Tuesday, August 12, 2014

Revised History of HIV in Kenya – Part II - Spaces and Times

It might sound reasonable to start a history of a virus that was only identified in the 1980s in the same decade, or perhaps the decade before, just to be safe. But many of the phenomena that are said to be involved in the HIV pandemic go back a long way. There’s no need for me to start with the earliest known historical accounts, nor even with the time the virus ‘jumped species’, from chimps to humans. That history has been well described elsewhere. But I have chosen to start at around the beginning of the 20th century for several reasons.
HIV itself can be dated to the early part of the century using genetic dating techniques, for one thing. But also, Britain had established Kenya as a protectorate in 1895. Christianity was already on the way to becoming the predominant religion (although there had been Christian Kenyans for several hundred years). Nairobi and other cities were only ‘trading posts’, but some of them eventually became heavily (and densely) populated. Several of the most important exports in Kenya today were already significant parts of the economy many decades ago. Even international social, health, educational and financial institutions that were eventually to play an important (though by no means always positive) role in Kenya’s development have been around for over half a century. Some environmental and ecological issues that only came to a head later had already begun, and much of the country’s current infrastructure was developed early on in the British occupation, to facilitate the extraction of resources, move large numbers of workers and soldiers around, etc.
I think it will become apparent why these issues are worth looking at. There is a potentially huge list of other issues that may be relevant, but I’m concentrating on the ones that I believe are in need of greater attention. Most official accounts of HIV epidemics, from the likes of the WHO, UNAIDS and others, obsess about labels, various ‘vulnerable’ groups, specific populations said to exemplify certain kinds of behavior (almost always sexual and generally presented as somehow illicit or ‘deviant’), people engaged in certain occupations and others. Examples from UNAIDS' latest offering (The GAP Report 2013), another multi hundred page, multicolored, expensively produced document, with some well chosen photographs are: "People living with HIV, Adolescent girls and young women, Prisoners, Migrants, People who inject drugs, Sex workers, Gay men and other men who have sex with men, Transgender people, Children and pregnant women living with HIV, Displaced persons, People with disabilities [and] People aged 50 years and older"; but other groups can easily be generated, and no doubt are, as and when required.
Naturally, we are concerned about human beings, people, their health, rights, welfare and wellbeing. But people are not the one dimensional entities denoted by the labels spewed out by international institutions (‘international’ generally meaning wealthy countries). Instead, I would draw readers' attention away from these ‘populations’, which almost all African people could be shoehorned into at some time in their lives; many would fall into several. I think it is far more fruitful, as well as a lot less demeaning, to pay some attention to places, for example, large-scale mines in southern Africa, ecological zones, such as Lake Victoria, certain hospitals and facilities that provide various health related services, perhaps even places where people go for cosmetic services and even various traditional practices, such as circumcision. As mentioned, HIV prevalence is low in the North African region, higher in the East African region and highest in the southern region. There are many spatial factors, and the HIV industry does consider them sometimes, but they always view them in terms of what kinds of sexual behavior may be practiced in high HIV prevalence areas.
In his book on the origins of HIV, mainly in Francophone African countries, Jacques Pepin talks about colonial health programs, which he and others sometimes refer to as ‘well meaning’. But, like infrastructure in general, health services were probably intended to enable the smooth running of armies, mines, companies exporting raw materials, such as timber and textiles, also high value goods such as tea. In other words, these ‘benefits’ were not developed, originally, for Africans; they were for colonials, for the colonial power. Mining companies and other big employers may find it good for business to be able to treat endemic illnesses that would otherwise threaten production (just as today, some might argue, funding is provided for diseases that we think may threaten wealthy countries, which was the case with HIV, and perhaps even ebola). Occupational and other private health services, also, may not be subject to the kind of (generally fairly superficial) scrutiny potentially faced by public health services. Pepin argues that healthcare transmission was very important early on in the pandemic, before AIDS was identified and the virus causing it was discovered. But he argues in the introduction that unsafe healthcare has long ceased to be a major factor in African countries. He also argues that almost all transmission, after a certain point in history, became sexual. For him, in a sense, there was an explosion of unsafe sexual behavior, although such a phenomenon has never been empirically described (sensationalist accounts based on high transmission rates, which have been empirically described, do not show that all or most transmission is a result of sex).
Despite the popularity of HIV related PR materials pointing the finger at certain people and their sexual behaviors, disease epidemics, HIV included, are not entirely determined by what individuals do. There are important environmental factors, ‘environmental’ being a very inclusive term indeed; and there is the pathogen itself, which I have less to say about. I have been concentrating to a large extent on spatio-temporal factors of the kind hinted at above because theories about ‘populations’ don’t seem to be very helpful, in addition to being highly prejudiced. Fishermen, miners, migrants, transport workers, teachers, soldiers and various others have at some time had the finger of blame pointed at them by the HIV industry. But often, a little background reading suggests that there is something other than their individual behavior, even their sexual behavior, that relates to high HIV prevalence. For example, HIV prevalence is very high in fishing communities, but it is not clearly highest among the fishermen themselves. Some research has suggested that proximity to and contact with Lake Victoria is associated with very high prevalence, not so much the occupations or behaviors of the people infected. Sex workers in some countries are unlikely to be infected, or at least, a lot less likely than sex workers in African countries (and infections are often a result of injection drug use). Sex workers in African countries may face elevated non sexual risks, such as frequent visits to sexual health clinics, where safety may not be prioritized. Also, some early reports of high rates among transport workers, teachers and healthcare workers may not have paid much attention to non-sexual risks, or they may have exaggerated sexual risks. Even some of the figures for prevalence have been exaggerated at times.
The HIV industry does, as I have said, pay attention to some of the factors that I would argue are important. It’s just that their starting point is how various phenomena clearly relate to people’s sexual behavior, without demonstrating that HIV is almost always transmitted sexually. People close to Lake Victoria may be more susceptible to HIV because of an endemic parasite called schistosoma. This means that sexual transmission of HIV is very significant, but there is no need to impute any kind of ‘deviant’ sexual behavior or any kind of ‘traditional’ practices that may (or may not) impinge on people’s sex lives. Just ordinary sex would be enough, sex in ordinary quantities, with ordinary people. Of course there are sex workers in Africa, just as there are sex workers everywhere. There are people who have a lot of sex in Africa, just as there are such people everywhere. But most people don’t have a lot of sex, and some have none at all. Regression to the mean doesn’t cease when you reach sub-Saharan Africa and sex is one of those things that most people can’t engage in to extreme levels. Whereas it is hard to imagine a limit to the amount of money one person can earn, there are several limits to how many different people one can have sex with, what kinds of sex, how often, etc. (I’m following Nasim Taleb’s concepts of Extremistan and Mediocristan; sexual behavior is probably not susceptible to black swan events.)
To finish Part II, HIV in Kenya is not just about individual behaviors, it is also about places, such as Lake Victoria, Turkana, Nairobi and other cities, and parts of those cities. The obsession with ‘African’ sexual behavior, which seems to have started with the eugenics movement, not with the discovery of HIV on the continent, has been entirely fruitless and highly stigmatizing. But the knowledge that certain places are clearly dangerous has yet to be translated into a similar obsession with healthcare safety, education about bloodborne HIV or a bit of effort to alleviate the most urgent concerns in the lives of ordinary people.
It’s also important also to consider certain temporalities in Kenya’s HIV epidemic. Pepin and others often mention things like societal breakdowns, urbanization, rapid population growth and the like, often with the implication that these ‘obviously’ explain massive increases in unsafe sexual behavior. But societal breakdowns did not start in the 1980s, no more than sex did (or even media fantasies about ‘African’ sexuality). Some societal breakdowns, such as wars, result in very low HIV transmission (for example, Mozambique, Angola, Sierra Leone, Somalia and others). Many societies are broken down but none of these breakdowns, that I have heard of, have been shown to result in widespread levels of unsafe sexual behavior. Urbanization and high population growth, too, have occurred at many times in many places. In Kenya there have been population growth rates as high as 8 or 9% per annum during the period 1969-2009. But often these high rates of growth were in areas where HIV prevalence never went very high, such as Mandera; some places where HIV prevalence is (or was) high experienced low population growth, such as Mombasa. Kenya’s epidemic is old enough to show that factors involved in the spread of the virus go back a long way and are still extant. Those factors, whatever they are, have eluded UNAIDS, WHO, CDC and other august institutions. But that doesn’t mean they can never be identified and successfully addressed.


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