Every time I see an article talking up technology in Kenya and in Africa in general, I wonder which aspect of people's lives will be transformed. Over the last few weeks myself and my colleagues from Ribbon of Hope Self Help Group have been visiting families who never complain about having little access to technology. They have very little money and little access to loans. They are often surrounded by mud roads, living a long way from the sealed roads, which are often in bad repair. There is little or no affordable public transport.
Their children sometimes have very little food, no access to clean water or improved sanitation, decent clothing, books and other basic things that they need just to be able to attend school. If children become sick, their parents have to decide between taking them out of school and treating them or leaving them in school and hoping for the best. Hospitals are a long way off, they are expensive and they are poorly equipped and staffed.
Distance education would be great for children who had basic education. But only about three quarters of children even enroll for primary school, let alone finish. And just over 40% enroll for secondary school. Even at university or tertiary level, something few ever reach (despite some great official figures), elearning cannot replace teachers, books and indeed, access. Those who have got to university are already a small percentage of Kenyans who have not been denied any of the many things that poorer children will always be denied.
One of these idiotic sites that produces lots of puff about technology says "Kenyan Universities are increasingly turning to e-learning as tool to facilitate improved education". Will this improve education? It may be a new medium for some educational content but I'd like to see research that shows that education is in any way better for being delivered by electronic means. Computers are also in short supply and skills can be non-existent, especially among those who rarely have access to a computer.
Young children, especially in rural areas, where about 80% of Kenyans live, often don't have electricity or a private place to study, or even their own personal copy of the necessary text books. Some, especially girls, have to do chores around the house and farm when they should be studying. And many have to do work in the fields and in other jobs when the need arises. These are not technology related problems.
Technologies, I suspect, work when other infrastructures are in place. A farmer can, as these fatuous articles often claim, find out the market price of a commodity by mobile phone. But if there is no road, or if the road is impassible, or transport unaffordable, what's the point? Another claim is that medical stocks and medicines can be monitored electronically. The biggest problem in a lot of hospitals is the shortage or staff and medicines. Who is going to do the stocktaking and what stock are they going to monitor if there is not an adequate supply of drugs?
If the problems that most people experience can be relieved by various technologies, great. If everyone has access to these technologies and things in Kenya can change radically, wonderful. But if all these articles want to show is that some people use and like and even profit from technology, they are pointless articles, only useful to people who are already convinced that technology will pull everyone out of every problem them currently face. Technology will not solve problems of inequalities between rich and poor, between males and females, between rural and urban dwellers. Technology seems, at present, to be the preserve of the rich. And if their past behaviour is anything to go by, it will stay that way.
Showing posts with label distance education. Show all posts
Showing posts with label distance education. Show all posts
Saturday, May 15, 2010
Friday, April 30, 2010
One Laptop Per Child: But What About the Teacher?
It's quite a few years now since someone came up with the idea of giving a cheap laptop to every child in developing countries. The price mentioned was $100 and the laptop would have a device for winding it up for when there was no power, it would be robust against harsh treatment, dust, heat, humidity, etc. It would be simple but attractive and have everything that a child could want in a computer.
Well, such a laptop has been available for some time, but those who came up with the idea have not been able to persuade funders or governments of developing countries to order the things. They were hoping for orders of about one million at a time but they haven't even offloaded 2 million of them yet. The laptops come with Linux and Windows preloaded but they are selling for over $200. I'm not sure how much more than $200.
Some will remember, it's only a few months ago, that both Britain and the US governments decided to withold funding earmarked for education in Kenya. It was a paltry amount, less than $40 million in all. But many people here are having problems paying for school fees and costs because the so called free primary and subsidized secondary education still cost more than a lot of people earn.
There are about 9 million school children in Kenya at the moment. The figure should be a lot higher because some are not attending, though how many is anyone's guess. The money being witheld sounds like only a few dollars a head. But most schools are underequipped and understaffed. Infrastructures that the schools need are crumbling or non-existent, for example, electricity, water and sanitation. Even roads are appalling and transport to and from school is one of the biggest hurdles children have to face, to say nothing of the costs to their parents.
But the one laptop per child scheme, OLPC, that's a substantial amount of money. And they are hoping to raise the money for 30 million of them for the whole of the East African Community. Two hundred and something dollars could pay all the costs that are levied but not considered to be school fees, along with quite a number of other items. Books, for example, are in very short supply. Kids often come to school without having done their homework because they have no book (or because there is no lighting at home).
It's not that I don't think children (or adults) in developing countries should not have such a valuable tool as a laptop, it would be great if everyone had one. But I wonder if it's such a priority. So many infants and under fives are dying of preventable and curable diseases because of conditions such as poor sanitation. Malnutrition is rife and causes growth stunting and retarded intellectual development. And the list is endless.
Not only are there many things children need that would put laptops quite low on the list of priorities, but a lot of the things they need are quite cheap. For the sort of billions that are being proposed for OLPC, a lot of childhood health conditions could be prevented or cured. Children could go to school with things like books and other tools. Girls wouldn't have to stay at home several days a month because they are having their period. And pupils could have enough food to prevent them from falling asleep during classes or just not going to school at all.
Children have a lot of things to grasp when they are young, reading, writing, languages, mathematics, sciences, etc. It's easy enough to see how laptops could be used to help with this. But I have a suggestion: give free laptops to teachers in teacher training schools (who also lack the books they need, sometimes); teach them how to use laptops and how to teach with them. Then roll them out that way. Instead of spending the $6 billion dollars or more on giving tens of millions of children laptops, make sure the educational system is ready for the laptops.
There is no point in just spilling out a few more million to give a laptop to teachers as well. They have to be taughted how to use them and how to teach with them. When I was doing an MA at a London University college just a few years ago, an institute of education, no less, some of the academic staff there had no idea how to use computers to teach, so why should people who have never had the opportunity to even use them? In fact, teaching with computers comes with some huge pedagogical hurdles.
Frankly, I think the project stinks. But it could be turned around, it hasn't even started yet, to make African countries among the first in the world to use a laptop as their main teaching tool in primary and secondary education. Ok, training the teachers may not iron out all the problems of trying to do without books and other everyday teaching materials. But it sure as hell won't work if the teachers get no training (and no laptop). If you can raise that much money, OLPC, don't blow it on the laptops alone. It's not as if the laptops can be recycled if the project goes pear shaped.
Well, such a laptop has been available for some time, but those who came up with the idea have not been able to persuade funders or governments of developing countries to order the things. They were hoping for orders of about one million at a time but they haven't even offloaded 2 million of them yet. The laptops come with Linux and Windows preloaded but they are selling for over $200. I'm not sure how much more than $200.
Some will remember, it's only a few months ago, that both Britain and the US governments decided to withold funding earmarked for education in Kenya. It was a paltry amount, less than $40 million in all. But many people here are having problems paying for school fees and costs because the so called free primary and subsidized secondary education still cost more than a lot of people earn.
There are about 9 million school children in Kenya at the moment. The figure should be a lot higher because some are not attending, though how many is anyone's guess. The money being witheld sounds like only a few dollars a head. But most schools are underequipped and understaffed. Infrastructures that the schools need are crumbling or non-existent, for example, electricity, water and sanitation. Even roads are appalling and transport to and from school is one of the biggest hurdles children have to face, to say nothing of the costs to their parents.
But the one laptop per child scheme, OLPC, that's a substantial amount of money. And they are hoping to raise the money for 30 million of them for the whole of the East African Community. Two hundred and something dollars could pay all the costs that are levied but not considered to be school fees, along with quite a number of other items. Books, for example, are in very short supply. Kids often come to school without having done their homework because they have no book (or because there is no lighting at home).
It's not that I don't think children (or adults) in developing countries should not have such a valuable tool as a laptop, it would be great if everyone had one. But I wonder if it's such a priority. So many infants and under fives are dying of preventable and curable diseases because of conditions such as poor sanitation. Malnutrition is rife and causes growth stunting and retarded intellectual development. And the list is endless.
Not only are there many things children need that would put laptops quite low on the list of priorities, but a lot of the things they need are quite cheap. For the sort of billions that are being proposed for OLPC, a lot of childhood health conditions could be prevented or cured. Children could go to school with things like books and other tools. Girls wouldn't have to stay at home several days a month because they are having their period. And pupils could have enough food to prevent them from falling asleep during classes or just not going to school at all.
Children have a lot of things to grasp when they are young, reading, writing, languages, mathematics, sciences, etc. It's easy enough to see how laptops could be used to help with this. But I have a suggestion: give free laptops to teachers in teacher training schools (who also lack the books they need, sometimes); teach them how to use laptops and how to teach with them. Then roll them out that way. Instead of spending the $6 billion dollars or more on giving tens of millions of children laptops, make sure the educational system is ready for the laptops.
There is no point in just spilling out a few more million to give a laptop to teachers as well. They have to be taughted how to use them and how to teach with them. When I was doing an MA at a London University college just a few years ago, an institute of education, no less, some of the academic staff there had no idea how to use computers to teach, so why should people who have never had the opportunity to even use them? In fact, teaching with computers comes with some huge pedagogical hurdles.
Frankly, I think the project stinks. But it could be turned around, it hasn't even started yet, to make African countries among the first in the world to use a laptop as their main teaching tool in primary and secondary education. Ok, training the teachers may not iron out all the problems of trying to do without books and other everyday teaching materials. But it sure as hell won't work if the teachers get no training (and no laptop). If you can raise that much money, OLPC, don't blow it on the laptops alone. It's not as if the laptops can be recycled if the project goes pear shaped.
Wednesday, March 31, 2010
Human Rights Are Not Just for the Rich World
According to Dr Marcos Espinal of the Stop TB Partnership, "TB is not a medical problem. It is a development issue. It is an economic problem. It's a human rights situation." And I applaud him for saying this. If developing countries are not allowed to develop (and I would argue that developed countries are doing all in their power to stop them from developing), diseases like TB will not successfully be treated by drugs alone. People in developing countries are poor, they suffer bad health, they receive little or no education, they live in terrible conditions and their human rights are being denied. It is no wonder that TB and many other diseases are rife and increasing.
I would add that HIV, also, is not just a medical problem, nor is it just a matter of sexual behaviour. Parallel arguments could be used to show that, so far, both HIV and TB programmes have failed to prevent the spread of the diseases and will continue to do so. If you don't deal with the conditions that result in diseases spreading, all diseases, you will not eradicate the diseases. After using little more than expensive pharmaceutical products to treat TB for many years, an estimated 440,000 people are now resistant to commonly used TB drugs. I have not been able to find estimates for the number of people with HIV strains that are resistant to first line drugs commonly used in developing countries, but resistance is a very serious threat.
There's an interesting article on the website of the United Nations Development Programme (UNDP). They have been publishing the Human Development Report for many years now and they are about to reveal some of the main trends over the past four decades. The Human Development Report measures development by criteria other than just economic, such as health, gender, education and other things. This article notes that there has been significant progress in development, but this has come from improvements in education and health, not economics.
It also notes that these improvements have little or nothing to do with globalization. Rather, they have been achieved by expansion of "educational and health systems, coupled by initiatives of the international community to enable access to vaccines and antibiotics." In other words, state intervention.
The research finds that there is no correlation between economic growth and changes in non-income components of human development. It concludes that "the oft-repeated dictum that growth is a necessary condition for increasing human development is simply not true."
So the approach to development and human rights related problem, such as HIV or TB, is to improve education, health, economic circumstances, gender imbalances, employment, infrastructure and many other things. The approach should not be to set up well financed vertical programmes that target single diseases or narrow issues at the expense of other, broader issues.
Throwing eye watering sums of money at a problem, such as HIV or TB, will not even solve the problems of HIV or TB. Especially if most of the money is spent on technologies that are produced in rich countries. That's just taking money out of one pocket and slipping most of it into another. It's time for new thinking on development. Development is not just one thing, it's many things. And if you don't know enough about any of them, just read the Universal Declaration of Human Rights and consider how many of those rights people in developing countries are currently being denied.
Tuesday, March 30, 2010
More Good News for Big Pharma: Resistant Gonorrhoea
Yesterday, I blogged about the fact that TB is on the rise worldwide. Funding for TB prevention, and even for treatment, are not commensurate with the threat to global health that this epidemic poses. And the rise of TB is often blamed on the current HIV pandemic. I would suggest that there is a TB epidemic of a level that can not wholly be explained by the HIV pandemic and that, like almost every disease and health issue aside from HIV, TB is being ignored.
Those heavily involved in the HIV industry, such as Michel Sidibe, the head of UNAIDS and Michel Kazatchkine, head of the UN Global Fund for HIV, TB and Malaria, deny that high levels of HIV funding have starved other diseases of cash. Kazatchkine claims that 'over a third of of overall funding of the Global Fund is actually going to strengthening health systems'. I don't know how he came up with this estimate but it seems to me that there are only certain aspects of health systems that are benefitting from HIV cash, and those aspects relate to HIV.
Kazatchkine says the money is not just going on condoms and drugs. I sometimes wonder if the money is even going on condoms, along with the logistics of ensuring that people use condoms all the time and properly. Even the claim that a lot of money is being spent on drugs can seem hollow when people supposed to be taking them often cannot do so because of lack of food. And 20% of the new HIV cases in Kenya every year come from vertical infection, from mothers transmitting HIV to their babies.
Treatment of people with HIV may well have exceeded expectations. And I would like to see every HIV positive person who needs treatment receiving the drugs and support they need. But since the recent expansion of HIV treatment, millions more have become infected. Prevention has been forgotten about. People like Kazatchkine and Sidibe like to argue that distinguishing between treatment and prevention is a false dichotomy, but this is not so. If treatment played such a huge role in preventing further infection, transmission rates would be much lower than they are. In fact, the majority of people in Kenya who are HIV positive do not know their status. Perhaps there shouldn't be a dichotomy between treatment and prevention, but there is.
And if you think the programmes to teach people about safe sex and to persuade them to use condoms have been successful, consider the figures for preventable and treatable sexually transmitted infections (STI). There are an estimated 340 million new cases of curable STIs every year. This is after over 20 years of preaching about safe sex in every country in the world. If people were practicing safe sex, transmission of most STIs would also be reduced. Prevention involves taking steps to ensure the infection is not transmitted. In the case of STIs, that could involve the correct use of condoms, minimally.
HIV treatment and care has received much of the money available for the disease. Kenya's official strategy papers make this quite clear. Prevention has received very little money and has been pretty unsuccessful, with 5 new infections for every two put on HIV treatment, globally. And HIV has been treated as if it's just an easy matter to round up people and give them some drugs. As a result, there is growing resistance to the few HIV drugs available in developing countries. This can be compared to TB, where it has long been recognised that you can't just send people away with some drugs and expect them to take them religiously for 9 months and never see them again.
If health solely involves treating sick people, how will you ensure the continuing health of those who are not (yet) sick? In the field of sexually transmitted diseases, gonorrhoea is now also developing resistance to the most commonly available drugs. There has been little recent research into alternative treatments for gonorrhoea (or TB) because, I would suggest, most of the money has been spent on other 'priorities' (Oh, and big pharma are waiting for public funding for their research, a very important component for these (private) companies). One of those priorities is HIV and despite ploughing a lot of money into condoms and safe sex campaigns, prevention has not received the level of funding it needs.
Yet more evidence of the lack of success of HIV prevention work is the level of pregnancies among women receiving HIV treatment. Women with untreated HIV have far lower fertility levels, so treatment should increase fertility. But women on HIV treatment should also be receiving advice about having unprotected sex and about unplanned pregnancies. I don't believe that all these HIV positive women are choosing to have more children, though some of them may be. Because other research has shown that the vast majority of pregnancies among women who are HIV positive were not planned.
Sidibe even seems to think that the global recession and climate change are distractions to the industry's fight against Aids. I would be hard pressed to find an attitude to which I am more opposed. He even has the cheek to suggest that HIV funding has not led to the neglect of other diseases because it has increased attention for TB, the two diseases being 'integrated', and that HIV prevention should take on a 'holistic approach'. Damn right, but I don't think his use of 'holistic' is the same as mine. But when is all this HIV money going to be spent on the many health issues that I and many others would claim have been ignored? Apparently, Sidibe and Kazatchkine think that's already taking place, and Sidibe feels that support from the big pharmaceutical companies is essential. Very funny.
Tuesday, March 2, 2010
Mass Male Circumcision: Science or Politics?
Following the claim that a drive to test Kenyans for HIV resulted in 1.5 million people being tested in three weeks, another paper claims that 36,000 (male) circumcisions were performed in two months. I have serious doubts about the first claim and I have serious worries about the future health of the 36,000. In 2004, Kenya had 16 doctors for every 100,000 people and per capita spending on health was $9.10. There were 72 hospitals in Nyanza and 30.3 beds per 100,000 people.
Most of the circumcisions were performed in Nyanza because it's the only province with relatively low rates of male circumcision. In fact, it's only the part of Nyanza where the Luo tribe predominates that circumcision rates are low, standing at about 48%. HIV prevalence is high in Nyanza and especially high among the Luo. It's around double the national rate of over 7%. While this is said to be because of low rates of circumcision, it is not clear whether there are other factors that may result in high HIV prevalence among this tribe.
The scientific papers claiming that mass male circumcision can significantly reduce HIV transmission are notable for the frequency with which they are cited rather than for their great number. And perhaps the evidence is overwhelming, from a scientific point of view. Perhaps this is the one big breakthrough that the world has been waiting for. But some of the areas where circumcision rates already stand at almost 100% in Kenya also have high and increasing rates of HIV transmission. For example, prevalence is rising in Coast province and it is higher than the national average, even though circumcision rates are nearly 100%.
So what awaits Luos who have been circumcised? Some people I have met who are already circumcised believe that they don't need to use condoms and that seems to be a common view. Some even believe that condoms 'don't work' if you are circumcised. Apparently people who are queuing up to be circumcised now are also being given advice about using condoms once they are able to have sex again. I suspect people are getting circumcised because they think they will no longer need condoms. They may well be getting advice that says they still need to practice safe sex, but if they are heeding this advice then they could just skip the circumcision.
The scientific evidence claims that being circumcised reduces the risk of HIV transmission by 60%, regardless of sexual practices, for example, whether a condom was used, whether one has multiple partners, etc. Still, I just don't see what people think they can gain from being circumcised unless they think they can dispense with the need to use a condom. And maybe a 60% reduction in transmission will make some think the risks of unsafe sex to be small enough to be worthwhile.
Kenya's intention to spend $56 million on a small percentage of the population to prevent a handful of sexually transmitted diseases, given how little is spent on health per capita, seems strange. But spending this kind of money on an intervention that may not have anywhere near the effect it is expected to have is rash. Why, in a country that has so many health priorities, is so much being spent on this handful of diseases and targeting this small demographic (adult male Luos)? Yet the main funding sources, PEPFAR, the Gates Foundation and the Global Fund are all behind the initiative.
I hope this mass male circumcision campaign is worth it and HIV transmission rates drop significantly in the Luo population. But I just wonder if people who have swallowed the hype know that they will only be well protected from sexual transmission of HIV (and some other sexually transmitted infections) if they always use a condom, properly. Because if there are any other factors behind high rates of HIV among the Luo, aside from those relating to sexual transmission, it could be some time before they are given any consideration.
Most of the circumcisions were performed in Nyanza because it's the only province with relatively low rates of male circumcision. In fact, it's only the part of Nyanza where the Luo tribe predominates that circumcision rates are low, standing at about 48%. HIV prevalence is high in Nyanza and especially high among the Luo. It's around double the national rate of over 7%. While this is said to be because of low rates of circumcision, it is not clear whether there are other factors that may result in high HIV prevalence among this tribe.
The scientific papers claiming that mass male circumcision can significantly reduce HIV transmission are notable for the frequency with which they are cited rather than for their great number. And perhaps the evidence is overwhelming, from a scientific point of view. Perhaps this is the one big breakthrough that the world has been waiting for. But some of the areas where circumcision rates already stand at almost 100% in Kenya also have high and increasing rates of HIV transmission. For example, prevalence is rising in Coast province and it is higher than the national average, even though circumcision rates are nearly 100%.
So what awaits Luos who have been circumcised? Some people I have met who are already circumcised believe that they don't need to use condoms and that seems to be a common view. Some even believe that condoms 'don't work' if you are circumcised. Apparently people who are queuing up to be circumcised now are also being given advice about using condoms once they are able to have sex again. I suspect people are getting circumcised because they think they will no longer need condoms. They may well be getting advice that says they still need to practice safe sex, but if they are heeding this advice then they could just skip the circumcision.
The scientific evidence claims that being circumcised reduces the risk of HIV transmission by 60%, regardless of sexual practices, for example, whether a condom was used, whether one has multiple partners, etc. Still, I just don't see what people think they can gain from being circumcised unless they think they can dispense with the need to use a condom. And maybe a 60% reduction in transmission will make some think the risks of unsafe sex to be small enough to be worthwhile.
Kenya's intention to spend $56 million on a small percentage of the population to prevent a handful of sexually transmitted diseases, given how little is spent on health per capita, seems strange. But spending this kind of money on an intervention that may not have anywhere near the effect it is expected to have is rash. Why, in a country that has so many health priorities, is so much being spent on this handful of diseases and targeting this small demographic (adult male Luos)? Yet the main funding sources, PEPFAR, the Gates Foundation and the Global Fund are all behind the initiative.
I hope this mass male circumcision campaign is worth it and HIV transmission rates drop significantly in the Luo population. But I just wonder if people who have swallowed the hype know that they will only be well protected from sexual transmission of HIV (and some other sexually transmitted infections) if they always use a condom, properly. Because if there are any other factors behind high rates of HIV among the Luo, aside from those relating to sexual transmission, it could be some time before they are given any consideration.
Wednesday, January 13, 2010
We Don't Need Evidence that Health, Education and Other Social Services Are Good
You might think that HIV prevention interventions have some bearing on the context in which they are implemented. For example, you might think that interventions to persuade people to have fewer partners are concentrated in areas where it has been shown that people have many sexual partners. Or you might think that about interventions to persuade people to avoid concurrent relationships, sexual relationships with more than one person at a time.
But in fact, interventions are mostly the same wherever you go, whether it's a developed country or an underdeveloped one. The little research that has been done into sexual behaviour suggests that in some places people have far more lifetime sexual partners than in others and even that in some places people have more concurrent sexual relationships. But no research shows that areas where people have more sexual partners or more concurrent sexual relationships actually correspond closely with areas of high HIV prevalence.
It's just an assumption that if HIV prevalence is high, people there much have more sex, more partners and more concurrent relationships. Some of the research that has been done clearly demonstrates that areas with high levels of HIV have lower levels of multiple partnerships and concurrent partnerships. It also demonstrates that areas with high levels of multiple partnerships and concurrent partnerships have lower rates of HIV. Clearly, unsafe sex is unsafe, wherever it occurs and however, but specific prevention programmes would need to be clear about what kind of 'unsafe' sexual behaviour, precisely, is occurring and how to change that.
But HIV prevention interventions are more likely to be dreamed up by those with political, religious or commercial interests, in complete isolation from anything that could be called evidence. And so far, they have almost all worked equally badly, whether it's in South Africa, which has the highest number of people living with HIV in the world or the US, which has the highest HIV prevalence in the developed world. These failures are not because of lack of available evidence about what would work and what would not work, though there is a lack of evidence. The failure is because HIV prevention funding has been seen as a matter of 'morals', petty politics and a good way to make some money.
If these circumstances were to change, what hope would there be that the high rates of HIV transmission in many countries of the world could be reduced? The issue of concurrent partners is hotly debated by the foremost academics in the field. But what these people don't disagree on is whether condoms work. There is no evidence that condoms don't work, though they are not 100% efficient. There is only a prejudice against the use of condoms because people who use condoms are having sex. But if people weren't having sex there would be no HIV pandemic.
I have never heard an academic, or anyone else, arguing that education, health education and sexual health education are bad and producing evidence to support their arguments. I have only heard bigoted politicians and religious leaders who seem to know little and care less about what their country's children know about sex and sexuality. Over and over again, it has been shown that children who know about sex and sexuality are more likely to delay their first sexual experience and to take precautions against unplanned pregnancy, HIV and other sexually transmitted infections.
Research into sexual behaviour is not just scarce, it's hard to do and the results are rightly hotly debated. But we don't need to wait for this difficult and costly research to be completed to aim to cut the transmission of HIV. It would be immoral to wait for this research. We know now that people have sex and they need sex education and contraception. They need health services, especially sexual and reproductive health services. The majority of new cases of HIV transmission in developing countries are still sexually transmitted, so to those who say HIV prevention is difficult or that evidence is lacking: this is not completely true.
Sure, there are controversies and there is research that badly needs to be done. But ignoring the efficacy of condoms, education, health and other social services in cutting the transmission is not only wrong, it is also disingenuous. Access to education, health and other social services are human rights so no 'evidence' is needed for these areas to be funded straight away. And while we're considering these human rights, we could also take a look at gender imbalances of all kinds, but especially relating to employment, family law, inheritance and marital power imbalances.
High HIV prevalence relates to the broad determinants of sexual and other types of behaviour, to the overall conditions in which people live, to their levels of health, education, wealth and many other things. HIV prevention has mainly concentrated on individual sexual behaviour and this is one of the things that makes reducing HIV transmission appear to be so intractable.
As the authors of a paper published in The Lancet over three years ago conclude: "No general approach to sexual-health promotion will work everywhere, and no single-component intervention will work anywhere. We need to know not only whether interventions work, but why and how they do so in particular social contexts. Comprehensive behavioural interventions are needed that take account of the social context, attempt to modify social norms to support uptake and maintenance of behaviour change, and tackle the structural factors that contribute to risky sexual behaviour."
But in fact, interventions are mostly the same wherever you go, whether it's a developed country or an underdeveloped one. The little research that has been done into sexual behaviour suggests that in some places people have far more lifetime sexual partners than in others and even that in some places people have more concurrent sexual relationships. But no research shows that areas where people have more sexual partners or more concurrent sexual relationships actually correspond closely with areas of high HIV prevalence.
It's just an assumption that if HIV prevalence is high, people there much have more sex, more partners and more concurrent relationships. Some of the research that has been done clearly demonstrates that areas with high levels of HIV have lower levels of multiple partnerships and concurrent partnerships. It also demonstrates that areas with high levels of multiple partnerships and concurrent partnerships have lower rates of HIV. Clearly, unsafe sex is unsafe, wherever it occurs and however, but specific prevention programmes would need to be clear about what kind of 'unsafe' sexual behaviour, precisely, is occurring and how to change that.
But HIV prevention interventions are more likely to be dreamed up by those with political, religious or commercial interests, in complete isolation from anything that could be called evidence. And so far, they have almost all worked equally badly, whether it's in South Africa, which has the highest number of people living with HIV in the world or the US, which has the highest HIV prevalence in the developed world. These failures are not because of lack of available evidence about what would work and what would not work, though there is a lack of evidence. The failure is because HIV prevention funding has been seen as a matter of 'morals', petty politics and a good way to make some money.
If these circumstances were to change, what hope would there be that the high rates of HIV transmission in many countries of the world could be reduced? The issue of concurrent partners is hotly debated by the foremost academics in the field. But what these people don't disagree on is whether condoms work. There is no evidence that condoms don't work, though they are not 100% efficient. There is only a prejudice against the use of condoms because people who use condoms are having sex. But if people weren't having sex there would be no HIV pandemic.
I have never heard an academic, or anyone else, arguing that education, health education and sexual health education are bad and producing evidence to support their arguments. I have only heard bigoted politicians and religious leaders who seem to know little and care less about what their country's children know about sex and sexuality. Over and over again, it has been shown that children who know about sex and sexuality are more likely to delay their first sexual experience and to take precautions against unplanned pregnancy, HIV and other sexually transmitted infections.
Research into sexual behaviour is not just scarce, it's hard to do and the results are rightly hotly debated. But we don't need to wait for this difficult and costly research to be completed to aim to cut the transmission of HIV. It would be immoral to wait for this research. We know now that people have sex and they need sex education and contraception. They need health services, especially sexual and reproductive health services. The majority of new cases of HIV transmission in developing countries are still sexually transmitted, so to those who say HIV prevention is difficult or that evidence is lacking: this is not completely true.
Sure, there are controversies and there is research that badly needs to be done. But ignoring the efficacy of condoms, education, health and other social services in cutting the transmission is not only wrong, it is also disingenuous. Access to education, health and other social services are human rights so no 'evidence' is needed for these areas to be funded straight away. And while we're considering these human rights, we could also take a look at gender imbalances of all kinds, but especially relating to employment, family law, inheritance and marital power imbalances.
High HIV prevalence relates to the broad determinants of sexual and other types of behaviour, to the overall conditions in which people live, to their levels of health, education, wealth and many other things. HIV prevention has mainly concentrated on individual sexual behaviour and this is one of the things that makes reducing HIV transmission appear to be so intractable.
As the authors of a paper published in The Lancet over three years ago conclude: "No general approach to sexual-health promotion will work everywhere, and no single-component intervention will work anywhere. We need to know not only whether interventions work, but why and how they do so in particular social contexts. Comprehensive behavioural interventions are needed that take account of the social context, attempt to modify social norms to support uptake and maintenance of behaviour change, and tackle the structural factors that contribute to risky sexual behaviour."
Friday, December 4, 2009
Foundations for HIV Prevention
I rarely come across articles criticizing HIV prevention programmes for their lack of success, but apparently a contributor to the Social Aspects of HIV/AIDS Research Alliance conference this year draws attention to the fact that many 'prevention' interventions were implemented without ever being tried. He may have gone on to say that ones that were tried and found to be useless continue to attract most prevention funding, but I wasn't at the conference.
Professor Geoff Setswe is right that HIV took some time to be recognised and had already infected many people before the most appropriate methods of preventing its spread had been investigated. But more than 25 years later, prevention programmes continue to be rolled out that are untested or that are tested but found to have little or no benefit. But no one is counting bodies when there is money to be made.
It's easy to blame health and other social problems on the global economic crisis now, but that wasn't the problem just over a year ago. In Kenya, since the 1980s, one excuse after another has been blamed on the lack of progress in education, health and other areas. If it wasn't economic, it was oil or food or political or environmental and if it wasn't a crisis it was a disaster. The HIV pandemic itself is just one of those many 'disasters' or 'crises'.
But poor health in Kenya is not a disaster, nor is it a short term crisis. Health services have been reduced in Kenya at least since the early 1980s, when the Moi government depended on loans from international financial institutions to prop up his form of democracy. These institutions funded him in return for his agreement to cut spending on social services and the public sector in general. It seems unlikely he or his colleagues (who overlap considerably with the present administration) were particularly worried about the idea of reducing public spending.
Health service spending in Kenya is now minimal (as are spending on education and other social services). Health infrastructure needs to be built from the ground up, more or less. Most people don't go to hospitals or clinics and many who do fare worse than they would have if they had stayed at home. It's little wonder that HIV was transmitted rapidly in Kenya during the 1980s and continues to spread today, despite the hundreds of millions of dollars spent on the disease. There are still far more people being newly infected than receiving treatment, though a lot more money is spent on treatment.
Fine, Professor Setswe, clinical trials are not always appropriate for testing social and behavioural interventions. But are clinical trials needed to show that starving people need food, that those suffering from malnutrition need proper nourishment, that poor people need support, that sick people, whatever they are suffering from, need medical attention, that those without adequate supplies of water die of thirst or water borne diseases? And the list goes on. Those who pigheadedly continue to talk about how difficult HIV is to prevent seem to be uninterested in what those in high HIV prevalence countries really suffer from.
HIV is a real disease. Those suffering from it need treatment and care. Those who are in danger of becoming infected need to be protected from it or to be enabled to protect themselves from it. But most people will get up in the morning and have food, water, work, school fees, day to day health and many other things on their minds. And in all the time that HIV has been around, these other concerns have been largely deprived of attention and funding.
Finally, mass male circumcision is mentioned as a possible HIV prevention method that is supported by a lot of evidence but has been held up for various reasons. Perhaps one of the reasons that circumcision has been held up is because health services in Kenya and other countries who were tricked by those same international financial institutions have been reduced to the extent that it is not possible to roll out any kind of mass health programme. Some of the HIV programmes that were rolled out failed because infrastructure, education, health and many other areas have been so underfunded for so long.
The same article mentions a Dr Ntanganira, who says that "We know what works". But the article doesn't say what works, unfortunately.
Professor Geoff Setswe is right that HIV took some time to be recognised and had already infected many people before the most appropriate methods of preventing its spread had been investigated. But more than 25 years later, prevention programmes continue to be rolled out that are untested or that are tested but found to have little or no benefit. But no one is counting bodies when there is money to be made.
It's easy to blame health and other social problems on the global economic crisis now, but that wasn't the problem just over a year ago. In Kenya, since the 1980s, one excuse after another has been blamed on the lack of progress in education, health and other areas. If it wasn't economic, it was oil or food or political or environmental and if it wasn't a crisis it was a disaster. The HIV pandemic itself is just one of those many 'disasters' or 'crises'.
But poor health in Kenya is not a disaster, nor is it a short term crisis. Health services have been reduced in Kenya at least since the early 1980s, when the Moi government depended on loans from international financial institutions to prop up his form of democracy. These institutions funded him in return for his agreement to cut spending on social services and the public sector in general. It seems unlikely he or his colleagues (who overlap considerably with the present administration) were particularly worried about the idea of reducing public spending.
Health service spending in Kenya is now minimal (as are spending on education and other social services). Health infrastructure needs to be built from the ground up, more or less. Most people don't go to hospitals or clinics and many who do fare worse than they would have if they had stayed at home. It's little wonder that HIV was transmitted rapidly in Kenya during the 1980s and continues to spread today, despite the hundreds of millions of dollars spent on the disease. There are still far more people being newly infected than receiving treatment, though a lot more money is spent on treatment.
Fine, Professor Setswe, clinical trials are not always appropriate for testing social and behavioural interventions. But are clinical trials needed to show that starving people need food, that those suffering from malnutrition need proper nourishment, that poor people need support, that sick people, whatever they are suffering from, need medical attention, that those without adequate supplies of water die of thirst or water borne diseases? And the list goes on. Those who pigheadedly continue to talk about how difficult HIV is to prevent seem to be uninterested in what those in high HIV prevalence countries really suffer from.
HIV is a real disease. Those suffering from it need treatment and care. Those who are in danger of becoming infected need to be protected from it or to be enabled to protect themselves from it. But most people will get up in the morning and have food, water, work, school fees, day to day health and many other things on their minds. And in all the time that HIV has been around, these other concerns have been largely deprived of attention and funding.
Finally, mass male circumcision is mentioned as a possible HIV prevention method that is supported by a lot of evidence but has been held up for various reasons. Perhaps one of the reasons that circumcision has been held up is because health services in Kenya and other countries who were tricked by those same international financial institutions have been reduced to the extent that it is not possible to roll out any kind of mass health programme. Some of the HIV programmes that were rolled out failed because infrastructure, education, health and many other areas have been so underfunded for so long.
The same article mentions a Dr Ntanganira, who says that "We know what works". But the article doesn't say what works, unfortunately.
Sunday, November 8, 2009
Lack of Sanitary Pads is a Threat to the Health of Kenya as a Whole
The hype about how brilliant the introduction of 'free' primary education has been in Kenya continues six years on but the reality is that most parents who couldn't afford primary education before 2003 still can't afford it. The hidden costs are endless and include levies for parent teacher associations, uniforms and overpriced books, equipment, 'extra' tuition, etc. A colleague recently pointed out to me that parents need to pay for their child's desk every year. There must be quite a surplus of desks in schools by now.
While enrollment figures are high for state schools, they have dropped in many private schools and the figures for attendance and completion, even of primary school, are not so brilliant. Numbers of girls completing primary school and going on to secondary school are particularly poor. There are many reasons for girls not completing their education, including the belief that as girls will marry into another family, it is not economical to 'water ones neighbour's fields'.
But a study in Uganda suggests that many girls are dropping out of school as soon as they start menstruating. Schools are not equipped to deal with girls once they start menstruating, apparently. Lack of separate sanitary facilities for girls, and even lack of water, mean that they will often stay at home, either for the duration of their period or even for good.
The extremely high cost of sanitary pads mean that they are inaccessible to many girls. They have to use substitutes or stay at home. To put it in perspective, ten of the cheapest sanitary pads cost more than several days worth of the staple ground maize for a large family. The commonly advertised branded versions cost twice or three times as much and, because one or two of them are sometimes given out as promotional 'gifts', some people think they must always use this version to be really safe.
As well as having to teach sex education without talking about sex, teachers are also in the position where they are usually not trained to include classes about menstruation, either. Teaching about the whole field of sex, sexuality, reproduction, sexual health and sanitation is often considered to lead to immoral behaviour in young people. This can be blamed on taboo or cultural considerations but in fact, it often has more to do with political and religious leadership and funding sources for sex education and education as a whole.
In the end, large numbers of girls with little or no education means that large numbers of children will, in the future, also be brought up with little or no education, knowledge of sex or reproduction or even with the level of empowerment needed to change anything for the better. Continuing gender imbalances mean continuation of the status quo. That's a status quo where much of the population will never be able to attain a decent standard of living, while the more privileged continue to enjoy the great wealth that exists in Kenya (despite the best attempts of colonials, neo-colonials, multinationals and other assorted leeches).
The introduction of 'free' primary education was a little like some of the other initiatives that only aim to tackle one or two headline indicators. (In fact, any of the millennium development goals (MDG) would be additional examples.) School fees were abolished but immediately replaced with costs that mean parents still have to pay de facto fees. There are still far too few teachers and classrooms in many areas to provide decent levels of education.
When it comes to education relating to sex, reproduction, health, sanitation or anything like that, few teachers have been trained to provide these. And there is little to be gained from health and sanitation education when the health and sanitation facilities, even reliable supplies of clean water, are not available to the majority.
Successive governments, along with those who dream up international 'initiatives' don't seem to have noticed that basic needs are basic for the very reason that, without any one of them, people's standard of living is compromised. Children who have little or no food for much of the time will have retarded growth and mental development, poor health and a short life. Lack of sanitary facilities reduce health but this also reduces access to education and the efficacy of education. Basic needs are connected to each other, so you can't just make a list and tick them off as you create an 'initiative' that relates to each one.
While enrollment figures are high for state schools, they have dropped in many private schools and the figures for attendance and completion, even of primary school, are not so brilliant. Numbers of girls completing primary school and going on to secondary school are particularly poor. There are many reasons for girls not completing their education, including the belief that as girls will marry into another family, it is not economical to 'water ones neighbour's fields'.
But a study in Uganda suggests that many girls are dropping out of school as soon as they start menstruating. Schools are not equipped to deal with girls once they start menstruating, apparently. Lack of separate sanitary facilities for girls, and even lack of water, mean that they will often stay at home, either for the duration of their period or even for good.
The extremely high cost of sanitary pads mean that they are inaccessible to many girls. They have to use substitutes or stay at home. To put it in perspective, ten of the cheapest sanitary pads cost more than several days worth of the staple ground maize for a large family. The commonly advertised branded versions cost twice or three times as much and, because one or two of them are sometimes given out as promotional 'gifts', some people think they must always use this version to be really safe.
As well as having to teach sex education without talking about sex, teachers are also in the position where they are usually not trained to include classes about menstruation, either. Teaching about the whole field of sex, sexuality, reproduction, sexual health and sanitation is often considered to lead to immoral behaviour in young people. This can be blamed on taboo or cultural considerations but in fact, it often has more to do with political and religious leadership and funding sources for sex education and education as a whole.
In the end, large numbers of girls with little or no education means that large numbers of children will, in the future, also be brought up with little or no education, knowledge of sex or reproduction or even with the level of empowerment needed to change anything for the better. Continuing gender imbalances mean continuation of the status quo. That's a status quo where much of the population will never be able to attain a decent standard of living, while the more privileged continue to enjoy the great wealth that exists in Kenya (despite the best attempts of colonials, neo-colonials, multinationals and other assorted leeches).
The introduction of 'free' primary education was a little like some of the other initiatives that only aim to tackle one or two headline indicators. (In fact, any of the millennium development goals (MDG) would be additional examples.) School fees were abolished but immediately replaced with costs that mean parents still have to pay de facto fees. There are still far too few teachers and classrooms in many areas to provide decent levels of education.
When it comes to education relating to sex, reproduction, health, sanitation or anything like that, few teachers have been trained to provide these. And there is little to be gained from health and sanitation education when the health and sanitation facilities, even reliable supplies of clean water, are not available to the majority.
Successive governments, along with those who dream up international 'initiatives' don't seem to have noticed that basic needs are basic for the very reason that, without any one of them, people's standard of living is compromised. Children who have little or no food for much of the time will have retarded growth and mental development, poor health and a short life. Lack of sanitary facilities reduce health but this also reduces access to education and the efficacy of education. Basic needs are connected to each other, so you can't just make a list and tick them off as you create an 'initiative' that relates to each one.
Sunday, August 2, 2009
Healthy People Have Needs Too
The aim to roll out antiretroviral treatment (ART) for everyone who needs it was always dogged by (usually tacit) questions about sustainability. In Uganda, for example, ART is 95% donor funded. For various reasons, much of that funding is now being reviewed or cut.
Many people who are put on ART will, sooner or later, need a course of second line drugs because of resistance to the first line drugs. This increases the cost of the drugs by 6 or even 10 times. And resistance can also develop to second line drugs.
The drugs themselves are only one cost involved in treatment but as the drug companies are getting the lion's share of HIV related money, there is little pressure for money to be spent on other treatment costs. The fact that the drugs are bought, paid for and delivered to the country in question doesn't mean that the country has the capacity to distribute them and actually treat people.
But the most unsustainable aspect of aiming for universal ART rollout is that little is being done to reduce the rate of new infections. The rate of new infections continues to exceed the number of people being put on treatment.
The trend towards putting people on ART earlier may have some impact on the rate of new infections. The idea of testing everyone and treating everyone found to be HIV positive may also have an impact. And the idea of putting everyone thought to be at risk of being exposed to HIV on ART, called pre-exposure prophylaxis or PrEP, should also reduce the rate of new infections further.
But all of these measures together will not cut HIV transmission to a sufficiently low level for the epidemic to be effectively eradicated. I know, mathematical modelling has shown that *if* around 80% of sexually active people opt for testing once a year, the epidemic could be more or less eradicated by 2050.
However, that’s a very big if. This sort of modelling has no bearing on the practicalities of how the sort of decrepit health and social service levels found in high prevalence countries will ever persuade large numbers of people to test regularly. At present, testing is between 10 and 20% of populations and that's after many years of trying to persuade people to test.
Epidemics are inherently unpredictable and we have been, consequently, fairly poor at predicting which direction the HIV epidemic will take. In the US, which hasn't lacked funding, high levels of circumcision and concentration on abstinence only education has resulted in the highest HIV prevalence in the developed world.
HIV spread rapidly in developing countries, especially among people in densely concentrated populations with low levels of education, health and social services and very high levels of gender and economic inequality. But well educated and wealthy people were, at least at one time, more at risk than poor and less well educated people.
Now, HIV is spreading in less densely populated areas and the effects of having such low levels of education, health and social services are clearly felt in that most HIV prevention efforts are failing. They are failing because, unsurprisingly, they require good education, health and social services; what a surprise!
Yes, people who are infected with HIV need to be treated, and they need a lot more than just drugs. They should be entitled to this treatment and care and that should also cut transmission considerably. But for widespread treatment to effectively cut transmission, we also need to target the people who are presently being infected with HIV and those who are at risk of being infected.
The process of identifying all infected people is too big a job to effect quickly enough to protect people who are presently uninfected. Targeting those who are presently uninfected means providing everyone with adequate health, education and social services. This means *not* spending all available money on drugs, mass male circumcision, PrEP, trying to test every sexually active person, etc, and providing people with the basics that they need just to survive.
I agree with those who are calling for more money for HIV but no amount of money will make up for the fact that people lack the most basic things. The current approach to HIV appears to assume that HIV is independent of the overall environments in which people live. HIV is not independent of each aspect of people’s day to day lives; no disease is. On the contrary, HIV is transmitted rapidly where people work and travel and behave much as they have been doing for as long as anyone can remember.
HIV transmission is reckoned to be low at the moment in Zimbabwe (although prevalence is high) because people’s day to day lives have been disrupted. The same thing is said to have happened in other countries that experienced wars and civil disturbances, such as Ethiopia and Angola. But that doesn’t mean that rates of HIV transmission will stay low in those countries.
Like all diseases, HIV is part of everyday life; it affects people who are rendered vulnerable by decades of falling public spending. A bigger chunk of the money needs to be spent on healthy people. I know that doesn’t fit in with the plans of the pharmaceutical companies and others who make a lot of money out of disease but healthy people need the means to stay healthy. If all the money is spent on drugs, healthy people will continue to suffer, as they are doing right now.
(For further discussion of PrEP, see my other blog, pre-exposureprophylaxis.blogspot.com)
Many people who are put on ART will, sooner or later, need a course of second line drugs because of resistance to the first line drugs. This increases the cost of the drugs by 6 or even 10 times. And resistance can also develop to second line drugs.
The drugs themselves are only one cost involved in treatment but as the drug companies are getting the lion's share of HIV related money, there is little pressure for money to be spent on other treatment costs. The fact that the drugs are bought, paid for and delivered to the country in question doesn't mean that the country has the capacity to distribute them and actually treat people.
But the most unsustainable aspect of aiming for universal ART rollout is that little is being done to reduce the rate of new infections. The rate of new infections continues to exceed the number of people being put on treatment.
The trend towards putting people on ART earlier may have some impact on the rate of new infections. The idea of testing everyone and treating everyone found to be HIV positive may also have an impact. And the idea of putting everyone thought to be at risk of being exposed to HIV on ART, called pre-exposure prophylaxis or PrEP, should also reduce the rate of new infections further.
But all of these measures together will not cut HIV transmission to a sufficiently low level for the epidemic to be effectively eradicated. I know, mathematical modelling has shown that *if* around 80% of sexually active people opt for testing once a year, the epidemic could be more or less eradicated by 2050.
However, that’s a very big if. This sort of modelling has no bearing on the practicalities of how the sort of decrepit health and social service levels found in high prevalence countries will ever persuade large numbers of people to test regularly. At present, testing is between 10 and 20% of populations and that's after many years of trying to persuade people to test.
Epidemics are inherently unpredictable and we have been, consequently, fairly poor at predicting which direction the HIV epidemic will take. In the US, which hasn't lacked funding, high levels of circumcision and concentration on abstinence only education has resulted in the highest HIV prevalence in the developed world.
HIV spread rapidly in developing countries, especially among people in densely concentrated populations with low levels of education, health and social services and very high levels of gender and economic inequality. But well educated and wealthy people were, at least at one time, more at risk than poor and less well educated people.
Now, HIV is spreading in less densely populated areas and the effects of having such low levels of education, health and social services are clearly felt in that most HIV prevention efforts are failing. They are failing because, unsurprisingly, they require good education, health and social services; what a surprise!
Yes, people who are infected with HIV need to be treated, and they need a lot more than just drugs. They should be entitled to this treatment and care and that should also cut transmission considerably. But for widespread treatment to effectively cut transmission, we also need to target the people who are presently being infected with HIV and those who are at risk of being infected.
The process of identifying all infected people is too big a job to effect quickly enough to protect people who are presently uninfected. Targeting those who are presently uninfected means providing everyone with adequate health, education and social services. This means *not* spending all available money on drugs, mass male circumcision, PrEP, trying to test every sexually active person, etc, and providing people with the basics that they need just to survive.
I agree with those who are calling for more money for HIV but no amount of money will make up for the fact that people lack the most basic things. The current approach to HIV appears to assume that HIV is independent of the overall environments in which people live. HIV is not independent of each aspect of people’s day to day lives; no disease is. On the contrary, HIV is transmitted rapidly where people work and travel and behave much as they have been doing for as long as anyone can remember.
HIV transmission is reckoned to be low at the moment in Zimbabwe (although prevalence is high) because people’s day to day lives have been disrupted. The same thing is said to have happened in other countries that experienced wars and civil disturbances, such as Ethiopia and Angola. But that doesn’t mean that rates of HIV transmission will stay low in those countries.
Like all diseases, HIV is part of everyday life; it affects people who are rendered vulnerable by decades of falling public spending. A bigger chunk of the money needs to be spent on healthy people. I know that doesn’t fit in with the plans of the pharmaceutical companies and others who make a lot of money out of disease but healthy people need the means to stay healthy. If all the money is spent on drugs, healthy people will continue to suffer, as they are doing right now.
(For further discussion of PrEP, see my other blog, pre-exposureprophylaxis.blogspot.com)
Friday, June 26, 2009
Health Related Political Footballs
It seems like a short time since the issue of mass male circumcision (MMC) became a political football and it is not even the latest issue to have that status any more. But articles about it still appear every now and again and there seem to be a handful of genuine projects aiming to roll out MMC in some countries.
The Integrated Regional Information Networks (IRIN) has a recent article on the subject and lists the countries that have made some progress towards rolling out MMC. I notice Kenya is not on the list and not much progress seems to have been made in the eight countries in the list. Most sub Saharan African countries suffer from a lack of capacity and this seems unlikely to change in the near future.
On the one hand, a country could approach HIV as if it was just one disease of many and build up their overall health services. But most donor funding goes towards a handful of diseases, the main one being HIV. Very little funding, if any, goes towards building up health services in general.
Alternatively, countries could extend the capacity of existing health services to accommodate some kind of MMC programme. The latter approach might be like the attempt to test people for HIV (in the form of voluntary counselling and testing clinics) and the attempt to distribute treatment to as many infected people as possible. But after many years and extraordinary amounts of money being spent on these areas, these efforts have had limited success.
It’s important to note also that there are still many questions about the benefits of MMC and precious little discussion about the downsides. This is worrying and gives the impression that MMC is being promoted without taking into account the welfare of the people who will be involved. Of course, that wouldn't make MMC much different from development projects in general.
But the aim of MMC, ostensibly, is to reduce HIV transmission. It is believed that circumcised men are far less likely to become infected with HIV than uncircumcised men. The level of protection offered by circumcision is a matter of debate. I hope the debate is comprehensive and well informed because any measure that could reduce HIV transmission should be welcomed.
That is, any measure that has substantial benefits and few, if any, adverse effects. And circumcision may have quite a number of adverse effects. Rather than rehearsing the possible adverse effects here, I recommend the Male Circumcision and HIV website.
But my objection to MMC is slightly different. Given that I would argue that if Kenya had good health, education and other social services in the first place, HIV would never have spread as it did and would be easier to fight now. Therefore I see little point in piecemeal programmes that address one small factor in HIV transmission at a time.
Men are becoming infected because they don't know enough about safe sex and they don't have a high level of sexual health. Women are becoming infected because they have, in general, even poorer levels of health and education than men. There are employment, infrastructure, legal, lifestyle, tribal and many other reasons why men and women continue to be infected with HIV.
All of the factors in HIV transmission need to be addressed, not just the one or two factors that seem most attractive at a given time. Why MMC seems so appealing is really not that clear but ask yourself this question: would you go to a clinic to be circumcised if you knew that 1 in 5 operations resulted in some kind of adverse effect? Would you allow a clinic to circumcise your children?
Who in their right mind would advocate a programme of MMC in a country where tens of thousands of women die giving birth or shortly after giving birth, where tens of thousands of children die of diarrhoea, acute respiratory conditions, malnutrition or other easily curable or treatable diseases or where a substantial number of people will never have access to a qualified doctor in their whole life?
Kenya needs good health services, education and other social services. I know I keep beating on about it but these other political footballs are just distractions. I guess they are supposed to distract but we shouldn't forget the problems that Kenyan people face: they relate to day to day issues, such as food shortages and high food prices, unaffordable health care, appalling educational facilities and standards, political unrest, corruption and many other things.
Tackle the issues that face people on a daily basis and the problem of reducing HIV transmission will be a whole lot easier, whatever measures are deemed most appropriate in the end.
The Integrated Regional Information Networks (IRIN) has a recent article on the subject and lists the countries that have made some progress towards rolling out MMC. I notice Kenya is not on the list and not much progress seems to have been made in the eight countries in the list. Most sub Saharan African countries suffer from a lack of capacity and this seems unlikely to change in the near future.
On the one hand, a country could approach HIV as if it was just one disease of many and build up their overall health services. But most donor funding goes towards a handful of diseases, the main one being HIV. Very little funding, if any, goes towards building up health services in general.
Alternatively, countries could extend the capacity of existing health services to accommodate some kind of MMC programme. The latter approach might be like the attempt to test people for HIV (in the form of voluntary counselling and testing clinics) and the attempt to distribute treatment to as many infected people as possible. But after many years and extraordinary amounts of money being spent on these areas, these efforts have had limited success.
It’s important to note also that there are still many questions about the benefits of MMC and precious little discussion about the downsides. This is worrying and gives the impression that MMC is being promoted without taking into account the welfare of the people who will be involved. Of course, that wouldn't make MMC much different from development projects in general.
But the aim of MMC, ostensibly, is to reduce HIV transmission. It is believed that circumcised men are far less likely to become infected with HIV than uncircumcised men. The level of protection offered by circumcision is a matter of debate. I hope the debate is comprehensive and well informed because any measure that could reduce HIV transmission should be welcomed.
That is, any measure that has substantial benefits and few, if any, adverse effects. And circumcision may have quite a number of adverse effects. Rather than rehearsing the possible adverse effects here, I recommend the Male Circumcision and HIV website.
But my objection to MMC is slightly different. Given that I would argue that if Kenya had good health, education and other social services in the first place, HIV would never have spread as it did and would be easier to fight now. Therefore I see little point in piecemeal programmes that address one small factor in HIV transmission at a time.
Men are becoming infected because they don't know enough about safe sex and they don't have a high level of sexual health. Women are becoming infected because they have, in general, even poorer levels of health and education than men. There are employment, infrastructure, legal, lifestyle, tribal and many other reasons why men and women continue to be infected with HIV.
All of the factors in HIV transmission need to be addressed, not just the one or two factors that seem most attractive at a given time. Why MMC seems so appealing is really not that clear but ask yourself this question: would you go to a clinic to be circumcised if you knew that 1 in 5 operations resulted in some kind of adverse effect? Would you allow a clinic to circumcise your children?
Who in their right mind would advocate a programme of MMC in a country where tens of thousands of women die giving birth or shortly after giving birth, where tens of thousands of children die of diarrhoea, acute respiratory conditions, malnutrition or other easily curable or treatable diseases or where a substantial number of people will never have access to a qualified doctor in their whole life?
Kenya needs good health services, education and other social services. I know I keep beating on about it but these other political footballs are just distractions. I guess they are supposed to distract but we shouldn't forget the problems that Kenyan people face: they relate to day to day issues, such as food shortages and high food prices, unaffordable health care, appalling educational facilities and standards, political unrest, corruption and many other things.
Tackle the issues that face people on a daily basis and the problem of reducing HIV transmission will be a whole lot easier, whatever measures are deemed most appropriate in the end.
Wednesday, June 24, 2009
Treatment As Prevention
An interesting discussion arose in Switzerland some months back. HIV positive people who are responding to antiretroviral therapy (ART) usually have an undetectable viral load. As a result, they are not very infectious. So discordant couples, where only one partner is HIV positive, are advised that they can enjoy a normal sex life, virtually as if neither was HIV positive.
It’s important to note that, even in countries like Switzerland, not everyone responds to ART to the extent that they have an undetectable viral load. And things can change. They need careful monitoring and advice. So this is great news for people living in countries where they get very good medical care, have good levels of nutrition, have enough money to pay for any kind of treatment and care and even have an adequate level of education to understand and discuss the implications of being in a HIV discordant relationship.
But most people don't live in rich, developed, Western countries. They are lucky to find out that they are HIV positive early enough for ART to work as well as it does in developed countries. They usually don't have access to good medical care, don't have adequate nutrition for any health status and can't afford any treatment or care, aside from the pills paid for by donor aid. And they are unlikely to have a standard of education that would allow them to follow the complex debates about sexual behaviour and lifestyle choices for HIV discordant couples and the like.
Who knows what percentage of HIV positive people on ART in developing countries are responding well and have an undetectable viral load. In most cases, nobody is checking. Things can change rapidly, like during the post election violence last year, when many people on ART were unable to get their drugs. There are stock outs, such as that experienced in Uganda on several occasions. And there is the current financial crisis, which has resulted in several countries finding that they are unable to guarantee supplies of drugs and related services, even to the minority currently on ART.
But in reality, for developing countries, the most worrying thing about the so called 'treatment as prevention' debate is that treatment is not prevention. The more people on treatment, the better, there's no doubt about that. But as more and more people are starting ART, there are still tens of thousands of people becoming infected with HIV in Kenya every year.
Treatment should support Kenya's prevention campaign but it should never become that campaign. At present, over 75% of the tens of millions of dollars being spent on HIV goes to treatment and care. 'Treatment and care', in this instance, mainly refers to drugs. Many areas of health are relevant to HIV treatment and care but once the grossly over priced pills have been paid for, there is not much left for anything else. That's why only about of third of the people who need ART at present are receiving it.
Nowhere near enough money is being spent on prevention and there is even a danger that the 'treatment as prevention' slogan could end up further skewing the way HIV funds are spent. People are being infected every day and they need education, health services, infrastructure, jobs, legal rights, equality and things like that. This is not just to do with HIV alone, it's also to do with ensuring people's human rights so they can enjoy a decent quality of life.
For too long, the development agenda has been determined by rich multinationals, such as pharmaceutical companies and the health care industry. Development has always been seen as a huge market for overpriced goods, which is why so much money goes 'into' developing countries without seeming to have much effect. It goes into the pockets of rich industrialists.
HIV treatment is vital, both for people who are already infected, those who are indirectly affected and those who are, as yet, uninfected and unaffected (if there are any of these). But prevention is also vital. And for treatment, care and prevention programmes to work properly, people need schools, teachers, hospitals, health professionals, legal protection, equality, employment and many other things.
The developing world is not populated with billions of customers; it is home to billions of extremely poor and vulnerable people. HIV needs to be prevented, not just treated.
It’s important to note that, even in countries like Switzerland, not everyone responds to ART to the extent that they have an undetectable viral load. And things can change. They need careful monitoring and advice. So this is great news for people living in countries where they get very good medical care, have good levels of nutrition, have enough money to pay for any kind of treatment and care and even have an adequate level of education to understand and discuss the implications of being in a HIV discordant relationship.
But most people don't live in rich, developed, Western countries. They are lucky to find out that they are HIV positive early enough for ART to work as well as it does in developed countries. They usually don't have access to good medical care, don't have adequate nutrition for any health status and can't afford any treatment or care, aside from the pills paid for by donor aid. And they are unlikely to have a standard of education that would allow them to follow the complex debates about sexual behaviour and lifestyle choices for HIV discordant couples and the like.
Who knows what percentage of HIV positive people on ART in developing countries are responding well and have an undetectable viral load. In most cases, nobody is checking. Things can change rapidly, like during the post election violence last year, when many people on ART were unable to get their drugs. There are stock outs, such as that experienced in Uganda on several occasions. And there is the current financial crisis, which has resulted in several countries finding that they are unable to guarantee supplies of drugs and related services, even to the minority currently on ART.
But in reality, for developing countries, the most worrying thing about the so called 'treatment as prevention' debate is that treatment is not prevention. The more people on treatment, the better, there's no doubt about that. But as more and more people are starting ART, there are still tens of thousands of people becoming infected with HIV in Kenya every year.
Treatment should support Kenya's prevention campaign but it should never become that campaign. At present, over 75% of the tens of millions of dollars being spent on HIV goes to treatment and care. 'Treatment and care', in this instance, mainly refers to drugs. Many areas of health are relevant to HIV treatment and care but once the grossly over priced pills have been paid for, there is not much left for anything else. That's why only about of third of the people who need ART at present are receiving it.
Nowhere near enough money is being spent on prevention and there is even a danger that the 'treatment as prevention' slogan could end up further skewing the way HIV funds are spent. People are being infected every day and they need education, health services, infrastructure, jobs, legal rights, equality and things like that. This is not just to do with HIV alone, it's also to do with ensuring people's human rights so they can enjoy a decent quality of life.
For too long, the development agenda has been determined by rich multinationals, such as pharmaceutical companies and the health care industry. Development has always been seen as a huge market for overpriced goods, which is why so much money goes 'into' developing countries without seeming to have much effect. It goes into the pockets of rich industrialists.
HIV treatment is vital, both for people who are already infected, those who are indirectly affected and those who are, as yet, uninfected and unaffected (if there are any of these). But prevention is also vital. And for treatment, care and prevention programmes to work properly, people need schools, teachers, hospitals, health professionals, legal protection, equality, employment and many other things.
The developing world is not populated with billions of customers; it is home to billions of extremely poor and vulnerable people. HIV needs to be prevented, not just treated.
Saturday, April 11, 2009
Prediction Versus Observation
Nobody could have predicted the development and spread of HIV/AIDS in the decades leading up to the 1980s, when the disease was identified. Why would I (or anyone) say something that seems so mind-numbingly obvious? Well, predictions relate to the future, they don't relate to the present or the past. Ok, that's pretty obvious as well.
But try this: in Kenya and other African countries, it was mind-numbingly obvious in the 1980s that, if any epidemic, natural disaster, economic crisis or other highly threatening event were to occur, many people would be adversely affected. Despite post independence improvements and optimism, the majority of people were poor and vulnerable, they had limited access to health, education and other social services. Things were improving, but not fast enough.
There were economic crises, there were oil crises, there were crop failures and famines, there were high rates of disease of various kinds and, inevitably, many people suffered and died prematurely. In the 1980s, it was obvious that most people in Kenya were highly vulnerable as a result of earlier events and also because of rising poverty and disease and decreasing levels of coverage of services that would reduce exposure and mitigate the effects of exposure to disease and other processes.
In the 1980s, there was a clear need for development to reduce the spread of disease, to reduce rising levels of malnutrition and food insecurity, to increase levels of education, to develop infrastructure, especially water and sanitation. Countries like Kenya had a lot of developing to do. The country lacked resilience and would continue to suffer badly every time disaster struck.
The economic fundamentalism of wealthy countries in the 1980s, which continued into the 90s and beyond, dictated that what developing countries needed was, exclusively, economic development. Maybe at the time it seemed like a good bet, that if the economy was ok, everything else would be ok. Perhaps it wasn't clear that most people would remain poor and vulnerable, even when the economy was doing well (whatever 'doing well' happens to mean). If it wasn't immediately clear, it became clear; economies, even in poor countries, waxed and waned. But disasters, diseases, poverty, starvation, etc, and their devastating effects, continued.
But in what way were economies improving? An article I came across recently points out that African economies grew by 1.8% in the 80s and 2% in the 90s and never kept up with population growth. The goal to halve absolute poverty by 2015 is predicated on the achievement of 7% economic growth. At the same time, the percentage of people living below the poverty line increased from 42.6% in the 80s to 44.1% in the 90s and 45.7% in 2003.
Over the decades following the identification of HIV/AIDS, researchers continue to make clear that HIV is transmitted as a result of many factors. These factors relate to the economy, the environment, infrastructure, labour, legal issues, equality, especially gender equality, human behaviour, especially, sexual behaviour and many others. Additional factors and their respective significances are being discovered all the time. Those involved in work to reduce the transmission of HIV and to mitigate its effects cannot be faulted for not knowing about things that have yet to be discovered.
But rather than approach HIV as the multifaceted threat that it is, most approaches to HIV ignore the broader picture of extreme underdevelopment in which HIV transmission needs to be viewed. Most approaches treat HIV as a disease that is spread by sexual intercourse and a disease that can be fought by influencing people's sexual behaviour. There are exceptions, of course, but most of the big HIV money goes into these approaches.
It’s true, HIV is mostly spread by sexual intercourse in developing countries like Kenya and it is vital to understand sexual behaviour and to influence it to the extent that people's levels of exposure and vulnerability can be reduced. But levels of exposure and vulnerability increase during times of economic and social stress. There is an increasing number of poor and unemployed people in Kenya right now. There have been high levels of civil disturbance for some time and there may be more to come. The poor working practices found in Export Processing Zones (EPZ, a polite term for sweat shops), mines, sugar, tea and flower plantations, continue. These, and other conditions, need to be addressed as a matter of urgency.
It has proved very hard to influence people's sexual behaviour and that will probably always be the case, the dangers of sexually transmitted infections (STI) notwithstanding. But services to screen and treat people for common STIs should already be an integral part of Kenya's health services. Children and adults can receive sex education and can be given access to family planning advice and services. These benefits already relate to human rights to which people were entitled long before HIV became an issue. HIV wasn't predictable but high levels of poor health and low levels of education have long been obvious. The fact that people were vulnerable to anything that struck has long been obvious.
In addition, the success of HIV interventions, whether they relate to health, education or anything else, depends on the levels of health, education and other social services in a country. It has never been a secret that, without these services, interventions would have little impact and mitigation of the effects of disease (or any other threat) would be difficult.
The virus may be an 'act of god' but levels of vulnerability are due to decades of underdevelopment and decades of impoverishment of developing countries by developed countries. There were good times in wealthy countries but most people in developing countries never experienced any good times. Now that times are bad again in wealthy countries, no doubt, developing countries will suffer even more.
It's not as if developing countries could never have done anything to help. Oxfam have estimated that the financial bailout package currently in operation represents $1250 for every person on the planet. The same amount of money could lift 1.4 billion of the world's poorest people out of poverty for fifty years. This package is unprecedented, but large financial packages have been made available in the past for wars, following wars and for really important things like the race to the moon.
But I don’t see the global financial industry sacrificing a handful of failed financial institutions for the benefit of a few billion people. As for whether it will work, the bailout package is probably as effective as eating beetroot to protect against HIV.
There is little point in approaching HIV as it were the first infectious disease in the history of medicine to be entirely independent of people’s living conditions. The areas of underdevelopment that were involved in the spread of HIV have been more or less ignored since HIV has been identified. Yet, any measure to reduce transmission of HIV requires those areas of underdevelopment, all of them, to be addressed. Once they have been addressed, HIV transmission will reduce and efforts to reduce transmission further and mitigate the impacts of HIV have a greater probability of success.
There are serious HIV epidemics in many developing countries because they are underdeveloped; the people are vulnerable. As long as they stay underdeveloped, people will continue to be vulnerable and the HIV epidemics will remain. Future predictions are tenuous and difficult but we should all be perfectly capable of making observations about the present and the past.
But try this: in Kenya and other African countries, it was mind-numbingly obvious in the 1980s that, if any epidemic, natural disaster, economic crisis or other highly threatening event were to occur, many people would be adversely affected. Despite post independence improvements and optimism, the majority of people were poor and vulnerable, they had limited access to health, education and other social services. Things were improving, but not fast enough.
There were economic crises, there were oil crises, there were crop failures and famines, there were high rates of disease of various kinds and, inevitably, many people suffered and died prematurely. In the 1980s, it was obvious that most people in Kenya were highly vulnerable as a result of earlier events and also because of rising poverty and disease and decreasing levels of coverage of services that would reduce exposure and mitigate the effects of exposure to disease and other processes.
In the 1980s, there was a clear need for development to reduce the spread of disease, to reduce rising levels of malnutrition and food insecurity, to increase levels of education, to develop infrastructure, especially water and sanitation. Countries like Kenya had a lot of developing to do. The country lacked resilience and would continue to suffer badly every time disaster struck.
The economic fundamentalism of wealthy countries in the 1980s, which continued into the 90s and beyond, dictated that what developing countries needed was, exclusively, economic development. Maybe at the time it seemed like a good bet, that if the economy was ok, everything else would be ok. Perhaps it wasn't clear that most people would remain poor and vulnerable, even when the economy was doing well (whatever 'doing well' happens to mean). If it wasn't immediately clear, it became clear; economies, even in poor countries, waxed and waned. But disasters, diseases, poverty, starvation, etc, and their devastating effects, continued.
But in what way were economies improving? An article I came across recently points out that African economies grew by 1.8% in the 80s and 2% in the 90s and never kept up with population growth. The goal to halve absolute poverty by 2015 is predicated on the achievement of 7% economic growth. At the same time, the percentage of people living below the poverty line increased from 42.6% in the 80s to 44.1% in the 90s and 45.7% in 2003.
Over the decades following the identification of HIV/AIDS, researchers continue to make clear that HIV is transmitted as a result of many factors. These factors relate to the economy, the environment, infrastructure, labour, legal issues, equality, especially gender equality, human behaviour, especially, sexual behaviour and many others. Additional factors and their respective significances are being discovered all the time. Those involved in work to reduce the transmission of HIV and to mitigate its effects cannot be faulted for not knowing about things that have yet to be discovered.
But rather than approach HIV as the multifaceted threat that it is, most approaches to HIV ignore the broader picture of extreme underdevelopment in which HIV transmission needs to be viewed. Most approaches treat HIV as a disease that is spread by sexual intercourse and a disease that can be fought by influencing people's sexual behaviour. There are exceptions, of course, but most of the big HIV money goes into these approaches.
It’s true, HIV is mostly spread by sexual intercourse in developing countries like Kenya and it is vital to understand sexual behaviour and to influence it to the extent that people's levels of exposure and vulnerability can be reduced. But levels of exposure and vulnerability increase during times of economic and social stress. There is an increasing number of poor and unemployed people in Kenya right now. There have been high levels of civil disturbance for some time and there may be more to come. The poor working practices found in Export Processing Zones (EPZ, a polite term for sweat shops), mines, sugar, tea and flower plantations, continue. These, and other conditions, need to be addressed as a matter of urgency.
It has proved very hard to influence people's sexual behaviour and that will probably always be the case, the dangers of sexually transmitted infections (STI) notwithstanding. But services to screen and treat people for common STIs should already be an integral part of Kenya's health services. Children and adults can receive sex education and can be given access to family planning advice and services. These benefits already relate to human rights to which people were entitled long before HIV became an issue. HIV wasn't predictable but high levels of poor health and low levels of education have long been obvious. The fact that people were vulnerable to anything that struck has long been obvious.
In addition, the success of HIV interventions, whether they relate to health, education or anything else, depends on the levels of health, education and other social services in a country. It has never been a secret that, without these services, interventions would have little impact and mitigation of the effects of disease (or any other threat) would be difficult.
The virus may be an 'act of god' but levels of vulnerability are due to decades of underdevelopment and decades of impoverishment of developing countries by developed countries. There were good times in wealthy countries but most people in developing countries never experienced any good times. Now that times are bad again in wealthy countries, no doubt, developing countries will suffer even more.
It's not as if developing countries could never have done anything to help. Oxfam have estimated that the financial bailout package currently in operation represents $1250 for every person on the planet. The same amount of money could lift 1.4 billion of the world's poorest people out of poverty for fifty years. This package is unprecedented, but large financial packages have been made available in the past for wars, following wars and for really important things like the race to the moon.
But I don’t see the global financial industry sacrificing a handful of failed financial institutions for the benefit of a few billion people. As for whether it will work, the bailout package is probably as effective as eating beetroot to protect against HIV.
There is little point in approaching HIV as it were the first infectious disease in the history of medicine to be entirely independent of people’s living conditions. The areas of underdevelopment that were involved in the spread of HIV have been more or less ignored since HIV has been identified. Yet, any measure to reduce transmission of HIV requires those areas of underdevelopment, all of them, to be addressed. Once they have been addressed, HIV transmission will reduce and efforts to reduce transmission further and mitigate the impacts of HIV have a greater probability of success.
There are serious HIV epidemics in many developing countries because they are underdeveloped; the people are vulnerable. As long as they stay underdeveloped, people will continue to be vulnerable and the HIV epidemics will remain. Future predictions are tenuous and difficult but we should all be perfectly capable of making observations about the present and the past.
Sunday, November 30, 2008
Kicora; Kigoma College by Radio
Ok, I've already posted today but I have time and I don't want a backlog later.
My Master's degree was in Education and International Development, but I don't limit my interests to narrow concerns. After all, education has a big part to play in reducing the spread of HIV. It also has a part to play in poverty reduction, agriculture and environment, health, business and the economy and whatever else you can think of.
Here in East Africa I have had the opportunity to visit a number of schools and educational projects and I will mention some of them by and by. But one of the most outstanding is called Kicora; Kigoma College by Radio. Kicora do distance learning by radio, although they have an education centre as well. They are based in Kigoma, Western Tanzania. This blog may be called 'HIV in Kenya' but I am not going to limit it to just one country or one disease!
At present, Kicora's broadcasts are limited to the immediate town but there are plans to build an antenna on a nearby hill, so the coverage will soon be much greater. As well as the two official languages of English and Kiswahili, there will also be courses using French as the language of instruction. The founder of the school, Dr Deo Baribwegure, is Burundian and several neighbouring countries are francophone, DRC, Rwanda and Burundi.
This distance education college is for people from the age of 14 upwards. Kigoma (some more photos) is a very isolated area. It has a population of about 2,000,000 people. However, it is not well served by infrastructure, communications, health or educational services.
Kigoma is host to many refugees from surrounding countries and some of Kicora’s aims are to strengthen civil society, democracy and sustainable development through education. The Kicora board is diverse, having members from both the Muslim and Christian communities. Another of the school’s stated aims is to reduce gender inequalities and thus influence the reproductive health of the community.
The 300 students presently at Kicora study for the national exams in mathematics, biology, physics, chemistry, geography, history, civics, Kiswahili and English.
Radio Mahoro is a local radio station, part of the Kicora project. Radio Mahoro concerns itself with issues such as environmental degradation, deforestation, poaching, responsible garbage disposal, overuse of non-renewable energy, over fishing and bush fire prevention. Radio Nuru also promotes local music, arts and culture and gives information about medicine, traditional medicine, HIV and safer sexual behaviour.
As a result of their work to date, Kicora have been awarded the Civil Society prize for their contribution to initiatives by Africans in Africa. The award was presented by the Belgian Government and the European Union in November of this year.
There are many similarities between Kenya and neighbouring countries. After all, someone thought it a good idea to draw some straight lines through anything and everything when carving up Africa. There are also significant differences. I am particularly interested in what Kenya and other African countries have in common and in their differences.
For example, Kenya, Tanzania and Uganda have reasonably similar HIV prevalence figures; 7.8%, 6.2% and 5.4% respectively in 2007. But the history of the spread of HIV in each country is quite different. It started and peaked much earlier in Uganda, peaking in the early 1990s at 13.8% and is now lower than prevalence in Kenya. It is currently flatlining but there is a possibility that it will start to increase again.
Tanzania's HIV prevalence, like Kenya's, peaked in the late 1990s but at a lower rate, 7.5%. Since then it has only declined a little. New infections are now most common in more isolated areas, further away from roads, schools, medical services and just about everything else.
Similarly, in Kenya, rural transmission of HIV affects far more people than urban transmission. A lot more work has been done on reducing HIV in urban epidemics, some of it, apparently, successful. And this is the problem outlined this week in Western Kenya. Testing centres and other facilities are almost always concentrated around towns and cities.
Therefore, education by radio has a lot to offer the fight against HIV. Radio can be used to reinforce messages about safe sex, the importance of testing, sex education, reproductive health and lots more. Indeed, radio can be used for all sorts of education and information content.
Now, this, for me, is the most important thing about HIV: it is NOT the biggest problem faced by Kenya or other developing countries. It is serious, but there is only a severe HIV problem because many other things are lacking and have been for many decades.
I can start the list of problems, but I can't finish it now (and probably never will):
1) Widespread gender inequality, especially for the most vulnerable females
2) Poor and declining health services, widespread disease, little access to facilities
3) Poor and declining education, low levels of school admission and attendance in many areas
4) Severely damaged environment with imminent threats from international crises
5) Fragile economy, widespread poverty, also threatened by international crises
6) Rudimentary infrastructure, particularly water and sanitation
7) Dependence on small number of raw materials with little manufacturing. Much production controlled by foreign interests
8) Low employment levels, many working in informal sector, little secure employment, loose labour laws, usually flouted by foreign employers
HIV is only a symptom of these and other problems. The HIV epidemic in Kenya will not decline significantly until these issues are also addressed. These issues were involved in the initial spread of HIV but now that the epidemic is widespread, it will not just disappear.
Distance education by radio could play a part in addressing all of the above issues. Community based organisations like SAIPE could do even more if they had access to facilities like Kicora's. Mumias is not as isolated as Kigoma, but it is not as big either. And neither of these towns are as isolated as the majority of people living in both countries.
HIV is just one issue and education is just one way of reducing the spread of HIV and other diseases. Others will be discussed over the coming months.
My Master's degree was in Education and International Development, but I don't limit my interests to narrow concerns. After all, education has a big part to play in reducing the spread of HIV. It also has a part to play in poverty reduction, agriculture and environment, health, business and the economy and whatever else you can think of.
Here in East Africa I have had the opportunity to visit a number of schools and educational projects and I will mention some of them by and by. But one of the most outstanding is called Kicora; Kigoma College by Radio. Kicora do distance learning by radio, although they have an education centre as well. They are based in Kigoma, Western Tanzania. This blog may be called 'HIV in Kenya' but I am not going to limit it to just one country or one disease!
At present, Kicora's broadcasts are limited to the immediate town but there are plans to build an antenna on a nearby hill, so the coverage will soon be much greater. As well as the two official languages of English and Kiswahili, there will also be courses using French as the language of instruction. The founder of the school, Dr Deo Baribwegure, is Burundian and several neighbouring countries are francophone, DRC, Rwanda and Burundi.
This distance education college is for people from the age of 14 upwards. Kigoma (some more photos) is a very isolated area. It has a population of about 2,000,000 people. However, it is not well served by infrastructure, communications, health or educational services.
Kigoma is host to many refugees from surrounding countries and some of Kicora’s aims are to strengthen civil society, democracy and sustainable development through education. The Kicora board is diverse, having members from both the Muslim and Christian communities. Another of the school’s stated aims is to reduce gender inequalities and thus influence the reproductive health of the community.
The 300 students presently at Kicora study for the national exams in mathematics, biology, physics, chemistry, geography, history, civics, Kiswahili and English.
Radio Mahoro is a local radio station, part of the Kicora project. Radio Mahoro concerns itself with issues such as environmental degradation, deforestation, poaching, responsible garbage disposal, overuse of non-renewable energy, over fishing and bush fire prevention. Radio Nuru also promotes local music, arts and culture and gives information about medicine, traditional medicine, HIV and safer sexual behaviour.
As a result of their work to date, Kicora have been awarded the Civil Society prize for their contribution to initiatives by Africans in Africa. The award was presented by the Belgian Government and the European Union in November of this year.
There are many similarities between Kenya and neighbouring countries. After all, someone thought it a good idea to draw some straight lines through anything and everything when carving up Africa. There are also significant differences. I am particularly interested in what Kenya and other African countries have in common and in their differences.
For example, Kenya, Tanzania and Uganda have reasonably similar HIV prevalence figures; 7.8%, 6.2% and 5.4% respectively in 2007. But the history of the spread of HIV in each country is quite different. It started and peaked much earlier in Uganda, peaking in the early 1990s at 13.8% and is now lower than prevalence in Kenya. It is currently flatlining but there is a possibility that it will start to increase again.
Tanzania's HIV prevalence, like Kenya's, peaked in the late 1990s but at a lower rate, 7.5%. Since then it has only declined a little. New infections are now most common in more isolated areas, further away from roads, schools, medical services and just about everything else.
Similarly, in Kenya, rural transmission of HIV affects far more people than urban transmission. A lot more work has been done on reducing HIV in urban epidemics, some of it, apparently, successful. And this is the problem outlined this week in Western Kenya. Testing centres and other facilities are almost always concentrated around towns and cities.
Therefore, education by radio has a lot to offer the fight against HIV. Radio can be used to reinforce messages about safe sex, the importance of testing, sex education, reproductive health and lots more. Indeed, radio can be used for all sorts of education and information content.
Now, this, for me, is the most important thing about HIV: it is NOT the biggest problem faced by Kenya or other developing countries. It is serious, but there is only a severe HIV problem because many other things are lacking and have been for many decades.
I can start the list of problems, but I can't finish it now (and probably never will):
1) Widespread gender inequality, especially for the most vulnerable females
2) Poor and declining health services, widespread disease, little access to facilities
3) Poor and declining education, low levels of school admission and attendance in many areas
4) Severely damaged environment with imminent threats from international crises
5) Fragile economy, widespread poverty, also threatened by international crises
6) Rudimentary infrastructure, particularly water and sanitation
7) Dependence on small number of raw materials with little manufacturing. Much production controlled by foreign interests
8) Low employment levels, many working in informal sector, little secure employment, loose labour laws, usually flouted by foreign employers
HIV is only a symptom of these and other problems. The HIV epidemic in Kenya will not decline significantly until these issues are also addressed. These issues were involved in the initial spread of HIV but now that the epidemic is widespread, it will not just disappear.
Distance education by radio could play a part in addressing all of the above issues. Community based organisations like SAIPE could do even more if they had access to facilities like Kicora's. Mumias is not as isolated as Kigoma, but it is not as big either. And neither of these towns are as isolated as the majority of people living in both countries.
HIV is just one issue and education is just one way of reducing the spread of HIV and other diseases. Others will be discussed over the coming months.
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