Sunday, May 27, 2012

Gates' Letter to Africa: Take These Pills and F**K Off!

Bill Gates' annual letter this year starts by claiming that "innovation is the key to improving the world". But he is quite wrong. It is very basic things that are key to improving the world, health, education, water and sanitation, infrastructure, etc. The sort of innovation Gates is talking about includes vaccines and these are not key to eradicating diseases; they will help, but they will never be enough on their own. Take water related diseases, for example. You can vaccinate everyone against various diseases, one by one, which is how Gates wants to do it, but sickness and premature deaths will continue.

According to Gates, polio has been eradicated in India. But for how long? As long as people are forced to drink contaminated water they will suffer from water related diseases, including polio. Even though it has not infected many people in India for some time it is still in the water and sewage systems. Indeed, throwing more drugs at water related diseases without ensuring that people no longer have to drink their own waste could be contributing to more powerful strains of polio and other diseases that are resistant to any current drugs.

By all means, give people access to drugs, vaccines and whatever else they need to ensure they are healthy. But these will only play a small part in keeping healthy people healthy and making sick people better. And that part will only be temporary if people continue to live in unhealthy conditions. The current discussion about making completion of polio 'eradication' a global emergency is being used by Gates to argue for other massive vaccination campaigns to follow. Even if polio is eradicated, and that's a big if, we will have failed in the far more important goal of achieving universal access to clean water and adequate sanitation. The whole thing seems like an expensive exercise in missing the point.

Resistance as a result of overuse of drugs is not a new discovery; it has happened many times before and will continue to happen. Perhaps it is an inevitable consequence of expanding access to drugs. But, as the experience of Uganda shows, there need to be some limits to how drugs are used. Pregnant mothers who are HIV positive need drugs to reduce the chances of transmitting the virus to their babies. But they are best used as a last resort, where the mother was unavoidably infected. It's by no means certain that HVI positive pregnant women are always infected through sexual behavior. Infection through unsafe healthcare can not be ruled out.

But while HIV positive people need ARVs once they have reached a particular stage of disease progression, some would question the increasing use of them for people who will probably remain healthy for years without treatment. And the proposed use of ARVs to 'prevent' HIV already appears to be backfiring in Uganda (sometimes called 'treatment as prevention'), even though it has yet to be officially implemented. Levels of resistance to ARVs there are very high, probably because widespread use of them began several years earlier than in other countries. Resistance means that a lot of people will become sick and many may die. But it also means that the cost of treatment goes up from unaffordable for Africans to astronomical for whoever pays.

As for pre-exposure prophylaxis (PrEP), the use of ARVs to prevent HIV for people who are not infected, there is no telling how widespread resistance may become. To make matters worse, people with resistant strains of HIV can transmit those to HIV negative people. In other words, instead of starting on the relatively cheaper first line ARVs, people who have been infected with a resistant strain need to start with the astronomically priced second line drugs, if they are available and affordable.

The received view of HIV transmission in African countries is that it is almost always transmtted through heterosexual sex and rarely through any non-sexual modes, such as through unsafe healthcare or cosmetic practices. This view is not a result of sustained research, more a result of sustained dismissal of any research that suggests HIV may sometimes be transmitted through the very health facilities that the HIV industry is so keen on people attending. The received view is that it is individual behavior that 'spreads' HIV and individual behavior that needs to be changed by the various finger wagging programs offered to effect this change.

In the same way, we are often told that ARVs fail because people don't adhere properly to the drug regime. Perhaps some don't follow the regime properly; that's certainly the case for most other kinds of drug treatment. But health facilities in African countries are appalling; things go wrong all the time, often without anyone noticing. Increasing the things that can go wrong by prescribing ARVs to all and sundry is asking for trouble. Instead of pointing the finger at individuals for failing to follow a drug regime that may have been impossible to follow to the letter, due to various circumstances, the role that drug use plays in people's health needs to be re-examined, especially in countries where drugs are nowhere near the top of the list of priorities but things like living conditions are.

Gates is deluded. It may be his money that he proposes spending on more and more drugs for Africans, but he is not the one who has to suffer the problems that result from overuse of drugs and underutilization of far more effective development activities, such as provision of clean water and sanitation and the like. If polio just keeps returning, it will be as a result of the sort of health interventions Gates has been advocating for, not despite them. How the man can continue to advocate for a 'decade of vaccines' without considering the conditions people live in is a mystery.

[For more about non-sexual HIV transmission and injectable Depo Provera, see the Don't Get Stuck With HIV site.]


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