Saturday, January 31, 2015
I have spent many months over the last few years trying to understand what is really going on in Tanzania surrounding attacks on persons with albinism but I have run out of time and money to take it any further. However, I think that after more than seven years of these attacks it is imperative that we go beyond journalistic speculation and carry out proper investigations into the persecution, attacks, murders, and even the media coverage itself. It is disgraceful that these attacks continue, with little more than a bit of press frenzy every time another attack occurs. Many media articles are effectively putting a price on the head of every person with albinism, with their speculation and half baked 'research'. Below is an abstract of some preliminary research, up to 2013, that I would be happy to share with anyone interested in taking this further.
Before April 2006, superstitions about persons with albinism (PWA) were widely reported and many were subjected to prejudice and persecution, in Tanzania and elsewhere. But following an attack on a man with albinism in 2006 whose body was dismembered, a spate of attacks began in 2007 and continued until 2013, involving more than one hundred victims, about 35 of whom were murdered (although the media claim the number was over 70). The media covered these attacks assiduously in 2008 and 2009 but coverage plummeted in the following three years. Secondary literature includes reports by UN bodies and international NGOs, and these are found to depend to a large extent on earlier media reports, or on the same sources of information as those media reports.
Using Google.com, a series of searches for the terms 'albino' and 'Tanzania' were carried out on a limited set of domain names, one by one, and a date search was used to ensure that articles from earlier years were also identified, resulting in a corpus of over 90 articles.
Data was tabulated from the articles and described in narrative, including mentions of PWAs that predate attacks. Appendix I lists the full data: mentions of 'witchcraft' (or similar), a 'trade' in body parts, possible reasons for using body parts and potions made from them (such as wealth), and suggestions about who the perpetrators may have been. Very early on, the media identifies a pattern whereby 'witchdoctors' (or similar) engage paid middlemen to attack PWAs for their body parts; these would be used for 'spells' and 'potions' that would bestow some benefit, almost always wealth. The witchdoctors were said to be responding to a demand for these services from wealthy and powerful people, and that there was a 'lucrative trade' in body parts. Although numerous articles exhibit some or all aspects of this pattern it is unclear to what extent media accounts resemble what was happening on the ground, or to what extent what was happening on the ground was being influenced by the media.
It is concluded that the corpus of media coverage of attacks on PWAs from this period consists of sets of ‘received views’, exaggerated or purely imagined phenomena on which each story depends, to a greater or lesser extent; received views relate to witchcraft, the ‘trade in body parts’ and a whole array of perpetrators, while most incidents involving attacks on PWAs have never been adequately documented, and only a small number of people have been convicted of any offences.
The media needs to make it quite clear that there is, in fact, no evidence for the existence of a 'lucrative trade' in body parts, that if people try to make money this way they will fail because there are not enough ‘clients’ to buy body parts or 'potions' made from body parts in order to gain wealth or power, if there are any at all, and that the role played by witchcraft and other related phenomena is not at all clear, certainly not clear enough to attribute to it the kind of causality that the media claims; in addition to the failure to identify perpetrators, media coverage may have increased the risks that persons with albinism face, and attacks continue; even those suspected of being involved may have been subjected to persecution as a result of poorly researched media coverage.
Posted by Simon at 8:23 PM
Monday, January 19, 2015
A senior epidemiologist at UNAIDS once argued that if unsafe healthcare was common in some African countries, hepatitis C prevalence in South Africa would also be high; the largest HIV positive population in the world is found there, but hepatitis C is not common. She insisted that HIV was mainly spread by heterosexual sex in Africa.
However, the simple answer is that hepatitis C was not around in South Africa to a great enough extent. If it had been around to any great extent it would have been transmitted sexually among the people who were said to engage in high levels of unsafe sex, as well as being spread by unsafe healthcare.
To the question of why HIV prevalence is not high in Egypt and other countries where hepatitis C was spread by unsafe healthcare, the answer is the same; HIV was not around to any great extent in Egypt when hepatitis was being spread. HIV arrived some time in the 1980s, after the injected treatment for mass schistosomiasis had been replaced by an oral dose. Otherwise HIV prevalence would be high in Egypt.
Recently I came across estimates of the 'sex worker' population in three countries with very different histories, Morocco, Kenya and South Africa.
People living with HIV
*This is an urban estimate, covering all towns of 5,000 or more people
The explanation that UNAIDS and others in the HIV industry give for differences in HIV epidemics always relates to sex. The typical argument about why prevalence is so low in Morocco and other northern African countries is that the populations are almost 100% Muslim, with some even claiming that male circumcision also protects men from HIV.
The sex worker population in Morocco is smaller than those in Kenya and South Africa (although the numbers for Kenya do seem pretty high, considering the urban population only includes about one quarter of people). But it is the figures for HIV prevalence and people living with HIV that are completely out of proportion.
Prevalence in Kenya is 61 times higher than prevalence in Morocco and prevalence in South Africa is 179 times higher. Are we expected to believe that the very different environments and histories found in these three countries, emerging over many decades and centuries, all result in an impact on sexual behavior alone, and that is as staggering as these figures suggest?
Surely there are some other important differences? For example, infrastructure is much better developed in South Africa than in Kenya. But much of Morocco is desert. More importantly, the Sahara may have protected countries around it from HIV. Health services are also better developed in South Africa.
HIV established itself in East Africa in the 1950s and had infected hundreds of thousands of people by the 1970s. The virus was not established in South Africa until the 1970s and by 1990 prevalence was still very low. So the majority of the six million infections occurred after 1990. But HIV only arrived in Morocco in the 1980s, from Europe, and it never really spread that widely.
Perhaps sexual behavior in Muslim countries is different from sexual behavior in non-Muslim countries. But numbers of sex workers, men who have sex with men and others suggest that it could not be differences in sexual behavior alone that accounts for huge differences in HIV prevalence and numbers of people infected.
The histories of countries where HIV failed to spread can be as enlightening as those of countries where the virus spread widely when it comes to understanding why a few countries have appalling epidemics, whereas others have relatively small ones. HIV spread most successfully in southern Africa, less successfully in eastern Africa and not very successfully in northern Africa.
Some have suggested that HIV was spread by unsafe healthcare several decades ago, but that sexual transmission took over in the 1970s or 1980s and that it now accounts for 80% or more of all transmission. But there is no evidence for this anomalous transition, with healthcare suddenly becoming safe and heterosexual sex becoming rampant, but only in some countries.
Even UNAIDS themselves don't believe that healthcare is safe in African countries. They warn their own employees to avoid 'non-UN approved' health facilities and people are advised to carry their own syringes and needles. Tourists from wealthy countries are similarly warned when they are travelling in African countries. So why are African people not warned about the risks and how to avoid them?
Posted by Simon at 8:46 PM
Monday, January 12, 2015
One of the remarks that many articles about the Cambodian HIV outbreak are mentioning now, almost as if every journalist is tweaking the same press release and putting their name on it, is about needlestick injuries and the CDC's estimate that "99.7% of needlestick occurrences involving HIV infected blood do not result in transmission".
This figure is irrelevant and entirely misleading: receiving an injection or an infusion is nothing like a needlestick injury when some or all of the equipment, or the substance being administered, are contaminated. Needlestick injuries are typically slight and shallow and the inoculant is likely to be very small.
Some of the titles also mention 'tainted needles', but this may give the incorrect impression that reused syringes are not also a likely factor in this outbreak, along with contaminated multi-dose vials of medicines, vaccines, distilled water and other substances.
An injection involves the needle going below the skin, into muscle or into a vein, depending on what kind of injection it is. Most of the contents of the syringe and needle, along with anything remaining in them from previous uses, goes into the patient's body. Some estimates of risks are given on this Don't Get Stuck With HIV webpage.
Most of the contents of the syringe and needle enter the patient's body. Some remains in the syringe and needle. In addition, it is possible for a vacuum to form in the syringe, allowing a small amount of blood from the patient to enter the syringe. To repeat, this is nothing like a needlestick injury.
Someone from the World Health Organization is reported as saying "different types of injection procedures carry different levels of risk", which is a major improvement on the CDC quotes, but the WHO remark needs to be explained further, while the CDC one needs to be removed altogether.
Similar remarks apply to infusions, intravenous drips, etc. The risk of transmission from some common procedures can be very high indeed. Visitors to Cambodia may have noticed how popular intravenous drips are, with passengers on the back of motorbike taxis holding up the bag as they ride, and small 'medical' practices opening on to streets in Phnom Penh (although I doubt if many visitors have used such clinics because they tend to be aware of the risks of infection with HIV and other viruses through unsafe healthcare).
It is also very disturbing that the single practitioner said to have been involved in the outbreak has been arrested, imprisoned and even accused of murder (though little mention has been made of any murder victims). This is not going to encourage other practitioners, or professionals of any kind, political, administrative, ancillary, etc, to come forward and assist with the inquiry.
Members of the public may be careful what they say to police if they think others may be arrested and accused of murder. But even employees of CDC, WHO, UNAIDS and the like may be reluctant to find evidence that the risk of healthcare associated HIV transmission is very high, because they have been insisting for several decades that it hardly ever occurs.
To ensure the cooperation of as many health practitioners as possible the Cambodian authorities need to consider a 'no blame' investigation. Every article so far suggests confusion, professionals not recognizing HIV risks from unsafe healthcare, politicians appearing to know nothing about it and, more importantly, members of the public not knowing about the risks they face, or how to avoid them (there is some useful advice here).
It is especially important that members of the public are involved and that they understand a 'no blame' investigation. While some people may be angry about the single unlicensed practitioner identified so far, the entire health service, department of health, and even the global health community must share some of the responsibility.
Local human rights NGO Licadho stresses this point. The government of Cambodia (and governments of every developing country) have been claiming to have implemented 'universal precautions' to prevent healthcare associated HIV transmission. But is this a mere tick in a box marked 'universal precautions'?
In the light of this and numerous other outbreaks, declarations about universal precautions may need to be questioned to establish if there is any mechanism for ensuring that these precautions are being followed, and even if it is possible to follow them in seriously under-resourced health services.
Posted by Simon at 10:50 AM
Thursday, January 8, 2015
There has been a lot of wringing of hands and gnashing of teeth among the global health community about how the recent ebola epidemics in Guinea, Liberia and Sierra Leone may have been contained if only there had been universal healthcare (UHC) in place. Amartya Sen even makes a similar point in his excellent article on UHC in the English Guardian.
But this public angst seems to imply that around 20 earlier outbreaks of ebola were contained because health systems in the countries involved, Nigeria, Uganda, Sudan and the Democratic Republic of the Congo, were adequate. In fact, the opposite was the case in some instances, with several outbreaks dying out once the local healthcare facilities were overwhelmed and forced to close down.
Perhaps UHC, however vital, is not enough on its own? For the seven countries listed above, can anyone say that health services, while weak, are safe? An article just published on knowledge and practice of universal precautions among healthcare workers in Nigeria concludes that "the practice of universal precaution is not given much attention in [Primary Health Care] and this may constitute health risk to the nurses and the patients in the study setting".
Nigeria is not alone; the Don't Get Stuck With HIV site's 'Cases of HIV from Blood Risks' section lists 17 African countries where healthcare related outbreaks have occurred, along with nine non-African countries. Cambodia will soon be added to the latter collection.
The number of people found to have been infected with HIV in Roka Commune, Battambang Province, probably through unsafe healthcare, possibly administered by an unlicensed practitioner, is now well over 230. But that number is already several days old.
More importantly, the inquiry appeared to go beyond the village where the first cases were found, as more turned up from other villages. Will the inquiry also look for outbreaks elsewhere around the country? Surely there are other unlicensed practitioners, other practices where safety is not the priority it should be?
In addition, there may be licensed practitioners and practices where risks are being taken. Perhaps few people have been infected as a result, perhaps none; but if unsafe practices are to be found anywhere in the country there is a risk that there will be other outbreaks in the future.
There have been no serious investigations of healthcare associated HIV outbreaks in African countries, where all the worst epidemics are to be found. The countries where there have been investigations are mostly ones where the global health community does not have a lot of influence, such as China, Kazakhstan, Uzbekistan and Kyrgyzstan.
An investigation carried out in 2008 in Pakistan after a very large number of people tested positive in this low prevalence country was too superficial to identify any additional infections, although the outbreak was clearly a result of unsafe healthcare. Here too, the finger was pointed at a few unlicensed practitioners, leaving licensed healthcare out of the picture altogether.
None of the media reports from Cambodia suggest that journalists are making any attempt to go beyond what they are fed in the form of press releases. They could quite easily ask people in any village in the country, or even in the cities, about unlicenced practitioners and practices. But the implications of this outbreak seems to be entirely lost on them.
The Australian media, in particular, has had little to add to the subject, although Cambodia is dominated by Australian NGOs, NGO workers, expats of various kinds, business people, tourists and the like. Australians are less likely to visit unlicensed practitioners or practices, but levels of safety in licensed healthcare are unknown.
The UN and its employees are not in any danger, of course, because they are all issued with advice, even injecting and other equipment when they visit certain areas. They have their own UN-approved health facilities and would rarely any serious healthcare risks.
The press may continue to wait for the scraps that will eventually be thrown to them, or they could carry out their own investigation into healthcare safety in the light of the outbreak of healthcare associated HIV in Battambang Province. But they may end up missing a cover-up on the same scale as the one that appears to have gone unnoticed by the press in Pakistan a few years ago.
Posted by Simon at 1:24 PM
Monday, January 5, 2015
If there was an injectible birth control method that doubled the risk of HIV positive people using it infecting their partner, and also doubled the risk that HIV negative people using it would be infected themselves (if their partner is infected), you'd expect the WHO to issue a warning, right?
But Depo-Provera (DMPA) is widely marketed by NGOs and other institutions running family planning programs in developing countries, and WHO (World Health Organization) evidently believes that reducing births is more important than safety.
This is great for Pfizer, and now, thanks to their new symbiotic relationship, it's great for Gilead too, because women using Depo-Provera may be able to reduce their risk of being infected, or of infecting their partner. All they have to do is take drugs kindly produced by Gilead, in the form of pre-exposure prophylaxis (the use of antiretroviral drugs, either daily or intermittently, to reduce the risk of infection with HIV).
You might think that this would not happen, that surely, Depo-Provera would be taken off the market, or at least carry a warning. But companies such as Pfizer and Gilead have been very successful in getting institutions like the WHO, along with various universities and donors (such as those listed in the AIDS Journal article), to help them market their products.
PrEP is something of a solution in search of a problem. It is possible that HIV negative people who wish to have unprotected sex with HIV positive people (or people whose status is unknown) would be able to reduce their risk of being infected. But the majority of people in African countries are probably not in this position; PrEP is likely to be more of a recreational drug for wealthy countries.
If people wish to reduce their risk of being infected with HIV (or of infecting others) they would be well advised to avoid Depo-Provera. There are plenty of other birth control methods, some of which also protect against HIV and various sexually transmitted infections.
The problem is that HIV positive people using Depo-Provera and HIV negative people whose partners use it are not being warned about these well documented risks. They are not suffering from a lack of pre-exposure prophylaxis, but they might be suffering from poor, incomplete or biased family planning advice.
There are industry sponsored trolls on social media sites, Twitter for example, who pounce on anyone who tries to question the safety of Depo-Provera. But the above AIDS Journal article seems to confirm what critics have been saying, while at the same time offering another patented solution that can be taken in conjunction with the discredited birth control method.
In contrast to PrEP, Depo-Provera seems to be almost exclusively marketed to poor people in rich countries and to anyone and everyone in poor countries. No conflict of interest is declared in the peer-reviewed journal that published the paper, and the donors listed are all well known and highly influential, particularly in relation to Depo-Provera studies.
Posted by Simon at 12:27 PM
Friday, January 2, 2015
According to an article in the UN's News "West Africa's Ebola epidemic has cruelly exposed the weaknesses of health systems in the countries where it struck". The director of the World Health Organization, Margaret Chan, is further quoted as saying that "what they lacked was a robust public health infrastructure to deal with the unexpected".
This is a very odd way of looking at the situation. Firstly, almost every country in Africa lacks a robust public health infrastructure; secondly, most of them have lacked such an infrastructure for many decades, as a cursory review of relevant literature, going back at least to the 1940s, will reveal.
Tens of millions of people suffer from numerous avoidable health problems, such as malnutrition, vitamin deficiencies, parasitic conditions, infectious diseases, non-communicable diseases and more; epidemics and outbreaks are so common that most of them don't even hit the headlines, least of all the headlines of non-African newspapers.
Not only that, but this has been the case throughout the whole of the WHO's history. Lack of health infrastructure to deal with the 'unexpected' has been the norm in sub-Saharan Africa for decades, as the WHO (as an institution) can confirm. They were involved in various campaigns to reduce or even eliminate some health conditions, sometimes successfully, sometimes not so successfully.
In fact, many of their less successful forays into eliminating or eradicating diseases demonstrated that it is not possible to ensure that diseases can even be eliminated from large areas without adequate health infrastructure, let alone eradicated. Various programs to reduce prevalence of certain sexually transmitted infections were unsuccessful precisely because of failures relating to overall health infrastructures, rather than to any weaknesses in the programs concerned.
The HIV epidemic has raged in many sub-Saharan African countries regardless of various expensive and well publicized programs to reduce transmission. Some country epidemics have declined, but many did so before the bulk of prevention campaigns were even dreamed up; in other countries there are few credible causal links between HIV prevention programs and drops in transmission rates.
Chan would be better off asking why the ongoing epidemics in West Africa are so much worse than any that have occurred elsewhere. It would also be interesting to know why HIV epidemics in West African countries were so much less severe than in African countries that are said to have far better developed health systems than Sierra Leone, Guinea and Liberia, such as South Africa and Botswana.
Chan goes on to bemoan lack of "background data on the usual...so that the unusual stands out". I've been reading articles about sexually transmitted infections in African countries published between the 1940s and the 1990s. Most of them attest to the lack of reliable information and statistics. 'The usual' is what you find in the three countries who have suffered the most in the current epidemic: health systems in most other African countries are in a similar state.
Decades of epidemics have, apparently, yet to teach us that you are unlikely to be able to mount a successful campaign against disease outbreaks if you don't have health infrastructures. You can't hurriedly put everything together in a package and send it off with some soldiers, so they can piece it together before heading off to their next dig a hole and fill it in scheme.
Chan is right in demanding "good quality care [that is] accessible and affordable to everyone, and not just to wealthy people living in urban areas; having enough facilities available in the right places with enough staff and uninterrupted supplies of essential medicines; diagnostic capacity that returns rapid and reliable results; and information systems that pinpoint gaps and direct strategies and resources towards unmet needs".
But she should start by taking a close look at those villages in Cambodia where several hundred people have been infected with HIV through unsafe healthcare. There is little point in developing health infrastructures without ensuring that they are also safe. Otherwise, she may end up with another Egypt on her hands, which has the highest prevalence of hepatitis C virus in the world following an otherwise successful schistosomiasis eradication campaign.
Posted by Simon at 2:38 PM