Thursday, June 15, 2017

Lisbon Declaration: Scare Stories about Sex Cost Lives

Why would women in an African country fear being diagnosed HIV positive, refuse to take part in a treatment program that would keep them alive, and probably prevent them from infecting others? After all, the virus has been around for over 30 years and treatment has been available, free of charge, for more than a decade. We know how it can be spread, we just haven't agreed on which are the most dangerous modes of transmission. But a study has found that women believe their husbands and families will reject them, perhaps divorce, disinherit, physically attack or even kill them because of their status.

Well, it's not quite clear why Measure Evaluation felt the need to ask women why they were afraid, given the role of the HIV industry in stirring up that fear. Do the researchers think anyone would like to be diagnosed HIV positive and have to go home to their partner and explain how they were infected with a virus? The HIV industry insists HIV is almost always transmitted through sexual intercourse in African countries. It's different in European countries, where people are not assumed to be 'promiscuous' just because they test positive.

HIV has long been presented as being primarily sexually transmitted among heterosexuals, in African countries. People who are infected tend to be told that they were almost certainly infected by having sexual intercourse with a HIV positive person. However, many people who have tested positive have objected that they have not had sexual intercourse at all; or they know that the person (or people) they have had sex with are negative; or they took adequate precautions, etc.

In non-African countries, such as the US, the largest group of people infected with HIV are men who have sex with men. The next largest group is injecting drug users. Therefore, many would ask why heterosexual sex appears to be so much more risky in some African countries than it does in non-African countries. Prevalence among certain groups, such as young women in parts of South Africa, has approached 50%, even higher sometimes. Prevalence is over 20% in some southern African countries (although not in any non-African country).

UNAIDS, WHO, the US Centers for Disease Control (CDC) and other parties have tied themselves in knots trying to explain away the glaring racism implied in the claim that up to 85% of infections in African countries are a result of unsafe sex. When non-African people say that they could not have been infected through sexual intercourse, the matter can be investigated. Otherwise, their own statement of their risks is accepted, and they are not branded as some kind of sexual deviant.

I'll quote Catherine Hankins, formerly a senior officer at UNAIDS, expressing her views on 'African men': "Take a middle-class African businessman. He has had five women - nothing excessive. But the pattern we find is that he has a wife. He also has an on-off affair with an office colleague. He also has what the French call a 'deuxième bureau' - a mistress who might have a child. And once a year he goes back to his home village and has sex with his original village sweetheart. Then he gets HIV from a bar girl on a business trip."

Hankins and her fellow scientists may see this as a reasonable explanation for extraordinarily high rates of transmission, usually in relatively clearly delineated pockets, in high prevalence African countries. But if that's what 'African' men tend to be like, you might expect HIV prevalence to be relatively high in almost every 'African' country, in all cities, and in all densely populated areas. You could also be forgiven for wondering whether Hankins believes that all women are similarly 'promiscuous', or if they are mostly victims.

The reality is quite different: HIV prevalence is highest in a handful of southern African countries; next highest are parts of East African countries, such as the area around Lake Victoria and one of the southern districts in Tanzania; Nairobi, Kampala and a few others places were also hard hit by the pandemic (with low prevalence elsewhere); but in central African countries, even West Africa, prevalence is much lower, and in North Africa rates are lower than in many western countries.

In fact, prevalence is often high among wealthier people, employed people, people with access to better road infrastructure and better access to healthcare. 'Promiscuity' (perhaps not as rich as Hankins' scenario) occurs everywhere, not just in a handful of southern African countries, in cities or in diamond and gold mines. You could say it is fairly widely distributed, in Africa and elsewhere. Some people are 'promiscuous', but most are not. So unless you accept redneckery like Hankins' (which is something of an industry standard), HIV should also be much more evenly distributed, at least in African countries around where the virus seems to have emerged.

The patterns of HIV transmission suggest that there are additional modes of transmission aside from heterosexual sex. These may include unsafe healthcare, where skin piercing equipment is reused without sterilization, unsafe traditional practices that involve skin piercing, even unsafe cosmetic practices, such as ear and body piercing, tattooing, etc. But the patterns of transmission do not suggest levels of unsafe sexual behavior that would be beyond most people, in inclination, energy, even time.

So instead of asking why women are afraid to be diagnosed as HIV positive, or why 'African' men are angry (especially HIV negative ones), the international HIV community should ask how they have allowed themselves to be fooled by such tired old myths, such as those about 'African' sexuality or typical behavior of 'African' men. The HIV industry is still happy to test people and send them home, so they can tell their HIV negative husbands and partners that they have a sexually transmitted virus. They then have to persuade their family and community that they are not 'promiscuous'. If the HIV industry didn't believe them, why would their family or community?

The World Medical Association's Declaration of Lisbon on the rights of the Patient states that: "Every person has the right to health education that will assist him/her in making informed choices about personal health and about the available health services. The education should include information about healthy lifestyles and about methods of prevention and early detection of illnesses. The personal responsibility of everybody for his/her own health should be stressed. Physicians have an obligation to participate actively in educational efforts." Failing to inform people adequately means they take risks they needn't take, are stigmatized because of their HIV status and are much less likely to accept treatment that keeps them alive, and reduces the risk of infecting others.

Of course people are afraid and angry, they are being told lies about HIV, about the people closest to them, and about 'Africans' and their superhuman 'promiscuity'. UNAIDS, WHO and the rest know that heterosexual sex cannot account for levels of HIV in certain areas in Africa. So no more lies about concurrency, 'traditional' sexual practices, predominant 'mores', migratory patterns and the like. HIV can be transmitted through heterosexual sex, but it is much more easily spread through unsafe healthcare and other bloodborne modes of transmission. If people are not informed, they will continue to avoid diagnoses, life saving drug programs and anything else to do with HIV.


Sunday, June 4, 2017

From Barefoot Doctors to Barefaced Bankers

The Oakland Institute researches and publishes about access to some of the most basic of human needs that continue to be denied to the majority of people in developing countries. These issues include land, food security and sovereignty, trade and aid. An exceptionally powerful barrier to access to these and other human needs is the World Bank and its associated institutions.
A recent report details how the WB's 'private sector arm' (or is the WB merely a public sector tool of the private sector?), the International Finance Corporation, is deeply involved in extensive land grabbing projects, particularly in some of the most impoverished countries in Africa. There's a brief article about the report, and other WB related reports, on Oakland's site.
These landgrabs are carried out purely for profit, although descriptions of them are often padded out with talk of 'sustainable development' and other honeyed words. Far from benefiting anyone in poor countries, these programs squeeze massive profits from the poor through exploitation of the land for palm oil and other damaging commodities.
The few ecologies that have survived decades of colonialism and neocolonialism continue to be destroyed by institutions that claim to be 'helping' the poor. Populations in the countries affected become more dependent, less food secure and less healthy, communities and government, local and national, become less stable.
The current president of the World Bank, Dr Jim Yong Kim, used to be a 'global health leader', co-founder of Partners in Health, holding senior positions in some of the biggest names in US educational institutions (albeit some of the most neoliberal and elitist ones).
He held a senior position in the World Health Organization, contradictory as that sounds for someone who used to champion the work of Barefoot Doctors, 'accompaniment' and other types of community health volunteer. Indeed, it was his associations with work with the very poor that were used as arguments for his appointment to the WHO and, eventually, the World Bank.
It's decades since the World Bank has even pretended to have anything to do with the world's poor. It has long prioritized the ambitions of rich countries to grab land, control food production, kill off any grassroots movements, destabilize governments that their rich country management don't like and generally promote the status quo: more for those who are already rich and powerful, never mind the exploited.
But organizations like Partners in Health have been elevated to almost cult status by the press, in papers and books and in the popular imagination. Their talk of 'liberation theology' (to those who have will be given more?) and frequent mentions of touchy-feely philosophers such as Michel Foucault and Paulo Freire attracts those who like a veneer of 'ideology' with their neoimperialism. Another founder of Partners in Health, Paul Farmer, has even been referred to as 'a saint' by Kim.
Perhaps this association with (currently fashionable) cultist tendencies and cult figures have been factors in Kim's rise to president of one of the most destructive institutions in the history of rich countries' savage profiteering in poor countries? It is very hard to find criticizm of people like Kim and Farmer, which is part of the reason for suggesting an element of cultism, of cult status.
However, there is some criticizm of Kim, given his prominence in fields beyond medicine and development. One critic even argues that Kim twisted the philosophies of several philosophers to put forward what is just a barefaced, market driven, neoliberal agenda, that he manages to sell to his adoring followers. The World Bank seem to have recognized Kim as a fellow traveler a long time ago.
There is also a powerful critique of Farmer, which adds to the impression that these guys have done very well under the status quo (thank you very much), have done everything in their power to 'fight' for the status quo and have become leading figures in promoting a kind of chocolate box version of activism, that you can buy and distribute among your friends on your way to the latest popular protest.
Apparently Kim was fond of urging students to study for MBAs rather than the medicine (and anthropology, don't forget, that's where the ideology gets a toe in the door) that he and Farmer studied. One critical account of Farmer suggests that "Farmer and Kim are...embodiments of the dark side of the spirit of 1968". Others question the wisdom of Kim urging for action without theory, especially those who have studied Marx and Freire.
Using polite terminology such as 'structural violence', rather than condemning anti-poor policies wielded by the World Bank, neither will question the actions of international development institutions, or the rich country governments who profit from poverty and inequality. So neither of them are likely to have the stomach to criticize an institution that played such a shameful role in destroying any opportunity African countries had to develop themselves in the decades following independence.
Depending on how you view him, Kim appears to have come a long way from his early work in bringing healthcare to the poor. But he also showed great foresight and diplomacy in his treatment of what has become one of the principal causes of poverty, the World Bank. So who knows, perhaps he always had a penchant for banking? He and Farmer like to warn against what they term 'immodest claims of causality'. But Freire reminds us that impeding those who would question the likes of the World Bank are themselves committing structural violence.