One of the results of the exceptionalization of HIV is that other health conditions end up being ignored, including sexually transmitted infections (STI). Given the HIV industry's obsession with sexually transmitted HIV, it might be expected that STIs such as syphilis might get a bit of attention.
However, many women can be tested and treated for HIV, and receive prevention of mother to child transmission (PMTCT), without being tested for syphilis and other STIs. These preventable and treatable STIs can be passed on to children, despite most women attending antenatal care facilities at least once during their pregnancy.
WHO estimates that two million pregnant women are infected with syphilis every year and about 1.2 million of them will transmit the infection to their child. Far fewer children are infected with HIV. And the number of deaths from syphilis during pregnancy is higher than the number of infants infected with HIV.
At one time, a lot of attention was given to treating STIs as a means of reducing HIV tranmsission. Trials showed that this had very little impact on HIV transmission and a recent Cochrane Review makes it clear that STI control is not an effective HIV prevention strategy.
But, importantly, the review concluded that there are "other compelling reasons why STI treatment services should be strengthened, and the available evidence suggests that when an intervention is accepted it can substantially improve quality of services provided."
Syphilis and many other STIs are preventable and treatable, yet they often seem to be ignored. And it sounds as if they have only received much recent attention because of the possibility that they may reduce HIV transmission.
Surely STIs should be prevented and treated where possible because they are diseases, not just because this might have an impact on HIV transmission? HIV is debilitating and incurable, but other STIs are debilitating and curable.
Whether STI treatment has an impact on HIV transmission or not, people should not have to suffer from them or risk passing them on to their partners and their children, especially when this is entirely avoidable. They have a right to prevention and treatment for all diseases, not just HIV.
Showing posts with label STI. Show all posts
Showing posts with label STI. Show all posts
Monday, May 2, 2011
Thursday, January 28, 2010
Religion and Health: Interference or Complementarity
Following my speculations about why some people seem to imagine that they can be made very rich by a miracle, a friend sent me an article entitled Religion, Spirituality, and Medicine. This article is a "comprehensive, though not systematic, review of the empirical evidence and ethical issues" and concludes that "the evidence of an association between religion, spirituality, and health is weak and inconsistent".
Perhaps more importantly, the authors question the ethics of mixing religion and medicine, a question that would still arise even if there was stronger evidence of an association between religion and health. One could ask, which religion would a doctor recommend or agree to discuss? What would they do with someone who didn't believe in any religion? Would each medical professional require special training and what kind of special training? (The authors of the paper did not raise all these questions, but they arise from considering the problems of combining medicine with religion).
Even if people go to a doctor without any expectation that the doctor is, to a large extent, a scientist, that doctor is obliged to do things that are supported by scientific evidence and avoid things that are not so supported. The fields of science and religion are completely different and the practitioners of each field work in different ways. Is it even feasible for doctors to also become experts in religion (as if religion were just one thing!)?
If I was renting a damp room that affected my health badly, should my doctor write a letter to my landlord and ask for my conditions to be improved? Medical advice could be brought to bear on an employer who was exposing me to health risks, but this is a matter for employment laws. The doctor doesn't intervene directly. Yet we know that environmental conditions are closely connected with people's health. We know that economic circumstances are closely connected with people's health but we don't expect our doctor to recommend a pay rise. Even government health advice about healthy eating is considered to be taking things too far by some.
I accept that certain beliefs can be comforting and I certainly wouldn't suggest that people should be told what to believe and what not to believe or how to express their beliefs. If they see praying as part of their recovery from illness or as helpful in bearing an illness from which they will not recover, no one has the right to interfere. But when it comes to prescribing medication, the doctor is the expert, not the religious leader. And when it comes to praying and giving religious advice, the religious leader is the expert.
In fact, I find it exasperating that there are many churches in developing countries who don't seem to be able to make that distinction. They feel they are experts in marriage, reproduction, sexual behaviour and protecting against sexually transmitted infections (STI). They are not experts, generally they know even less than lay people and should certainly have less experience. If you can't persuade someone to give up having sex or sex outside marriage, the least you can do is tell them how to avoid becoming infected with an STI, infecting someone else with one or giving rise to an unplanned pregnancy. Otherwise, these leaders are failing to do what they can to prevent serious consequences.
If religious leaders wish to give medical advice, they had better know what they are talking about. As for advice about sexual behaviour, contraception and reducing the spread of STIs and unwanted pregnancies, many don't seem to have had a lot of success and should leave the job to someone who has the appropriate knowledge and training. In the same token, doctors should discuss religious matters with patients if they feel able to do so and if they are requested to do so but it should never be seen as a type of medical care or treatment.
If someone has a particular set of religious beliefs, presumably they hold those beliefs regardless of their health or lack of health. It seems unlikely that they just 'adopt' those beliefs in the hope that they will get well. Whether someone is religious or not, some will suffer illnesses and injuries and all will die eventually. If the 'belief' is purely conditional on their health, the person's piety would be quite questionable. So I don't see why a religious person would be interested in whether religion is in any way connected with health outcomes in the first place.
Perhaps more importantly, the authors question the ethics of mixing religion and medicine, a question that would still arise even if there was stronger evidence of an association between religion and health. One could ask, which religion would a doctor recommend or agree to discuss? What would they do with someone who didn't believe in any religion? Would each medical professional require special training and what kind of special training? (The authors of the paper did not raise all these questions, but they arise from considering the problems of combining medicine with religion).
Even if people go to a doctor without any expectation that the doctor is, to a large extent, a scientist, that doctor is obliged to do things that are supported by scientific evidence and avoid things that are not so supported. The fields of science and religion are completely different and the practitioners of each field work in different ways. Is it even feasible for doctors to also become experts in religion (as if religion were just one thing!)?
If I was renting a damp room that affected my health badly, should my doctor write a letter to my landlord and ask for my conditions to be improved? Medical advice could be brought to bear on an employer who was exposing me to health risks, but this is a matter for employment laws. The doctor doesn't intervene directly. Yet we know that environmental conditions are closely connected with people's health. We know that economic circumstances are closely connected with people's health but we don't expect our doctor to recommend a pay rise. Even government health advice about healthy eating is considered to be taking things too far by some.
I accept that certain beliefs can be comforting and I certainly wouldn't suggest that people should be told what to believe and what not to believe or how to express their beliefs. If they see praying as part of their recovery from illness or as helpful in bearing an illness from which they will not recover, no one has the right to interfere. But when it comes to prescribing medication, the doctor is the expert, not the religious leader. And when it comes to praying and giving religious advice, the religious leader is the expert.
In fact, I find it exasperating that there are many churches in developing countries who don't seem to be able to make that distinction. They feel they are experts in marriage, reproduction, sexual behaviour and protecting against sexually transmitted infections (STI). They are not experts, generally they know even less than lay people and should certainly have less experience. If you can't persuade someone to give up having sex or sex outside marriage, the least you can do is tell them how to avoid becoming infected with an STI, infecting someone else with one or giving rise to an unplanned pregnancy. Otherwise, these leaders are failing to do what they can to prevent serious consequences.
If religious leaders wish to give medical advice, they had better know what they are talking about. As for advice about sexual behaviour, contraception and reducing the spread of STIs and unwanted pregnancies, many don't seem to have had a lot of success and should leave the job to someone who has the appropriate knowledge and training. In the same token, doctors should discuss religious matters with patients if they feel able to do so and if they are requested to do so but it should never be seen as a type of medical care or treatment.
If someone has a particular set of religious beliefs, presumably they hold those beliefs regardless of their health or lack of health. It seems unlikely that they just 'adopt' those beliefs in the hope that they will get well. Whether someone is religious or not, some will suffer illnesses and injuries and all will die eventually. If the 'belief' is purely conditional on their health, the person's piety would be quite questionable. So I don't see why a religious person would be interested in whether religion is in any way connected with health outcomes in the first place.
Wednesday, January 20, 2010
Kenyans Don't Need Rights, Especially if They Are Women
The Kenyan MPs reviewing the draft constitution have decided that women will not have equal rights to men in marriage. They don't at present, so no change there. And a big missed opportunity in the fight against domestic violence, family impoverishment and indeed, the spread of HIV and other sexually transmitted infections (STI), along with unplanned pregnancies, including those among women who are HIV positive.
These extremely well paid MPs have decided to exclude much in the constitution that relates to rights and the role of civil society. This includes religious groups (and the Kenyan National Commission on Human Rights), so I'm sure the MPs will be persuaded to change their minds about the former! But Kenyans certainly, these MPs feel, don't need rights to water, housing or food (or social security, health, founding a family, safe environment, access to quality goods or efficient administrative action). It could be wondered what rights Kenyans are deemed to be entitled to by these (Kenyan) MPs.
One of the reasons that the use of condoms for reducing the spread of HIV, STIs and unplanned pregnancies has not been too successful is that women say they don't have the option to refuse to have unprotected sex with their husbands or partners. Effectively, they don't have the option to avoid becoming pregnant, even when they don't want more children or when they know they or their partners are HIV positive.
The Christian churches, the ones whose part in running the country may or may not be threatened by this constitutional review, of course, object to the use of contraception. The fact that it could prevent all sorts of social problems, such as the ones mentioned above, is irrelevant. Harm reduction will probably never cut any ice with Christian dogma. But it is unlikely that women's rights will fare any better in the ultimate male dominated institution.
However, on the insistence of the same Christian churches, the controversial paragraph that mentions the right to life without stating when life begins has been altered to stipulate that life begins at conception. Are all Kenyans Christians? Clearly not, but some vocal sectors of the civil society that these MPs seem to want to silence appear to have a lot more say in the new constitution than others.
Abortion is already illegal in Kenya. With very few exceptions, the hundreds of thousands of abortions that take place in Kenya every year are, therefore, unsafe. These unsafe abortions contribute to the maternal death rate of 30% and an estimated 2000 women die every year from unsafe abortions.
So the Christian churches are interested in the right to life of the unborn, but they don't seem to be so interested in the right of women to choose whether to become pregnant or even to choose who can make them pregnant or when. Women who know their partner or husband is HIV positive do not have the right to refuse to have sex or to insist on the use of a condom. Why are these Christian churches not as concerned about the rights of the very women who are expected to carry, give birth to and raise children where they do not choose to, perhaps because they or their partner is HIV positive?
A canon who was interviewed about this matter said that 'pregnancy is God's design' and that men and women are 'responsible to control themselves and engage in sex as a husband and wife', which, if you are a Christian, may well be true. But is the canon not aware that a lot of sexual activity doesn't take place between husbands and wives, that a lot of people have sex with people other than their husbands and wives, that some people don't get to choose when, where and with whom they have sex? The Christian churches, of all churches, should be aware of things like this.
If the Christian churches wish to oppose the use of contraception and a woman's right to choose, they need to pay some attention to the rights that women are currently being denied. Because it is in part the denial of these rights that is giving rise to huge numbers of unplanned pregnancies in the first place. If they sincerely want to reduce unplanned pregnancies, transmission of HIV and other STIs, sexual and gender based violence and other social problems, they would need to reconsider their position on contraception, for a start. If they are unable or unwilling to do that, these churches will find their relevance to the majority of Kenyans, especially poor Kenyans, diminishing as quickly as it has done in Western countries over the past few decades.
These extremely well paid MPs have decided to exclude much in the constitution that relates to rights and the role of civil society. This includes religious groups (and the Kenyan National Commission on Human Rights), so I'm sure the MPs will be persuaded to change their minds about the former! But Kenyans certainly, these MPs feel, don't need rights to water, housing or food (or social security, health, founding a family, safe environment, access to quality goods or efficient administrative action). It could be wondered what rights Kenyans are deemed to be entitled to by these (Kenyan) MPs.
One of the reasons that the use of condoms for reducing the spread of HIV, STIs and unplanned pregnancies has not been too successful is that women say they don't have the option to refuse to have unprotected sex with their husbands or partners. Effectively, they don't have the option to avoid becoming pregnant, even when they don't want more children or when they know they or their partners are HIV positive.
The Christian churches, the ones whose part in running the country may or may not be threatened by this constitutional review, of course, object to the use of contraception. The fact that it could prevent all sorts of social problems, such as the ones mentioned above, is irrelevant. Harm reduction will probably never cut any ice with Christian dogma. But it is unlikely that women's rights will fare any better in the ultimate male dominated institution.
However, on the insistence of the same Christian churches, the controversial paragraph that mentions the right to life without stating when life begins has been altered to stipulate that life begins at conception. Are all Kenyans Christians? Clearly not, but some vocal sectors of the civil society that these MPs seem to want to silence appear to have a lot more say in the new constitution than others.
Abortion is already illegal in Kenya. With very few exceptions, the hundreds of thousands of abortions that take place in Kenya every year are, therefore, unsafe. These unsafe abortions contribute to the maternal death rate of 30% and an estimated 2000 women die every year from unsafe abortions.
So the Christian churches are interested in the right to life of the unborn, but they don't seem to be so interested in the right of women to choose whether to become pregnant or even to choose who can make them pregnant or when. Women who know their partner or husband is HIV positive do not have the right to refuse to have sex or to insist on the use of a condom. Why are these Christian churches not as concerned about the rights of the very women who are expected to carry, give birth to and raise children where they do not choose to, perhaps because they or their partner is HIV positive?
A canon who was interviewed about this matter said that 'pregnancy is God's design' and that men and women are 'responsible to control themselves and engage in sex as a husband and wife', which, if you are a Christian, may well be true. But is the canon not aware that a lot of sexual activity doesn't take place between husbands and wives, that a lot of people have sex with people other than their husbands and wives, that some people don't get to choose when, where and with whom they have sex? The Christian churches, of all churches, should be aware of things like this.
If the Christian churches wish to oppose the use of contraception and a woman's right to choose, they need to pay some attention to the rights that women are currently being denied. Because it is in part the denial of these rights that is giving rise to huge numbers of unplanned pregnancies in the first place. If they sincerely want to reduce unplanned pregnancies, transmission of HIV and other STIs, sexual and gender based violence and other social problems, they would need to reconsider their position on contraception, for a start. If they are unable or unwilling to do that, these churches will find their relevance to the majority of Kenyans, especially poor Kenyans, diminishing as quickly as it has done in Western countries over the past few decades.
Monday, November 30, 2009
'Religiosity' and Levels of Social Capital
The work continues with Ribbon of Hope Self Help Group, Nakuru, in Kenya's Rift Valley. We have ongoing projects producing basic foods such as vegetables and staples, dairy cattle and hens, etc. And we are still hoping to spread the word about ways of saving money by using solar cookers and home made fuel briquettes for cooking and various other techniques. Any project that costs very little or nothing will be considered as long as it is appropriate for people in this area and as long as it is sustainable and not destructive or damaging in any way.
As usual, some people are cooperative and hard working, otherwise, there would be no point in an organisation such as Ribbon of Hope. But sometimes it seems as if there are as many obstructive people as there are constructive people and it can be hard not to dwell on them. Especially when they so often win out and destroy projects that would have worked well without their interference. Today, we had the experience of trying to find out why some people abandoned their basic accounting and record keeping several months ago and now seem both unable and unwilling to say how they have been running their organisation.
It would be unreasonable to expect everyone to be equally successful in their endeavours and it is natural for some people to get involved initially, only to step back later and contribute less than before. But, much though I'd like to think that there are more cooperative than destructive people here, the evidence suggests that this is not true. I'm sure there are all sorts of possible explanations and I would be the first to admit that the people we work with live under all sorts of stresses and pressures that can make them a bit desperate. But I'm not going to make excuses for some of the things I've seen and heard about. I'll just hope that in the long run there are more positives than negatives and that Ribbon of Hope manages to attract serious contributors rather than time and resource wasting people.
There is a very interesting 'index' called The Legatum Prosperity Index, which aims to look at prosperity beyond the one dimensional Gross Domestic Product (GDP) favoured by so many economic analyses. The index looks at various economic figures, politics and governance, education, health, security, personal freedom and social capital. The whole index seems skewed by what are almost exclusively Western values but it's still an interesting exercise and their report is well worth the read.
Kenya doesn't come out very well, scoring 95 overall out of 104 countries for which there was adequate data available. This is not to say that Kenya's data is particularly reliable but let's give it the benefit of the doubt. The country receives a pretty low score for almost all the various indexes and rankings available. Economically, the country is weak in many ways and is particularly dependent on raw materials. Education, health, governance, personal freedom and security rankings are very poor. Surprisingly, the country is said to have well developed democratic institutions.
But the real shocker for me is that the country is ranked 25th for its level of social capital; 'most Kenyans find others to be reliable and some actively volunteer or help strangers'. Sadly, some people who 'volunteer' only do so for what they can get out of it. Apparently Kenya's social capital score is 'boosted by exceptionally high levels of religiosity'. Well, that's certainly no surprise. But many of the people who profess the loudest to be Christian, Saved, Born Again or whatever else are the ones who never miss an opportunity to get something by deceit.
I think this element of the Prosperity Index begs the question about whether high levels of religiosity is an indication that Kenya is strong on social capital. The police and other officials who require a standard bribe in order to do what is just their job are often as ostentatiously religious as anyone else. An official who tried to get a 50 dollar bribe out of me asked me to pray for him when he found I wasn't going to pay. The people who dress up for church on Sundays overlap with the mob that crowded around a young homeless boy to beat him for some offence, real or imagined. This sort of mob rule, usually aimed at very vulnerable people, such as elderly people branded as 'witches' or homeless people branded as thieves, is very common. Some of the 'volunteers' I have met never miss an opportunity to mention their love for Jesus but nor do they miss an opportunity to get something that is intended for sick and dying people.
This is not an attempt to bash the 'religious' people of Kenya or of any other country, just a question about what kind of connection there is between 'high levels of religiosity' and high levels of social capital. Reluctant as I am to come to this conclusion, I would say that social capital is one of the things that Kenya is most sorely lacking in. And this lack of social capital has had, and continues to have, a profound influence on high levels of HIV, sexually transmitted infections (STI), unplanned pregnancies, stigma, discrimination and probably many other problems.
As usual, some people are cooperative and hard working, otherwise, there would be no point in an organisation such as Ribbon of Hope. But sometimes it seems as if there are as many obstructive people as there are constructive people and it can be hard not to dwell on them. Especially when they so often win out and destroy projects that would have worked well without their interference. Today, we had the experience of trying to find out why some people abandoned their basic accounting and record keeping several months ago and now seem both unable and unwilling to say how they have been running their organisation.
It would be unreasonable to expect everyone to be equally successful in their endeavours and it is natural for some people to get involved initially, only to step back later and contribute less than before. But, much though I'd like to think that there are more cooperative than destructive people here, the evidence suggests that this is not true. I'm sure there are all sorts of possible explanations and I would be the first to admit that the people we work with live under all sorts of stresses and pressures that can make them a bit desperate. But I'm not going to make excuses for some of the things I've seen and heard about. I'll just hope that in the long run there are more positives than negatives and that Ribbon of Hope manages to attract serious contributors rather than time and resource wasting people.
There is a very interesting 'index' called The Legatum Prosperity Index, which aims to look at prosperity beyond the one dimensional Gross Domestic Product (GDP) favoured by so many economic analyses. The index looks at various economic figures, politics and governance, education, health, security, personal freedom and social capital. The whole index seems skewed by what are almost exclusively Western values but it's still an interesting exercise and their report is well worth the read.
Kenya doesn't come out very well, scoring 95 overall out of 104 countries for which there was adequate data available. This is not to say that Kenya's data is particularly reliable but let's give it the benefit of the doubt. The country receives a pretty low score for almost all the various indexes and rankings available. Economically, the country is weak in many ways and is particularly dependent on raw materials. Education, health, governance, personal freedom and security rankings are very poor. Surprisingly, the country is said to have well developed democratic institutions.
But the real shocker for me is that the country is ranked 25th for its level of social capital; 'most Kenyans find others to be reliable and some actively volunteer or help strangers'. Sadly, some people who 'volunteer' only do so for what they can get out of it. Apparently Kenya's social capital score is 'boosted by exceptionally high levels of religiosity'. Well, that's certainly no surprise. But many of the people who profess the loudest to be Christian, Saved, Born Again or whatever else are the ones who never miss an opportunity to get something by deceit.
I think this element of the Prosperity Index begs the question about whether high levels of religiosity is an indication that Kenya is strong on social capital. The police and other officials who require a standard bribe in order to do what is just their job are often as ostentatiously religious as anyone else. An official who tried to get a 50 dollar bribe out of me asked me to pray for him when he found I wasn't going to pay. The people who dress up for church on Sundays overlap with the mob that crowded around a young homeless boy to beat him for some offence, real or imagined. This sort of mob rule, usually aimed at very vulnerable people, such as elderly people branded as 'witches' or homeless people branded as thieves, is very common. Some of the 'volunteers' I have met never miss an opportunity to mention their love for Jesus but nor do they miss an opportunity to get something that is intended for sick and dying people.
This is not an attempt to bash the 'religious' people of Kenya or of any other country, just a question about what kind of connection there is between 'high levels of religiosity' and high levels of social capital. Reluctant as I am to come to this conclusion, I would say that social capital is one of the things that Kenya is most sorely lacking in. And this lack of social capital has had, and continues to have, a profound influence on high levels of HIV, sexually transmitted infections (STI), unplanned pregnancies, stigma, discrimination and probably many other problems.
Monday, March 9, 2009
Facts that do not Speak for Themselves
It's very tempting to blame the spread of a sexually transmitted infection (STI) such as HIV on promiscuity. It would be useful to have a criterion for 'promiscuity' as opposed to reasonably normal levels of sexual activity, of course. But the fact is that there is no evidence that Africans, as opposed to people from other continents, are more promiscuous. The evidence suggests that in Africa, as in other continents, some people have a lot of sex and some don't.
It would be very easy to dismiss the last paragraph on the grounds that so many articles state or imply that Africans are more promiscuous than the rest of the world. However, I have yet to come across any evidence for the belief, unless the constant reassertion of something counts as evidence. We don't need an explicit definition of promiscuity, we understand what it means. It's just that the term is being applied indiscriminately.
An interesting study of sexual behaviour was carried out in four African countries with very different rates of HIV; Benin and Cameroon, which both have low HIV prevalence and Kenya and Zambia, which both have high prevalence. The highest rates of partner change were found in Cameroon, especially among men. Even among women, partner change was higher in Cameroon.
In Kenya and Zambia, the age of sexual initiation was slightly lower. There were also lower rates of circumcision and higher rates of other STIs, such as herpes simplex virus (HSV). But there was simply no correlation between HIV prevalence and indicators of sexual behaviour, such as concurrent sexual partners.
Another study found that there were more people in African countries than in countries in other continents who reported having had no sex in the month preceding the survey. And most men in all countries surveyed had no extramarital sex or no sex outside of a long term relationship. Overall, the views of Africans surveyed were more enlightened than the views of those from other continents.
Yet another survey found that age of sexual initiation for females was increasing in most countries surveyed in Africa between the 1960s and the 1990s. But it's interesting to compare age of sexual initiation in developed and developing countries. The country with the highest percentage of 15-19 year olds who are not married and have already had sexual intercourse is the UK, and this stands for both males and females. Also high on the list are Brazil, the US and the Dominican Republic. All these countries have low HIV prevalence, less than 1% in the UK, the US and Brazil.
When it comes to lack of knowledge about sex, contraception and safe sex, levels of unwanted and teenage pregnancies and other matters, the US and the UK are usually very high on the list. It is interesting that these two countries have so many worrying indicators, yet they both have relatively low HIV prevalence.
And so on. Eileen Stillwaggon in AIDS and the Ecology of Poverty lists a number of studies that show that the evidence does not bear out the assumptions about HIV transmission being explained wholly by sexual behaviour. In every country, people have sex. In every country some people have more sex than others. But there is no country where HIV rates can be correlated with high levels of unsafe sexual behaviour, partner change, concurrent relationships and the rest.
This is not to say that there is not a lot of evidence of unsafe sex in developing countries. There is a lot of unsafe sex taking place all over the world. But not all countries have high HIV prevalence. That is the question that researchers have been trying to find the answer to for so many years. It hasn't escaped their notice that STIs are spread by people having sex. They are asking why there are extremely high levels of HIV transmission in some countries and low levels in other countries.
Some have suggested that poverty is a key factor in the spread of HIV. Indeed, people probably don't engage in commercial sex work when they have money coming in from other activities. So poverty must play a part. Others have gone on to show that poverty alone doesn't explain HIV prevalence rates because some poor countries don't have high rates of HIV. One response to this is that economic inequality may be a better way of looking at wealth and poverty, some people are dependent and others have the opportunity to buy sex as and when they want it, they can afford concurrent partnerships.
There are many counter examples to poverty and even inequality driving HIV epidemics and it has been clear for a long time that HIV has many drivers. It is futile to expect to find one factor that drives all epidemics and pointless to argue that poverty or inequality or whatever have no part to play. Epidemics involve many different people with different lives and circumstances interacting with each other.
This blog already covered Senegal, where education, health and other social indicators are probably not that different from those in Kenya, certainly not different enough to explain the low levels of HIV in Senegal. The histories of HIV transmission are many and various, between and within different countries.
A recent literature review listed the top factors contributing to HIV transmission as: "poverty, famine, low status of women in society, corruption, naive risk taking perception, resistance to sexual behaviour change, high prevalence of sexually transmitted infections (STI), internal conflicts and refugee status, antiquated beliefs, lack of recreational facilities, ignorance of individual's HIV status, child and adult prostitution, uncertainty of safety of blood intended for transfusion, widow inheritance, circumcision, illiteracy and female genital cutting and polygamy."
The article also finds these factors to be "interrelated and complementary". There is no one factor that is the most significant. Even poverty, which is by far the most significant, is closely related to many of the other factors. For example, people who are poor are also more likely to have lower levels of heath and therefore be more susceptible to HIV. They have worse living conditions, they have fewer opportunities, less education, they are more vulnerable to the effects of corruption, crime, global financial crises, food prices and global environmental degradation, and the list goes on.
The issue of connections between poverty and HIV transmission keeps coming up, as if examples of HIV transmission that are not related to poverty suggest that poverty is not a problem. Even if HIV were to disappear tomorrow, poverty is a problem. Poverty needs to be eradicated because it denies people many of their human rights. But also, in countries where wealthy people are more likely to be HIV positive, poverty is not in any way less relevant.
If there are some people who can afford to pay to have wide sexual networks and there are some people who need to be part of a sexual network because they are poor, then 'poverty' doesn't describe the problem. The level of economic inequality more accurately describes it. And before anyone starts throwing counterexamples at me, this is not to say that there are not many other factors involved. The very point is that there are many factors in the transmission of HIV. Poverty and inequality are important but they relate to numerous areas of underdevelopment that are also important factors.
It has been recognised for some time that in Kenya and Tanzania, for example, HIV prevalence is higher in wealthier quintiles. Clearly, there are different circumstances surrounding each instance of HIV transmission. But the problem is to explain what circumstances give rise to, say, the fact that women in the wealthiest quintile in Tanzania have four times the level of HIV positive people than the poorest quintile.
If your causal story is that rich men pay to have sex with poor women, would you add to this that rich women are even more likely to pay to have sex with poor men? I'm not saying that this never happens but I have seen no evidence that this is common. I don't know where all these transactions could take place because I haven't seen young men in bars looking for rich women. There are many young men in bars looking for women to have sex with but they tend to target foreigners, so this doesn't explain the level of HIV among wealthy Tanzanian women.
There is clearly a lot about HIV transmission that we don't yet know. I took a quick look at the occupations of women who are in the wealthiest quintile and was surprised to find that 10% say they do subsistence work and 25% say they do stall and market work. The highest percentage say they have no occupation. Those in the wealthiest quintile may well be dependent on their husbands, but this does not explain why the correlation between wealth and HIV prevalence is stronger for women than for men.
There is more to wealth than occupation and those surveyed are also asked about property, household income as a whole, amenities, etc. But it is remarkable that more than 75% of women in the bottom three quintiles give their occupation as subsistence work. Even in the second wealthiest quintile, more than 50% list their occupation as subsistence work. The bottom three quintiles have a lot in common on the basis of occupation type, the top quintile is quite different. No doubt, these differences in occupation type are related to many other differences in factors that relate to HIV transmission.
But this is only speculation, there is too little data available and it is not finely grained enough to work out or evaluate all the important drivers of HIV epidemics. There are many factors and therefore there are many facts. But the ‘facts’ often appear counterintuitive and there are probably many that we, as yet, know nothing about. What is clear is that a lot of interpretation and clarification is needed and that the facts do not in any sense speak for themselves.
It would be very easy to dismiss the last paragraph on the grounds that so many articles state or imply that Africans are more promiscuous than the rest of the world. However, I have yet to come across any evidence for the belief, unless the constant reassertion of something counts as evidence. We don't need an explicit definition of promiscuity, we understand what it means. It's just that the term is being applied indiscriminately.
An interesting study of sexual behaviour was carried out in four African countries with very different rates of HIV; Benin and Cameroon, which both have low HIV prevalence and Kenya and Zambia, which both have high prevalence. The highest rates of partner change were found in Cameroon, especially among men. Even among women, partner change was higher in Cameroon.
In Kenya and Zambia, the age of sexual initiation was slightly lower. There were also lower rates of circumcision and higher rates of other STIs, such as herpes simplex virus (HSV). But there was simply no correlation between HIV prevalence and indicators of sexual behaviour, such as concurrent sexual partners.
Another study found that there were more people in African countries than in countries in other continents who reported having had no sex in the month preceding the survey. And most men in all countries surveyed had no extramarital sex or no sex outside of a long term relationship. Overall, the views of Africans surveyed were more enlightened than the views of those from other continents.
Yet another survey found that age of sexual initiation for females was increasing in most countries surveyed in Africa between the 1960s and the 1990s. But it's interesting to compare age of sexual initiation in developed and developing countries. The country with the highest percentage of 15-19 year olds who are not married and have already had sexual intercourse is the UK, and this stands for both males and females. Also high on the list are Brazil, the US and the Dominican Republic. All these countries have low HIV prevalence, less than 1% in the UK, the US and Brazil.
When it comes to lack of knowledge about sex, contraception and safe sex, levels of unwanted and teenage pregnancies and other matters, the US and the UK are usually very high on the list. It is interesting that these two countries have so many worrying indicators, yet they both have relatively low HIV prevalence.
And so on. Eileen Stillwaggon in AIDS and the Ecology of Poverty lists a number of studies that show that the evidence does not bear out the assumptions about HIV transmission being explained wholly by sexual behaviour. In every country, people have sex. In every country some people have more sex than others. But there is no country where HIV rates can be correlated with high levels of unsafe sexual behaviour, partner change, concurrent relationships and the rest.
This is not to say that there is not a lot of evidence of unsafe sex in developing countries. There is a lot of unsafe sex taking place all over the world. But not all countries have high HIV prevalence. That is the question that researchers have been trying to find the answer to for so many years. It hasn't escaped their notice that STIs are spread by people having sex. They are asking why there are extremely high levels of HIV transmission in some countries and low levels in other countries.
Some have suggested that poverty is a key factor in the spread of HIV. Indeed, people probably don't engage in commercial sex work when they have money coming in from other activities. So poverty must play a part. Others have gone on to show that poverty alone doesn't explain HIV prevalence rates because some poor countries don't have high rates of HIV. One response to this is that economic inequality may be a better way of looking at wealth and poverty, some people are dependent and others have the opportunity to buy sex as and when they want it, they can afford concurrent partnerships.
There are many counter examples to poverty and even inequality driving HIV epidemics and it has been clear for a long time that HIV has many drivers. It is futile to expect to find one factor that drives all epidemics and pointless to argue that poverty or inequality or whatever have no part to play. Epidemics involve many different people with different lives and circumstances interacting with each other.
This blog already covered Senegal, where education, health and other social indicators are probably not that different from those in Kenya, certainly not different enough to explain the low levels of HIV in Senegal. The histories of HIV transmission are many and various, between and within different countries.
A recent literature review listed the top factors contributing to HIV transmission as: "poverty, famine, low status of women in society, corruption, naive risk taking perception, resistance to sexual behaviour change, high prevalence of sexually transmitted infections (STI), internal conflicts and refugee status, antiquated beliefs, lack of recreational facilities, ignorance of individual's HIV status, child and adult prostitution, uncertainty of safety of blood intended for transfusion, widow inheritance, circumcision, illiteracy and female genital cutting and polygamy."
The article also finds these factors to be "interrelated and complementary". There is no one factor that is the most significant. Even poverty, which is by far the most significant, is closely related to many of the other factors. For example, people who are poor are also more likely to have lower levels of heath and therefore be more susceptible to HIV. They have worse living conditions, they have fewer opportunities, less education, they are more vulnerable to the effects of corruption, crime, global financial crises, food prices and global environmental degradation, and the list goes on.
The issue of connections between poverty and HIV transmission keeps coming up, as if examples of HIV transmission that are not related to poverty suggest that poverty is not a problem. Even if HIV were to disappear tomorrow, poverty is a problem. Poverty needs to be eradicated because it denies people many of their human rights. But also, in countries where wealthy people are more likely to be HIV positive, poverty is not in any way less relevant.
If there are some people who can afford to pay to have wide sexual networks and there are some people who need to be part of a sexual network because they are poor, then 'poverty' doesn't describe the problem. The level of economic inequality more accurately describes it. And before anyone starts throwing counterexamples at me, this is not to say that there are not many other factors involved. The very point is that there are many factors in the transmission of HIV. Poverty and inequality are important but they relate to numerous areas of underdevelopment that are also important factors.
It has been recognised for some time that in Kenya and Tanzania, for example, HIV prevalence is higher in wealthier quintiles. Clearly, there are different circumstances surrounding each instance of HIV transmission. But the problem is to explain what circumstances give rise to, say, the fact that women in the wealthiest quintile in Tanzania have four times the level of HIV positive people than the poorest quintile.
If your causal story is that rich men pay to have sex with poor women, would you add to this that rich women are even more likely to pay to have sex with poor men? I'm not saying that this never happens but I have seen no evidence that this is common. I don't know where all these transactions could take place because I haven't seen young men in bars looking for rich women. There are many young men in bars looking for women to have sex with but they tend to target foreigners, so this doesn't explain the level of HIV among wealthy Tanzanian women.
There is clearly a lot about HIV transmission that we don't yet know. I took a quick look at the occupations of women who are in the wealthiest quintile and was surprised to find that 10% say they do subsistence work and 25% say they do stall and market work. The highest percentage say they have no occupation. Those in the wealthiest quintile may well be dependent on their husbands, but this does not explain why the correlation between wealth and HIV prevalence is stronger for women than for men.
There is more to wealth than occupation and those surveyed are also asked about property, household income as a whole, amenities, etc. But it is remarkable that more than 75% of women in the bottom three quintiles give their occupation as subsistence work. Even in the second wealthiest quintile, more than 50% list their occupation as subsistence work. The bottom three quintiles have a lot in common on the basis of occupation type, the top quintile is quite different. No doubt, these differences in occupation type are related to many other differences in factors that relate to HIV transmission.
But this is only speculation, there is too little data available and it is not finely grained enough to work out or evaluate all the important drivers of HIV epidemics. There are many factors and therefore there are many facts. But the ‘facts’ often appear counterintuitive and there are probably many that we, as yet, know nothing about. What is clear is that a lot of interpretation and clarification is needed and that the facts do not in any sense speak for themselves.
Thursday, December 11, 2008
Who Paid for those Christmas Presents?
I will probably say this many times in one way or another on this blog:
HIV may well be mainly sexually transmitted in Kenya, but under what circumstances do people have sex? Why do some have sex frequently and with many different people? Why do they not take precautions, perhaps by using a condom, avoiding people they know to have a sexually transmitted infection (see note below about health) or people they know to be violent? Why do they agree to more dangerous sexual practices, such as anal sex or dry sex?
IRIN ran an article recently about a young woman who had to have sex with her supervisor in order to be guaranteed regular work. She works in an Export Processing Zone (EPZ). EPZs were set up with the specific intention of allowing companies to operate their production units where labour is cheap.
This is not to say that EPZs were set up with purely evil intentions. Countries with EPZs could have had strong labour laws that protected their labour force and that punished employers who flouted these laws.
But competition ensured that the country with the fewest employee protections would win the contracts. Laws in Kenya governing EPZs rarely mention employees but are pretty explicit when it comes to the companies that are flocking to the country to take advantage of the cheap labour.
The companies setting up production units in Kenya and other countries with the 'unique selling point' of cheap labour are ones that produce fashionable clothes, popular brands of watches, pharmaceuticals and other things bought by most people in developed countries, the 'minority world'.
The number of people implicated in the abuse suffered by employees of EPZs is high, taking in multinational corporations, governments and the very population driving the process: the market.
That means you and I; the people who buy sports shoes, laptops, MP3 players, mobile phones and various other things that are only affordable because of a high level of exploitation. Cheap labour ensures our access to these goods.
Don't buy the popular media reflex that developing countries are poor because of corrupt governments. Serious corruption is global.
I almost forgot to mention the part played by the organisations that are supposed to be assisting developing countries to develop: those international financial institutions whose names shall remain the World Bank and the International Monetary Fund. They loan money to desperate countries with certain conditions attached. Those countries must be 'flexible', they must deregulate, they must reduce 'barriers to trade' and public services, they must reduce the civil service...
... many civil servants being involved in the 'anticompetitive' practice of regulating employers, ensuring workers rights, inspecting companies to reduce dangerous conditions and exploitation. In fact, EPZs are not bound by the Factories Act and do not have unions because such things would seriously reduce their competitiveness. EPZs don't even make people redundant, they only 'retrench' them, which is completely different. Well, it’s far cheaper for employers, anyway.
These measures keep international financial institutions, governments, consumers and employers happy. With EPZs, the world is almost perfect.
Except for the majority world; the place where over five billion people live (out of a global population of over six billion). The people who work in these EPZs are not guaranteed work, they must accept any conditions without complaint and they cannot strike. As the Kenya Human Rights Commission say in their report 'Manufacture of Poverty', employees 'report to the factory gates every morning without pay to check whether or not there is work'.
So what makes a prospective employee more 'competitive', more likely to work today and subsequent days? Aside from being silent about flouted fire regulations and other safety measures, impossible production targets, compulsory overtime and other abuses?
Well, agreeing to sleep with the person responsible for choosing who works and who doesn't work would be a start. Sleep with the supervisor. And every time the question of who to employ comes up, the question of what price is to be paid must also be answered. The woman interviewed in IRIN's article is not the only one who suffered abuse and continues to suffer abuse in this way.
So this is a whole field of scenarios where HIV is transmitted. But the issue here is not the transmission of HIV, alone. There is a whole range of human rights being abused with impunity, with the tacit acceptance of most of the people and institutions in the world who could and who should be objecting.
So instead of criticizing people's sexual practices, perhaps we could examine our own purchasing practices.
Note about health:
The International Monetary Fund and World Bank, mentioned above, have also given loans on condition that the number of people employed by public services such as health, education and infrastructure be fixed at low levels. Spending on such services is severely limited and this has many consequences for people’s overall health.
For example, intestinal parasites are very common, as is TB, malaria and many waterborne diseases like cholera. Sexually transmitted infections are also common, especially Herpes Simplex Virus. All of these make people more susceptible to HIV. The health of Kenyans is severely compromised by these loan conditions.
The HIV ‘experts’ who implement prevention programmes do so with the expectation that existing health, education and infrastructure will ensure the success of these programmes. Even the World Bank itself funds such programmes.
So, when they find that there are very few health and education facilities and very little infrastructure in Kenya and other developing countries, one hopes they will also know who to call on to find out why: themselves.
Maybe I am hopelessly idealistic.
HIV may well be mainly sexually transmitted in Kenya, but under what circumstances do people have sex? Why do some have sex frequently and with many different people? Why do they not take precautions, perhaps by using a condom, avoiding people they know to have a sexually transmitted infection (see note below about health) or people they know to be violent? Why do they agree to more dangerous sexual practices, such as anal sex or dry sex?
IRIN ran an article recently about a young woman who had to have sex with her supervisor in order to be guaranteed regular work. She works in an Export Processing Zone (EPZ). EPZs were set up with the specific intention of allowing companies to operate their production units where labour is cheap.
This is not to say that EPZs were set up with purely evil intentions. Countries with EPZs could have had strong labour laws that protected their labour force and that punished employers who flouted these laws.
But competition ensured that the country with the fewest employee protections would win the contracts. Laws in Kenya governing EPZs rarely mention employees but are pretty explicit when it comes to the companies that are flocking to the country to take advantage of the cheap labour.
The companies setting up production units in Kenya and other countries with the 'unique selling point' of cheap labour are ones that produce fashionable clothes, popular brands of watches, pharmaceuticals and other things bought by most people in developed countries, the 'minority world'.
The number of people implicated in the abuse suffered by employees of EPZs is high, taking in multinational corporations, governments and the very population driving the process: the market.
That means you and I; the people who buy sports shoes, laptops, MP3 players, mobile phones and various other things that are only affordable because of a high level of exploitation. Cheap labour ensures our access to these goods.
Don't buy the popular media reflex that developing countries are poor because of corrupt governments. Serious corruption is global.
I almost forgot to mention the part played by the organisations that are supposed to be assisting developing countries to develop: those international financial institutions whose names shall remain the World Bank and the International Monetary Fund. They loan money to desperate countries with certain conditions attached. Those countries must be 'flexible', they must deregulate, they must reduce 'barriers to trade' and public services, they must reduce the civil service...
... many civil servants being involved in the 'anticompetitive' practice of regulating employers, ensuring workers rights, inspecting companies to reduce dangerous conditions and exploitation. In fact, EPZs are not bound by the Factories Act and do not have unions because such things would seriously reduce their competitiveness. EPZs don't even make people redundant, they only 'retrench' them, which is completely different. Well, it’s far cheaper for employers, anyway.
These measures keep international financial institutions, governments, consumers and employers happy. With EPZs, the world is almost perfect.
Except for the majority world; the place where over five billion people live (out of a global population of over six billion). The people who work in these EPZs are not guaranteed work, they must accept any conditions without complaint and they cannot strike. As the Kenya Human Rights Commission say in their report 'Manufacture of Poverty', employees 'report to the factory gates every morning without pay to check whether or not there is work'.
So what makes a prospective employee more 'competitive', more likely to work today and subsequent days? Aside from being silent about flouted fire regulations and other safety measures, impossible production targets, compulsory overtime and other abuses?
Well, agreeing to sleep with the person responsible for choosing who works and who doesn't work would be a start. Sleep with the supervisor. And every time the question of who to employ comes up, the question of what price is to be paid must also be answered. The woman interviewed in IRIN's article is not the only one who suffered abuse and continues to suffer abuse in this way.
So this is a whole field of scenarios where HIV is transmitted. But the issue here is not the transmission of HIV, alone. There is a whole range of human rights being abused with impunity, with the tacit acceptance of most of the people and institutions in the world who could and who should be objecting.
So instead of criticizing people's sexual practices, perhaps we could examine our own purchasing practices.
Note about health:
The International Monetary Fund and World Bank, mentioned above, have also given loans on condition that the number of people employed by public services such as health, education and infrastructure be fixed at low levels. Spending on such services is severely limited and this has many consequences for people’s overall health.
For example, intestinal parasites are very common, as is TB, malaria and many waterborne diseases like cholera. Sexually transmitted infections are also common, especially Herpes Simplex Virus. All of these make people more susceptible to HIV. The health of Kenyans is severely compromised by these loan conditions.
The HIV ‘experts’ who implement prevention programmes do so with the expectation that existing health, education and infrastructure will ensure the success of these programmes. Even the World Bank itself funds such programmes.
So, when they find that there are very few health and education facilities and very little infrastructure in Kenya and other developing countries, one hopes they will also know who to call on to find out why: themselves.
Maybe I am hopelessly idealistic.
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