmission, condoms, rejecting 'misconceptions', etc, with little or nothing ever being mentioned about non-sexually transmitted HIV, such as that from unsafe healthcare or cosmetic practices like tattooing, body piercing and manicures.

The upshot is that one third of women have the 'knowledge' and only just over 40% of men do. A lot of research has shown that 'knowledge' about sexual behavior, what's said to be safe and what's said to be unsafe, does not in any obvious way translate into people only engaging in 'safe' sex and always avoiding 'unsafe' sex; often, it's quite the contrary. While many have been taught what to say when asked about HIV, or to take a stab at answering a handful of questions, this has had little effect on behavior and probably none at all on HIV transmission rates.

But if one of the HIV industry's insights is that people are illiterate, then perhaps randomised controlled trials of the sort that have been popular in African countries are not particularly appropriate. Are they even ethical? How can someone give informed consent under such circumstances? Supposing the 50% who appeared to know the correct answer to the question about mosquitoes were also asked about the effect of male circumcision on HIV transmission? Would they be deemed to be well enough informed, or informable, to give their consent to be circumcised? And how about the other 50%?

If one of the HIV industry's insights is that people are illiterate, why do they not spend money on education and literacy, instead of pushing doctrinaire agenda that are infused with global politics, religion, pseudo-morality and the like? The aim is to reduce HIV transmission, but circumcision, on its own, doesn't reduce HIV transmission. In fact, you have to give those who undergo the operation a fairly complex message: circumcision only protects against HIV (if at all) if condoms are also used. Now, those who have been receiving the messages know all about condoms, at least, they know what they have been told. So if they don't already use them, circumcision is not going to help, and may do harm. And if they do use them, circumcision is of no advantage whatsoever. Would people who know that agree to be circumcised? Why?

Hasn't the HIV industry noticed the conditions in health services in countries like Uganda? Haven't they noticed that hospitals are not safe places to receive health services, particularly circumcisions and other operations? Don't they think that illiterate people with abysmal health services need accessible and safe healthcare? Despite this apparent lack of insight, all the industry can think about is male circumcision, prevention of mother to child transmission and a few other tricks. Never mind education and health. Preventing infections in mothers should be prior to mother to child transmission, which means non-sexually transmitted HIV needs to be investigated. But male circumcision is likely to increase transmission to mothers, which increases the likelihood of mother to child transmission.

The problem with spreading a mixture of truths, half-truths and lies is that you don't get to choose which ones you can take back, which ones people will believe, which ones they totally misunderstand, etc. What a mess. But hey, just think of the commercial opportunities! Given that married people and those in long term relationships contribute most to Uganda's epidemic, the take-home message of the video seems to be that Ugandan men are feckless and the women are promiscuous. Data collected about sexual behavior doesn't support those messages so the HIV industry says or implies that they are lying.

That's why I would suggest that the HIV industry programs treat Africans like a bunch of animals being rounded up to receive whatever they are handing out. It's hard not to conclude that those who receive this kind of treatment are not seen as humans and that human rights are not relevant. Would this happen to white, middle-class Westerners? Well, HIV, we are told, is mostly transmitted through male to male sex and intravenous drug use in Western countries, so circumcision is not relevant. But isn't that, in itself, very surprising? Isn't there something odd about the claim that HIV is almost always transmitted heterosexually in Africa, but nowhere else?

Someone posting a comment on my last blog post drew my attention to an article on the Johns Hopkins School of Public Health website, JH being one of the bastions of male circumcision for Africans. This article, from 2008, predates the time when it became impolite to mention the possibility that African health services may not be able to meet the demand for circumcision, although at that time, there was virtually no demand at all! But the respondents in the article, Ron Gray and Maria Wawer, don't have so much to say about safety in the health facilities, apparently thinking all that's required is a bit of training.

Gray says "This is completely unique in public health. We've never used surgery to prevent an infectious disease. The learning curve is steep"; would Westerners agree to undergo surgery, or to allow their children or infants to undergo surgery, because there may be some reduction in the risk of being infected with HIV? I believe most people would not give their consent, however informed. It's not just unprecedented, it's unethical to excise a healthy piece of flesh for an advantage that may not be realized until many years later, if at all. Nor would anyone be more likely to give their consent if they knew that about 75 operations need to be carried out to prevent one infection, and that's in controlled trial conditions.

One of the biggest flaws in the received view of HIV is the claim that it is (or was) spread by 'high-risk' groups. The majority of people infected in high prevalence countries don't appear to be members of any high-risk groups; they are not even all sexually active. The difference between Western countries and high prevalence African countries is that, in the former, HIV is mainly confined to a handful of risks, such as male to male sex and intravenous drug use; in the latter, HIV is not mainly confined to identifiable risks. But, rather strikingly, Africans are not generally aware of what could pose the highest risks of all, unsafe healthcare and cosmetic services. UN employees, tourists and others are informed about such risks, but Africans are not. Surgery to prevent an infectious disease is not just unique in public health; if informed consent is required, mass male circumcision is probably not even part of public health.

[For more about male circumcision as a strategy for HIV reduction, see the Don't Get Stuck With HIV site.]



Joseph said...

Gray says "This is completely unique in public health. We've never used surgery to prevent an infectious disease."

And he would be lying through his teeth.

Circumcision advocates have been trying to use surgery to prevent infectious disease for quite some time now. See for yourself:

Simon said...

Thanks Joseph, that's quite a timeline. I still find it hard to understand why male circumcision has cropped up so many times in history as a proposed solution to so many different things and that it is now being proposed for HIV, despite the lack of evidence for its effectiveness.

Petit Poulet said...

Like anything involving genitals and children, it is all about power and control (ie. domination). There may be a little jealousy thrown in (if I can't have it, why should you).

Great blog!

Simon said...

They have to control the parents, who must give consent for their children. But scary to think how many people may do that.