At present, Tanzania is Africa's third largest producer of gold but may be set to become the largest. Gold mines towards the North of the country, formerly mined by Tanzanian artisanal miners, have for a long time been making a handful of foreign mining companies very rich. But recently, gold that is still being mined by Tanzanian artisanal miners in the South of the country has attracted the interest of a handful of foreign mining companies, who can expect this to make them very rich.
It's interesting how this is a 'discovery' because, as far as Tanzanian artisanal miners are concerned, they discovered the gold. It's their livelihood and not a very good one at that. But it's better than the nothing they will be left with once the big gold extractors move in. Typically, big gold miners employ a few thousand people, compared to the hundreds of thousands that will be displaced.
Time and time again, such gold 'discoveries' have been trumpeted as great news for Tanzania (or Kenya or Uganda or where ever). But Tanzanians should be well aware of how much they have profited from their vast mineral resources. Or rather, they should be aware that they have been systematically impoverished because of their vast mineral resources. Uganda has had a recent opportunity to find out how gold 'discoveries' affect ordinary people and even Kenya will have an opportunity soon, as gold has also been 'discovered' in the Kenyan Mara region.
The American company buying a large but very cheap interest in these recently 'discovered' gold deposits will be given all the usual benefits of non-existent oversight, few taxes, if any, minute royalty payments, most of which they will probably renege on, somehow, and the freedom to exploit Tanzania's rather loose employment and other human rights protections. In return, Tanzania will experience a large increase in unemployment and a loss of resources that will never be compensated for; Tanzania being, already, one of the poorest countries in the world.
Oddly enough, there is also a recent article about safety in small mines in Tanzania. This issue is not often reported on, although the issue of safety in large mines is even less reported on. Not because large mining interests have a great safety record, they just spend more on publicity. The secrecy that surrounds big mining in Tanzania and other developing countries doesn't come cheap. Only the employees do that. It's true that safety in smaller mines has been neglected by the government for a long time but that's no excuse for giving the Americans, the South Africans and the Canadians carte blanche to plunder the country's gold. I'm just assuming the appearance of these two articles at around the same time is not a coincidence.
To be fair, many mining employees earn better than average wages, though nothing to write home about. But this doesn't make up for the fact that for every one employed there could have been ten or twenty put out of a job. Nor does it excuse the mind boggling, tax free salaries that the non-Tanzanian employees get (which are usually kept secret). And it certainly doesn't make up for the fact that the country is highly dependent on foreign aid, not because it is poor, but because everything it has of value is stolen with the connivance of senior statespeople and businesspeople, Tanzanian and non-Tanzanian alike.
Critics of large scale theft of gold from developing countries recommend that donor countries, international institutions and the like champion the interests of countries such as Tanzania. Well, the World Bank, the International Monetary Fund (IMF), America, Britain, Canada and many others who could be championing the interests of development are too busy fighting for the other side. The lack of regulation in Tanzania and other developing countries mainly emanates from the so-called international institutions, whose focus always appears rather national.
And America, Britain and Canada may well be big donors. But the amount of money they give in aid donations is very small compared to the amount they pilfer. I don't think it's reasonable to expect thieves to just put their hands up, so it's up to the Tanzanian people, through their government, to fight this one out. It remains to be seen whether they will continue to hand over their future or whether they will demand a more equitable way of managing their resources. So far they have behaved like a person confronted by someone raping their wife and offering the rapist their mothers and children.
Showing posts with label international monetary fund. Show all posts
Showing posts with label international monetary fund. Show all posts
Tuesday, November 24, 2009
Monday, June 29, 2009
Basic Health Care is the Key; Well, One of Them
A recent article from Integrated Regional Information Networks (IRIN) argues that basic health care is vital to HIV treatment and care, as well as HIV prevention. While it is refreshing to hear expressions of this view from such an influential source, the article doesn't make any suggestions as to where money to build up basic health care in Kenya and other developing countries would come from. Most of the large sources of donor money (the President's Emergency Fund for Aids Relief (PEPFAR), the Global Fund, the Bill and Melinda Gates Foundation) are earmarked for HIV or one or two of a handful of other diseases. Even funding for so called 'neglected diseases' does not usually aim to build up basic health care. And non-transmissible diseases (for example nutritional deficiencies, various forms of cancer, type 2 diabetes, etc) receive hardly any funding at all, despite being responsible for a sizeable proportion of deaths in developing countries.
There are those who would defend these approaches to health and disease, often arguing that health care in general does benefit from programmes that address one disease or health area. But this is not good enough. There are too many diseases, transmissible and non-transmissible, that are being ignored. Health services are in a terrible state. The number of qualified health personnel is a disgrace to a country that is nowhere near the poorest in Sub-Saharan Africa. And the health infrastructure has been crumbling since the 1980s. Most health services are inaccessible to the majority of Kenyans and people will continue to die and suffer from easily curable and treatable conditions if this state of affairs doesn't change.
In addition to basic health care, many children still don't receive basic education, many don't receive enough basic education and most receive a poor standard of education. Levels of equality between males and females and between the haves and the have-nots are inexcusable and, in common with almost every country in the world, developing and developed, these are disimproving. And bad health is almost guaranteed in countries where there is little food security, very low levels of nutrition and low access to clean water and modern sanitation facilities.
The article in question refers to an ActionAid report which rightly points out that basic health care is the key to tackling HIV. But health on its own is not enough. The health of a country also depends on levels of education, social services, infrastructure, equality, opportunity and many other things. I hope this is a sign that a climate of more inclusive development programmes is on the horizon, but the global economy will not make this an easy job. continuing to involve NGOs and the private sector is all very well but most NGOs are focused on one or a relatively small group of issues. No NGO is big enough to be particularly inclusive. And the private sector are completely single minded. They will ship condoms to countries regardless of what happens to those condoms when they get there; they will ship pills to people who have no water or food. They want markets and little else.
I hope ActionAid is right but they may also like to lobby the World Bank and the International Monetary Fund while they are at it. These international financial institutions spent the last few decades persuading developing countries that the best way to develop was to reduce spending on health, education, social services and infrastructure, to limit the number of public sector personnel they employ (teachers, nurses, doctors, etc), cap spending on public sector wages and to introduce a whole host of 'austerity' measures. The institutions have continued to insist on the continuation of these measures and the introduction of even more of them, despite overwhelming evidence of the damage they were doing to people's lives. Ironically, these institutions are also big donors, so it's not as if they couldn't help out, if and when they eventually see the light.
Health and HIV don't exist in a vacuum and they are not short term emergencies. Unless developing countries are helped to develop and the many obstacles to their developing are removed, HIV treatment and eradication programmes have limited success.
There are those who would defend these approaches to health and disease, often arguing that health care in general does benefit from programmes that address one disease or health area. But this is not good enough. There are too many diseases, transmissible and non-transmissible, that are being ignored. Health services are in a terrible state. The number of qualified health personnel is a disgrace to a country that is nowhere near the poorest in Sub-Saharan Africa. And the health infrastructure has been crumbling since the 1980s. Most health services are inaccessible to the majority of Kenyans and people will continue to die and suffer from easily curable and treatable conditions if this state of affairs doesn't change.
In addition to basic health care, many children still don't receive basic education, many don't receive enough basic education and most receive a poor standard of education. Levels of equality between males and females and between the haves and the have-nots are inexcusable and, in common with almost every country in the world, developing and developed, these are disimproving. And bad health is almost guaranteed in countries where there is little food security, very low levels of nutrition and low access to clean water and modern sanitation facilities.
The article in question refers to an ActionAid report which rightly points out that basic health care is the key to tackling HIV. But health on its own is not enough. The health of a country also depends on levels of education, social services, infrastructure, equality, opportunity and many other things. I hope this is a sign that a climate of more inclusive development programmes is on the horizon, but the global economy will not make this an easy job. continuing to involve NGOs and the private sector is all very well but most NGOs are focused on one or a relatively small group of issues. No NGO is big enough to be particularly inclusive. And the private sector are completely single minded. They will ship condoms to countries regardless of what happens to those condoms when they get there; they will ship pills to people who have no water or food. They want markets and little else.
I hope ActionAid is right but they may also like to lobby the World Bank and the International Monetary Fund while they are at it. These international financial institutions spent the last few decades persuading developing countries that the best way to develop was to reduce spending on health, education, social services and infrastructure, to limit the number of public sector personnel they employ (teachers, nurses, doctors, etc), cap spending on public sector wages and to introduce a whole host of 'austerity' measures. The institutions have continued to insist on the continuation of these measures and the introduction of even more of them, despite overwhelming evidence of the damage they were doing to people's lives. Ironically, these institutions are also big donors, so it's not as if they couldn't help out, if and when they eventually see the light.
Health and HIV don't exist in a vacuum and they are not short term emergencies. Unless developing countries are helped to develop and the many obstacles to their developing are removed, HIV treatment and eradication programmes have limited success.
Monday, April 6, 2009
A Short History of HIV in Kenya
[UPDATE: August 10 2014 - I am completely revising this short history and posting the new version in parts, on this blog and on my other blogs, Blogtivist.and Don't Get Stuck With HIV - Part I Part II Part III Part IV]
In response to a recent blog post on the history of the HIV epidemic in South Africa, I would like to provide a brief history of the HIV epidemic in Kenya.
Kenya had a very different history from South Africa. In fact, the histories of most African countries may share similarities but are also subtly different. Therefore, each country is now experiencing very different HIV epidemics and need different sets of HIV prevention interventions.
Following independence in the early 60s, Kenya under Kenyatta saw many changes, some good and some bad. Spending on education, health, infrastructure and various social services increased. The country underwent a transformation and enjoyed a level of prosperity that was unmatched, before or since.
The early independence period was not perfect, of course. Some gained, some remained in the position they had always been in. In general, many people were employed and social and economic indicators showed improvement. But at the same time, those in the Kenyatta government had already started the process of enriching themselves from the public purse.
It is important to note an advantage that Kenya had over some other African countries. They opposed the soviet regime and were well rewarded for the part they played in the cold war. Kenya continues to support the current ‘war against terror’ and appears to be generally sympathetic to US aggression. It is probably not an accident, therefore, that they currently receive the tenth highest share of US aid money.
So, while health, education and other social infrastructures were being built up during the 70s, politics and governance were taking shape to eventually undermine many of the earlier gains. Kenyatta died and was replaced by Moi in 1978. (The current president, Mwai Kibaki, held senior cabinet posts in the Kenyatta and Moi regimes, so there is a high level of continuity between the early independence years and the present decade.)
HIV probably first reached Kenya in the late 1970s, coming from the Western Equatorial region via Uganda and perhaps via Tanzania. This was still some years before it would be identified, though some health professionals working in Kenya at the time retrospectively noted an unusual health situation characterised by acute versions of relatively common conditions.
1980: retrospective tests of blood samples from Nairobi commercial sex workers (CSW) show zero HIV prevalence (the percentage found to be HIV positive), but a sexually transmitted infection (STI) programme was established. So the virus may well have already been present in other areas because in 1981, retrospective tests show a prevalence of 4%. Around this time the US Center for Disease Control (CDC) noted a new disease that affected gay men.
Kenya had been receiving loans from the International Monetary Fund (IMF) and the World Bank for some years but it was in the 1980s that these institutions started to build conditionality into its loans. ‘Structural Adjustment Policies’ (SAP), which resulted in reduced spending on education, health, infrastructure and social services, had an enormous impact on the country. When HIV prevention efforts started, belatedly, they were seriously curtailed by these SAPs.
These SAPs continue to this day, sometimes under different names. This is despite clear evidence that their effects are almost entirely destructive. They play a major part in what can only be described as retrogressive development and the sooner they are reformed the better. As long as developing countries are compelled to reduce health, education and other services, they will be unable to develop or, therefore, to reduce the spread of HIV.
1982: AIDS is named and vertical (mother to child) and heterosexual transmission are recognised. The following year a virus is identified that is suspected of causing AIDS. It is later named HIV and World Health Organisation (WHO) HIV surveillance starts. In 1984 the first case of HIV in Kenya is identified and in the following year the National AIDS Committee is established.
For the whole of the 1980s and 1990s, even into the 2000s, Kenyan leaders persisted in denying the existence of HIV. There was plenty of evidence that HIV was a serious problem in Nairobi because prevalence among CSWs there peaked at 81%. Prevalence subsequently declined, despite the fact that HIV prevention efforts were not very widespread until many years later. In fact, it remains unclear why prevalence peaked so early among CSWs and then declined.
1987: the WHO formed the Global Programme on AIDS. The following year, Kenya’s Ministry of Health issues guidelines stating that patients should be told their HIV status. In 1989, President Moi is said to have ordered the quarantining of people with HIV/AIDS but the order was quietly ignored. By 1990, there were an estimated 7.5 million people living with HIV, globally.
Without the Kenyan government substantially moving from their position of denial, HIV incidence (the number of new infections per year) peaked at 2%. Prevalence in one province, Rift Valley, peaks at 14% in the same year. At this time, Moi publicly refused to admit that the HIV epidemic had become national in scope. Prevalence peaks in Western Province at 17% in 1994 and the government as a whole recognises HIV as a critical issue.
But in 1995, the Kenyan government still seems uninterested in the epidemic. Donor funds are not distributed or go missing and, although the countries blood stocks are found to be unsafe, the government denies that this poses a major problem. At this time 17.5 million people are living with AIDS, globally. Prevalence in Nairobi peaks at 17% and national prevalence is estimated at between 10 and 14%.
1996: Highly Active Anti-Retroviral Therapy is developed (HAART). In the same year, a Kenyan cardinal condemns the use of condoms to prevent HIV infection. The following year, HIV prevalence peaks. Early prevalence figures were subsequently revised and it is now thought that HIV prevalence peaked at 9 or 10% in the late 1990s.
1997: UNAIDS (Joint United Nations Programme on HIV/AIDS) is formed. The Kenyan Parliament approves a 15 year national AIDS policy and forms the National AIDS Council. Moi bows to election year pressure from religious leaders and shelves sex education plans.
1998: incidence is thought to have peaked globally at around 3.4%. A large number of Kenyan public sector employees die as a result of AIDS. The Great Lakes Initiative on AIDS (GLIA) is established. The following year, HIV in the last of Kenya’s provinces peaks; North Western Province peaks at a relatively low rate, 6%, although this and other figures are often questioned.
In the same year, Moi declares AIDS a national disaster but is still reluctant to do anything about it. He says he feels it would be improper to encourage the use of condoms in schools and colleges. However, the National AIDS Control Council was formed and is still in operation.
2000: an estimated 27.5 million people are living with AIDS, globally. Kenya develops a five year National AIDS Strategic Plan and plans AIDS education for all schools and colleges. The Millennium Development Goals (MDG) are adopted by the international community and reducing the spread and impact of HIV are include in this initiative.
2001: the Global Fund to Fight AIDS, TB and Malaria (Global Fund) is formed by the World Bank. Moi, in the run up to another election, publicly expresses reluctance to spend public money on condoms. He recommends abstinence as protection against AIDS. Christian and Muslim leaders join him in opposing condoms.
2002: the new president, Mwai Kibaki, declares ‘Total War on AIDS’. However, the following year, Global Fund grants are withheld because of corruption allegations. Widespread corruption, misuse and disappearance of funds are discovered and, unusually, some people are held accountable.
2003: Kenya’s prevalence is found to have dropped to 6.7% and the death rate peaks at 120,000 per year. These are highly significant milestones. As HIV incidence peaked in 1993 and declined thereafter, it would follow that prevalence would peak some years later, around the end of the 90s, say. A few years after that, it follows that many people would die of AIDS and prevalence would drop dramatically. The first wave of the HIV epidemic ended in the early 2000s.
2005: globally, 37 million people are living with HIV. AIDS deaths peak at around 2.2 million. Kenyan prevalence is said to stand at around 6.1%. A new five year strategic plan, due to run up to 2010, is published. The following year, Kenyan prevalence is said to have fallen again, to around 5.1%.
2007: global prevalence is revised downwards as a result of improved reporting methods. HIV figures are confusing, but data collected in Kenya suggest that prevalence had been rising since 2004 and had reached 7.8%. This is despite the previous assumption that prevalence had been falling continuously since the late 90s and had dropped to about 5.1%
The data published in 2008 show rising prevalence and my interpretation is that this may indicate a ‘new wave’ of the HIV epidemic. On the other hand, it may indicate no such thing. Estimations are very imprecise and predictions are dangerous. Some say HIV in Kenya is declining, some say otherwise. Personally, given the apparent connections between the spread of HIV and the country’s history, I would suggest that that Kenya is in a worse state now than it was in the 1980s and is therefore experiencing another serious HIV epidemic.
Holding a pessimistic position when everyone wants something to be optimistic about is hazardous; people want you to be wrong. But, as I have said elsewhere on this blog, I too would like to be wrong. I am not an epidemiologist, I could well be ignoring many factors and exaggerating the effects of others. No doubt it will be some years before the true picture is known. It is to be hoped, in the meantime, that some effort is made to improve health, education, social services and governance. These are in serious need of attention, regardless of what the HIV epidemic is doing at present.
In response to a recent blog post on the history of the HIV epidemic in South Africa, I would like to provide a brief history of the HIV epidemic in Kenya.
Kenya had a very different history from South Africa. In fact, the histories of most African countries may share similarities but are also subtly different. Therefore, each country is now experiencing very different HIV epidemics and need different sets of HIV prevention interventions.
Following independence in the early 60s, Kenya under Kenyatta saw many changes, some good and some bad. Spending on education, health, infrastructure and various social services increased. The country underwent a transformation and enjoyed a level of prosperity that was unmatched, before or since.
The early independence period was not perfect, of course. Some gained, some remained in the position they had always been in. In general, many people were employed and social and economic indicators showed improvement. But at the same time, those in the Kenyatta government had already started the process of enriching themselves from the public purse.
It is important to note an advantage that Kenya had over some other African countries. They opposed the soviet regime and were well rewarded for the part they played in the cold war. Kenya continues to support the current ‘war against terror’ and appears to be generally sympathetic to US aggression. It is probably not an accident, therefore, that they currently receive the tenth highest share of US aid money.
So, while health, education and other social infrastructures were being built up during the 70s, politics and governance were taking shape to eventually undermine many of the earlier gains. Kenyatta died and was replaced by Moi in 1978. (The current president, Mwai Kibaki, held senior cabinet posts in the Kenyatta and Moi regimes, so there is a high level of continuity between the early independence years and the present decade.)
HIV probably first reached Kenya in the late 1970s, coming from the Western Equatorial region via Uganda and perhaps via Tanzania. This was still some years before it would be identified, though some health professionals working in Kenya at the time retrospectively noted an unusual health situation characterised by acute versions of relatively common conditions.
1980: retrospective tests of blood samples from Nairobi commercial sex workers (CSW) show zero HIV prevalence (the percentage found to be HIV positive), but a sexually transmitted infection (STI) programme was established. So the virus may well have already been present in other areas because in 1981, retrospective tests show a prevalence of 4%. Around this time the US Center for Disease Control (CDC) noted a new disease that affected gay men.
Kenya had been receiving loans from the International Monetary Fund (IMF) and the World Bank for some years but it was in the 1980s that these institutions started to build conditionality into its loans. ‘Structural Adjustment Policies’ (SAP), which resulted in reduced spending on education, health, infrastructure and social services, had an enormous impact on the country. When HIV prevention efforts started, belatedly, they were seriously curtailed by these SAPs.
These SAPs continue to this day, sometimes under different names. This is despite clear evidence that their effects are almost entirely destructive. They play a major part in what can only be described as retrogressive development and the sooner they are reformed the better. As long as developing countries are compelled to reduce health, education and other services, they will be unable to develop or, therefore, to reduce the spread of HIV.
1982: AIDS is named and vertical (mother to child) and heterosexual transmission are recognised. The following year a virus is identified that is suspected of causing AIDS. It is later named HIV and World Health Organisation (WHO) HIV surveillance starts. In 1984 the first case of HIV in Kenya is identified and in the following year the National AIDS Committee is established.
For the whole of the 1980s and 1990s, even into the 2000s, Kenyan leaders persisted in denying the existence of HIV. There was plenty of evidence that HIV was a serious problem in Nairobi because prevalence among CSWs there peaked at 81%. Prevalence subsequently declined, despite the fact that HIV prevention efforts were not very widespread until many years later. In fact, it remains unclear why prevalence peaked so early among CSWs and then declined.
1987: the WHO formed the Global Programme on AIDS. The following year, Kenya’s Ministry of Health issues guidelines stating that patients should be told their HIV status. In 1989, President Moi is said to have ordered the quarantining of people with HIV/AIDS but the order was quietly ignored. By 1990, there were an estimated 7.5 million people living with HIV, globally.
Without the Kenyan government substantially moving from their position of denial, HIV incidence (the number of new infections per year) peaked at 2%. Prevalence in one province, Rift Valley, peaks at 14% in the same year. At this time, Moi publicly refused to admit that the HIV epidemic had become national in scope. Prevalence peaks in Western Province at 17% in 1994 and the government as a whole recognises HIV as a critical issue.
But in 1995, the Kenyan government still seems uninterested in the epidemic. Donor funds are not distributed or go missing and, although the countries blood stocks are found to be unsafe, the government denies that this poses a major problem. At this time 17.5 million people are living with AIDS, globally. Prevalence in Nairobi peaks at 17% and national prevalence is estimated at between 10 and 14%.
1996: Highly Active Anti-Retroviral Therapy is developed (HAART). In the same year, a Kenyan cardinal condemns the use of condoms to prevent HIV infection. The following year, HIV prevalence peaks. Early prevalence figures were subsequently revised and it is now thought that HIV prevalence peaked at 9 or 10% in the late 1990s.
1997: UNAIDS (Joint United Nations Programme on HIV/AIDS) is formed. The Kenyan Parliament approves a 15 year national AIDS policy and forms the National AIDS Council. Moi bows to election year pressure from religious leaders and shelves sex education plans.
1998: incidence is thought to have peaked globally at around 3.4%. A large number of Kenyan public sector employees die as a result of AIDS. The Great Lakes Initiative on AIDS (GLIA) is established. The following year, HIV in the last of Kenya’s provinces peaks; North Western Province peaks at a relatively low rate, 6%, although this and other figures are often questioned.
In the same year, Moi declares AIDS a national disaster but is still reluctant to do anything about it. He says he feels it would be improper to encourage the use of condoms in schools and colleges. However, the National AIDS Control Council was formed and is still in operation.
2000: an estimated 27.5 million people are living with AIDS, globally. Kenya develops a five year National AIDS Strategic Plan and plans AIDS education for all schools and colleges. The Millennium Development Goals (MDG) are adopted by the international community and reducing the spread and impact of HIV are include in this initiative.
2001: the Global Fund to Fight AIDS, TB and Malaria (Global Fund) is formed by the World Bank. Moi, in the run up to another election, publicly expresses reluctance to spend public money on condoms. He recommends abstinence as protection against AIDS. Christian and Muslim leaders join him in opposing condoms.
2002: the new president, Mwai Kibaki, declares ‘Total War on AIDS’. However, the following year, Global Fund grants are withheld because of corruption allegations. Widespread corruption, misuse and disappearance of funds are discovered and, unusually, some people are held accountable.
2003: Kenya’s prevalence is found to have dropped to 6.7% and the death rate peaks at 120,000 per year. These are highly significant milestones. As HIV incidence peaked in 1993 and declined thereafter, it would follow that prevalence would peak some years later, around the end of the 90s, say. A few years after that, it follows that many people would die of AIDS and prevalence would drop dramatically. The first wave of the HIV epidemic ended in the early 2000s.
2005: globally, 37 million people are living with HIV. AIDS deaths peak at around 2.2 million. Kenyan prevalence is said to stand at around 6.1%. A new five year strategic plan, due to run up to 2010, is published. The following year, Kenyan prevalence is said to have fallen again, to around 5.1%.
2007: global prevalence is revised downwards as a result of improved reporting methods. HIV figures are confusing, but data collected in Kenya suggest that prevalence had been rising since 2004 and had reached 7.8%. This is despite the previous assumption that prevalence had been falling continuously since the late 90s and had dropped to about 5.1%
The data published in 2008 show rising prevalence and my interpretation is that this may indicate a ‘new wave’ of the HIV epidemic. On the other hand, it may indicate no such thing. Estimations are very imprecise and predictions are dangerous. Some say HIV in Kenya is declining, some say otherwise. Personally, given the apparent connections between the spread of HIV and the country’s history, I would suggest that that Kenya is in a worse state now than it was in the 1980s and is therefore experiencing another serious HIV epidemic.
Holding a pessimistic position when everyone wants something to be optimistic about is hazardous; people want you to be wrong. But, as I have said elsewhere on this blog, I too would like to be wrong. I am not an epidemiologist, I could well be ignoring many factors and exaggerating the effects of others. No doubt it will be some years before the true picture is known. It is to be hoped, in the meantime, that some effort is made to improve health, education, social services and governance. These are in serious need of attention, regardless of what the HIV epidemic is doing at present.
Thursday, April 2, 2009
Is a Woman with Obstetric Fistula Worth Less than an Uncircumcised Man?
The debate about mass male circumcision (MMC) as a solution to the HIV epidemic rages on. The evidence that, in ideal conditions, male circumcision is protective against HIV, is convincing. On the surface, it seems crazy not to implement MMC in Kenya immediately. Many new infections could be prevented and even rates of transmission of other sexually transmitted infections (STI), such as herpes simplex virus, could be cut.
But Kenyans do not live in ideal conditions. If they did, the HIV epidemic there would not be as serious as it is now. The health infrastructure that would be required for MMC does not exist. After independence in the 60s, Kenya's health infrastructure improved. But from the early 80s, global and domestic crises halted this progress.
Then the World Bank and IMF (International Monetary Fund) introduced structural adjustment policies. Countries that got loans from these institutions had to reduce their social services, reduce their public sector employment, privatise as much as possible, remove 'barriers to trade', etc. This process of impoverishment, despite overwhelming evidence of the damage it causes, continues today.
Men in Kenya would be well advised to think twice about being circumcised. The level of adverse affects is 35% for traditional circumcisions, though these have long been known to be hazardous. But the level of adverse affects for clinically performed circumcisions is 18%. I wouldn't even have a tooth extracted in a health service like this. Kenyan health infrastructure is not up to an MMC campaign. It has been systematically run down for thirty years. It will take a long time to build up. Then an MMC campaign may be more feasible.
But there are still problems. Men (all over the world) don't like using condoms. I have met men who will use any excuse to avoid using them and they jump at any 'evidence' that they don't work, such as the maunderings of some Catholic with odd taste in headgear. There is even a myth that condoms don't work for circumcised men. So, if circumcised men use condoms, circumcision may have some effect on HIV and other STI transmission rates.
There is also a phenomenon referred to as 'disinhibition'. People who have been circumcised have been found to behave as if they are protected from HIV and can do without condoms. The same process is thought to occur among people who are on antiretroviral treatment (ART). There is a danger that people who feel disinhibited are likely to have unprotected sex and thus to undermine the effects of all this expensive prevention and treatment.
It is sometimes argued that circumcision is a small and routine operation. Well, in Western countries, maybe it is. But compare it to another small and routine operation, the operation to correct obstetric fistula (OF). Women who have difficulties in labour sometimes suffer from damage to their bladder or rectum. The result is that the baby usually dies and the mother suffers from chronic incontinence.
Lifelong, chronic incontinence is bad enough in itself, but in some societies, where there is no way to reduce the effects of this condition, the person suffering OF is shunned and stigmatised. They can spend their whole life with a preventable condition that could be reversed by a simple, routine operation. OF often occurs in younger girls and it occurs where births are not attended by trained midwives or otherwise qualified people. Lack of education, as well as poor healthcare, is an important factor in maternal health.
An estimated 3000 women suffer OF every year and most don't get treatment. There is currently a backlog of hundreds of thousands. OF is preventable but Kenyan reproductive and maternal healthcare is inadequate, it is unable to prevent this and other maternal health problems. The infant deaths just add to the huge infant mortality rate, which has been growing since the 1980s. Kenyan healthcare is also unable to provide the operation to reverse the damage and allow women to live a normal life.
If the health infrastructure is not up to preventing OF, it is not up to MMC and the follow up care that would be required. And if this simple, routine operation cannot be carried out for those who continue to suffer from OF, what are the chances that the hundreds of thousands of male children born every year can be safely circumcised and cared for? If there is money available for MMC, there must be money available for OF.
But the problem with MMC is that a simple, routine operation for millions of people requires complex health infrastructure. The basic infrastructure needs to be built first. Then, MMC has a chance of working. If the basic infrastructure is there, OF will not even occur or will be as rare as it is in developed countries.
The persistence of OF bears witness to the lack of health infrastructure in Kenya and clearly indicates that MMC or any other grand programme has little chance of success.
But Kenyans do not live in ideal conditions. If they did, the HIV epidemic there would not be as serious as it is now. The health infrastructure that would be required for MMC does not exist. After independence in the 60s, Kenya's health infrastructure improved. But from the early 80s, global and domestic crises halted this progress.
Then the World Bank and IMF (International Monetary Fund) introduced structural adjustment policies. Countries that got loans from these institutions had to reduce their social services, reduce their public sector employment, privatise as much as possible, remove 'barriers to trade', etc. This process of impoverishment, despite overwhelming evidence of the damage it causes, continues today.
Men in Kenya would be well advised to think twice about being circumcised. The level of adverse affects is 35% for traditional circumcisions, though these have long been known to be hazardous. But the level of adverse affects for clinically performed circumcisions is 18%. I wouldn't even have a tooth extracted in a health service like this. Kenyan health infrastructure is not up to an MMC campaign. It has been systematically run down for thirty years. It will take a long time to build up. Then an MMC campaign may be more feasible.
But there are still problems. Men (all over the world) don't like using condoms. I have met men who will use any excuse to avoid using them and they jump at any 'evidence' that they don't work, such as the maunderings of some Catholic with odd taste in headgear. There is even a myth that condoms don't work for circumcised men. So, if circumcised men use condoms, circumcision may have some effect on HIV and other STI transmission rates.
There is also a phenomenon referred to as 'disinhibition'. People who have been circumcised have been found to behave as if they are protected from HIV and can do without condoms. The same process is thought to occur among people who are on antiretroviral treatment (ART). There is a danger that people who feel disinhibited are likely to have unprotected sex and thus to undermine the effects of all this expensive prevention and treatment.
It is sometimes argued that circumcision is a small and routine operation. Well, in Western countries, maybe it is. But compare it to another small and routine operation, the operation to correct obstetric fistula (OF). Women who have difficulties in labour sometimes suffer from damage to their bladder or rectum. The result is that the baby usually dies and the mother suffers from chronic incontinence.
Lifelong, chronic incontinence is bad enough in itself, but in some societies, where there is no way to reduce the effects of this condition, the person suffering OF is shunned and stigmatised. They can spend their whole life with a preventable condition that could be reversed by a simple, routine operation. OF often occurs in younger girls and it occurs where births are not attended by trained midwives or otherwise qualified people. Lack of education, as well as poor healthcare, is an important factor in maternal health.
An estimated 3000 women suffer OF every year and most don't get treatment. There is currently a backlog of hundreds of thousands. OF is preventable but Kenyan reproductive and maternal healthcare is inadequate, it is unable to prevent this and other maternal health problems. The infant deaths just add to the huge infant mortality rate, which has been growing since the 1980s. Kenyan healthcare is also unable to provide the operation to reverse the damage and allow women to live a normal life.
If the health infrastructure is not up to preventing OF, it is not up to MMC and the follow up care that would be required. And if this simple, routine operation cannot be carried out for those who continue to suffer from OF, what are the chances that the hundreds of thousands of male children born every year can be safely circumcised and cared for? If there is money available for MMC, there must be money available for OF.
But the problem with MMC is that a simple, routine operation for millions of people requires complex health infrastructure. The basic infrastructure needs to be built first. Then, MMC has a chance of working. If the basic infrastructure is there, OF will not even occur or will be as rare as it is in developed countries.
The persistence of OF bears witness to the lack of health infrastructure in Kenya and clearly indicates that MMC or any other grand programme has little chance of success.
Monday, January 26, 2009
Expediters of Suffering
The International Monetary Fund (IMF) and the World Bank (WB) give loans to developing countries on condition that they introduce certain measures such as elimination of tariffs, subsidies, state intervention, regulation (that includes regulation to protect people against unscrupulous practices), public sector recruitment and many other things. Yet, many of the items that are advised against under WB and IMF Structural Adjustment Policies (SAPs) are widespread in Western countries. Not only did these countries depend on protecting their industries to become as rich as they are now, they still depend on protection today.
Take agricultural subsidies, for example. The European Community and the US insist on the need for everything being market driven, on the need to reduce protectionism. At the same time, they grow sugar that is uneconomical to grow, they produce more cereals and dairy products than they can use. The US is the biggest cotton producer in the world, not because labour is so cheap there or because they are so efficient but because cotton farmers receive such high subsidies. Then these rich countries dump their surplus produce on developing country markets, resulting in farmers in developing countries being unable to sell their products, often having to leave them in the field to rot.
Worse than that, much 'aid' money is spent on buying up surpluses in developed countries and distributing it in developing countries. This has the same effect as dumping surpluses but it has the advantage for developing countries that they can claim it is 'aid'. This trick is even seen as a way of palming off genetically modified (GM) food in the hope that people who are starving will not be in a position to refuse whatever they can get. And the chief beneficiaries of these subsidies in rich countries are big farmers. In developing countries, most agriculture is very small scale. Many small farmers who don't get some form of help go bankrupt and/or starve.
But some developing countries have challenged IMF and WB strictures on subsidies. Malawi, who introduced a subsidy programme in 2005, is a good example. They have realised that SAPs have made them poorer and more vulnerable, despite all the promises they were given by international agencies. Last year they trebled maize production by subsidising seed and fertilizer. Therefore, in the present season they will treble their agricultural subsidies because this policy has worked so well already. They are exporters of grain and have won praise for their success in reducing food insecurity. The IMF and the WB opposed an earlier version of these measures and advised the country to sell its national grain reserve, which it did!
This was followed by a famine that killed more than 1000 people. Donors, belatedly, supported the programme and subsequently, Zambia, Ghana, Senegal and Kenya announced plans for similar subsidies. How far they have got with the plans is still not clear. Mozambique has also decided to subsidise fertilizer for its farmers, a move opposed by the US. But Mozambique realises that, long term, they need to produce their own fertilizer. They also realise that they need to improve roads, something the IMF and the WB would, doubtless, disapprove of (unless foreign, private contractors were to be utilised).
This doesn't mean that Malawian agriculture is sustainable, of course. Malawi, like many other developing countries, is highly dependent on imported pesticides, fertilizers and other technologies. In the long run, it is to be hoped that they will be able to reduce their dependence and achieve better sustainability. More importantly, it is vital that they don't fall for the GM propaganda that claims it to be sustainable and productive. That will only increase their dependence and reverse whatever gains they have made.
But against all advice, especially international agency advice, Malawi went ahead with this programme. Will Kenya eventually do the same thing? They don't have the advantage of a president who is also a minister of agriculture. Worse than that, their president is an economist. So it seems unlikely that the present administration will go for subsidies. But even unlikely things sometimes happen. After all, the current president was re-elected against all odds, wasn't he?
Malawi has reduced their food budget by 120 million dollars and it has reduced their dependence on food aid. That must appeal to an economist, especially given the food insecurity and budgetary problems being faced by Kenya right now. But even if the government were willing to consider it, the IMF and WB would probably object. In fact, a cynic might suggest that these international financial institutions are not really interested in the good of ordinary people in developing countries. After all, in the 1970s Africa was a net food exporter, now it is highly dependent on imports and aid, at least in part as a result of their policies.
Before SAPs were concocted by IMF and WB economists some time in the late 70s or early 80s, Kenya was enjoying a period of relative prosperity. It wasn't to last long because those ruling the country were mainly interested in enriching themselves. (That makes them sound like the present rulers but, hey, most of this lot have been in senior positions since the early days of independence!) The international community went along with this because Kenya was being a good capitalist and opening up the country to foreign direct investment. In fact, the country was dominated by foreign capital, but this also suited the Kenyan elite very well.
Once Kenya accepted loans with SAPs, things changed. The foreign (and native) investors who were doing so well out of subsidised industry found that costs were getting high in Kenya and they left as quickly as they could. Unemployment increased as public sector employees were laid off and recruitment was cut. That's still going on, by the way, and if you think little of public sector employees, just think doctors, nurses, educators and other public service employees. There are good reasons why the roads are so bad in Kenya. There are good reasons why under five mortality, maternal mortality and many other health indicators have been slipping for most of the last three decades. (And from the point of view of this blog, there are good reasons why HIV was able to spread rapidly among people with so many increasing vulnerabilities, but I'll return to that another time.)
Many of the problems being reported in this week's newspapers stem from policies that were adopted nearly thirty years ago. These policies were honed and twisted to suit those who stood to gain most from them, the rich and powerful in Kenya and in other countries. The whole process couldn't have been carried out without much help from an array of international financial, political and other institutions. And while the policies may often be referred to as 'economic', or even 'ideological', they are more correctly political. They cannot be justified on economic grounds because they destroy economies. They cannot be justified on ideological grounds because they are applied inconsistently, where and when it suits.
These policies have long been backed up, and continue to be backed up by their advocates. This is so, regardless of any evidence that they are responsible for hunger, disease, suffering and death. And that's because they suit a particular political standpoint. They could be called 'pragmatic', but I prefer the term 'expedient'.
Take agricultural subsidies, for example. The European Community and the US insist on the need for everything being market driven, on the need to reduce protectionism. At the same time, they grow sugar that is uneconomical to grow, they produce more cereals and dairy products than they can use. The US is the biggest cotton producer in the world, not because labour is so cheap there or because they are so efficient but because cotton farmers receive such high subsidies. Then these rich countries dump their surplus produce on developing country markets, resulting in farmers in developing countries being unable to sell their products, often having to leave them in the field to rot.
Worse than that, much 'aid' money is spent on buying up surpluses in developed countries and distributing it in developing countries. This has the same effect as dumping surpluses but it has the advantage for developing countries that they can claim it is 'aid'. This trick is even seen as a way of palming off genetically modified (GM) food in the hope that people who are starving will not be in a position to refuse whatever they can get. And the chief beneficiaries of these subsidies in rich countries are big farmers. In developing countries, most agriculture is very small scale. Many small farmers who don't get some form of help go bankrupt and/or starve.
But some developing countries have challenged IMF and WB strictures on subsidies. Malawi, who introduced a subsidy programme in 2005, is a good example. They have realised that SAPs have made them poorer and more vulnerable, despite all the promises they were given by international agencies. Last year they trebled maize production by subsidising seed and fertilizer. Therefore, in the present season they will treble their agricultural subsidies because this policy has worked so well already. They are exporters of grain and have won praise for their success in reducing food insecurity. The IMF and the WB opposed an earlier version of these measures and advised the country to sell its national grain reserve, which it did!
This was followed by a famine that killed more than 1000 people. Donors, belatedly, supported the programme and subsequently, Zambia, Ghana, Senegal and Kenya announced plans for similar subsidies. How far they have got with the plans is still not clear. Mozambique has also decided to subsidise fertilizer for its farmers, a move opposed by the US. But Mozambique realises that, long term, they need to produce their own fertilizer. They also realise that they need to improve roads, something the IMF and the WB would, doubtless, disapprove of (unless foreign, private contractors were to be utilised).
This doesn't mean that Malawian agriculture is sustainable, of course. Malawi, like many other developing countries, is highly dependent on imported pesticides, fertilizers and other technologies. In the long run, it is to be hoped that they will be able to reduce their dependence and achieve better sustainability. More importantly, it is vital that they don't fall for the GM propaganda that claims it to be sustainable and productive. That will only increase their dependence and reverse whatever gains they have made.
But against all advice, especially international agency advice, Malawi went ahead with this programme. Will Kenya eventually do the same thing? They don't have the advantage of a president who is also a minister of agriculture. Worse than that, their president is an economist. So it seems unlikely that the present administration will go for subsidies. But even unlikely things sometimes happen. After all, the current president was re-elected against all odds, wasn't he?
Malawi has reduced their food budget by 120 million dollars and it has reduced their dependence on food aid. That must appeal to an economist, especially given the food insecurity and budgetary problems being faced by Kenya right now. But even if the government were willing to consider it, the IMF and WB would probably object. In fact, a cynic might suggest that these international financial institutions are not really interested in the good of ordinary people in developing countries. After all, in the 1970s Africa was a net food exporter, now it is highly dependent on imports and aid, at least in part as a result of their policies.
Before SAPs were concocted by IMF and WB economists some time in the late 70s or early 80s, Kenya was enjoying a period of relative prosperity. It wasn't to last long because those ruling the country were mainly interested in enriching themselves. (That makes them sound like the present rulers but, hey, most of this lot have been in senior positions since the early days of independence!) The international community went along with this because Kenya was being a good capitalist and opening up the country to foreign direct investment. In fact, the country was dominated by foreign capital, but this also suited the Kenyan elite very well.
Once Kenya accepted loans with SAPs, things changed. The foreign (and native) investors who were doing so well out of subsidised industry found that costs were getting high in Kenya and they left as quickly as they could. Unemployment increased as public sector employees were laid off and recruitment was cut. That's still going on, by the way, and if you think little of public sector employees, just think doctors, nurses, educators and other public service employees. There are good reasons why the roads are so bad in Kenya. There are good reasons why under five mortality, maternal mortality and many other health indicators have been slipping for most of the last three decades. (And from the point of view of this blog, there are good reasons why HIV was able to spread rapidly among people with so many increasing vulnerabilities, but I'll return to that another time.)
Many of the problems being reported in this week's newspapers stem from policies that were adopted nearly thirty years ago. These policies were honed and twisted to suit those who stood to gain most from them, the rich and powerful in Kenya and in other countries. The whole process couldn't have been carried out without much help from an array of international financial, political and other institutions. And while the policies may often be referred to as 'economic', or even 'ideological', they are more correctly political. They cannot be justified on economic grounds because they destroy economies. They cannot be justified on ideological grounds because they are applied inconsistently, where and when it suits.
These policies have long been backed up, and continue to be backed up by their advocates. This is so, regardless of any evidence that they are responsible for hunger, disease, suffering and death. And that's because they suit a particular political standpoint. They could be called 'pragmatic', but I prefer the term 'expedient'.
Wednesday, January 7, 2009
Development by Omission
In a previous posting on male circumcision, I suggested two possible ways of looking at this HIV prevention intervention. Of course, there are many other ways of looking at it! But first, it could be seen as a desperate attempt to throw huge amounts of money at an intervention that will only have limited benefits for a relatively small part of the population.
Or second, it could be seen as a good opportunity to strengthen the whole of Kenya's health sector in order to ensure maximum benefits and sustainability. If several million people are to be circumcised in clinical settings, over a lengthy period, a large number of health personnel will need to be trained, new clinics will have to be built, existing ones will have to be improved, the whole programme will need careful monitoring and evaluation.
Health capacity in Kenya is not very high at present. There are very few facilities per person and very few trained personnel. The figures are better for some provinces, such as Nairobi and Central, but still not encouraging. There have been small improvements in capacity but they don't usually keep pace with the growing population or increasing need.
A reflection of how poor health capacity is at the moment comes from Bungoma in Western province. There, circumcision is very widespread. Some of the operations take place in traditional settings, some in clinical settings. However, the rate of complications resulting from circumcision is very high in both settings, about 25%, overall. Unsurprisingly, the rate is higher in traditional settings, standing at 35%. But it is also worryingly high in clinical settings, standing at 18%.
The pro circumcision argument is generally, either tacitly or explicitly, for circumcision in clinical settings. A recent paper suggests that mass circumcision would involve high costs in the first five years but the savings and benefits would eventually outweigh the costs.
These findings apply to Nyanza province only, where male circumcision is the lowest in Kenya and HIV prevalence is highest. The model the authors use assumes circumcision rates are 10%, which is lower than other estimates I have seen. They also estimate HIV prevalence to be 24%, which is much higher than other estimates, especially for males, male rates being far lower than female rates in Kenya at present. But their results should still hold.
So if total health capacity in Kenya is going to be increased, this can only be a good thing. Of course, the improved capacity only directly applies to a minority of men in the country, though it should benefit health capacity as a whole as well, albeit indirectly. But in short, I find it hard to believe that the intention of those advocating mass circumcision includes strengthening health capacity. I think it is an intervention with very narrow aims (much like universal testing and mass rollout of antiretroviral therapy).
I believe circumcision is an important prevention intervention but it is not the only one and it is not going to have much effect on its own. It is expected to reduce the risk of HIV infection by 60%. That is not enough. Kenyans also need better sexual and reproductive health, better education about sex, health and other things, better social services, employment opportunities, etc. Even if you believe sexual behaviour is the only relevant factor in the transmission of HIV, circumcision on its own will not cut transmission very much.
If programmes to roll out mass circumcision, universal testing and antiretroviral therapy for all those who are found to be HIV positive were to include development of all health, education and social services in Kenya, that would be great. Because at present, public expenditure on health is very low (most expenditure comes from individuals or from donors). For example, immunisation rates are low and infant and child mortality rates are high, especially in the poorer quintiles. Many Kenyans don't live for long enough to become sexually active.
HIV is just one disease, just one of many sexually transmitted diseases. There are many other, more pressing health problems, such as poor nutrition and lack of access to clean water and sanitation. These affect people on a daily basis, causing more illness and death than HIV. HIV takes a long time to kill people, water borne diseases are very quick. On the other hand, nutritional deficiencies are treatable and most water borne diseases are curable!
Incidentally, there are many reasons why health capacity in Kenya is so low. Several decades of structural adjustment policies emanating from the International Monetary Fund (IMF) and the World Bank (WB) have reduced capacity, especially personnel, severely.
But brain drain has also had an enormous influence. Brain drain is not just the process of trained personnel looking for work in other countries because they can't find work in their own country. They often can't find work in their own country because of aforementioned IMF and WB policies. (A cynic may suggest that, however unintended, these policies often seem to benefit wealthy countries.) And they often end up going to other countries because those countries come looking for them.
The costs of educating professional personnel plus other losses that Kenya must bear are huge. The benefits to the wealthy countries who poach them are also huge. Hence the practice of aggressively poaching personnel whenever there is a shortage in these wealthy countries. Countries that have been heavily involved in poaching doctors in large numbers include the US and the UK. Countries that have poached significant numbers of nurses include Canada, Denmark, Finland, Ireland, Portugal, UK and USA.
The UK recently published a nauseatingly sanctimonious document detailing how they did not poach personnel from developing countries. They didn't say that this was only because they discovered they had an oversupply of doctors and nurses and they no longer needed to poach so aggressively, for the moment, anyway. It could be compared to their similarly sanctimonious claim to have reduced carbon emissions when all they had done is externalised them by exporting them to developing countries. But their change of policy is too late to be of much help to Kenyan health services, regardless of their motives.
Development is not, therefore, just about figuring out 'what we can do to help developing countries'. We also need to look at policies and practices that impoverish and exploit developing countries, such as structural adjustment policies, exporting carbon emissions and aggressive poaching of skilled personnel. But these are what the title of this blog refers to, a theme I shall return to frequently.
Or second, it could be seen as a good opportunity to strengthen the whole of Kenya's health sector in order to ensure maximum benefits and sustainability. If several million people are to be circumcised in clinical settings, over a lengthy period, a large number of health personnel will need to be trained, new clinics will have to be built, existing ones will have to be improved, the whole programme will need careful monitoring and evaluation.
Health capacity in Kenya is not very high at present. There are very few facilities per person and very few trained personnel. The figures are better for some provinces, such as Nairobi and Central, but still not encouraging. There have been small improvements in capacity but they don't usually keep pace with the growing population or increasing need.
A reflection of how poor health capacity is at the moment comes from Bungoma in Western province. There, circumcision is very widespread. Some of the operations take place in traditional settings, some in clinical settings. However, the rate of complications resulting from circumcision is very high in both settings, about 25%, overall. Unsurprisingly, the rate is higher in traditional settings, standing at 35%. But it is also worryingly high in clinical settings, standing at 18%.
The pro circumcision argument is generally, either tacitly or explicitly, for circumcision in clinical settings. A recent paper suggests that mass circumcision would involve high costs in the first five years but the savings and benefits would eventually outweigh the costs.
These findings apply to Nyanza province only, where male circumcision is the lowest in Kenya and HIV prevalence is highest. The model the authors use assumes circumcision rates are 10%, which is lower than other estimates I have seen. They also estimate HIV prevalence to be 24%, which is much higher than other estimates, especially for males, male rates being far lower than female rates in Kenya at present. But their results should still hold.
So if total health capacity in Kenya is going to be increased, this can only be a good thing. Of course, the improved capacity only directly applies to a minority of men in the country, though it should benefit health capacity as a whole as well, albeit indirectly. But in short, I find it hard to believe that the intention of those advocating mass circumcision includes strengthening health capacity. I think it is an intervention with very narrow aims (much like universal testing and mass rollout of antiretroviral therapy).
I believe circumcision is an important prevention intervention but it is not the only one and it is not going to have much effect on its own. It is expected to reduce the risk of HIV infection by 60%. That is not enough. Kenyans also need better sexual and reproductive health, better education about sex, health and other things, better social services, employment opportunities, etc. Even if you believe sexual behaviour is the only relevant factor in the transmission of HIV, circumcision on its own will not cut transmission very much.
If programmes to roll out mass circumcision, universal testing and antiretroviral therapy for all those who are found to be HIV positive were to include development of all health, education and social services in Kenya, that would be great. Because at present, public expenditure on health is very low (most expenditure comes from individuals or from donors). For example, immunisation rates are low and infant and child mortality rates are high, especially in the poorer quintiles. Many Kenyans don't live for long enough to become sexually active.
HIV is just one disease, just one of many sexually transmitted diseases. There are many other, more pressing health problems, such as poor nutrition and lack of access to clean water and sanitation. These affect people on a daily basis, causing more illness and death than HIV. HIV takes a long time to kill people, water borne diseases are very quick. On the other hand, nutritional deficiencies are treatable and most water borne diseases are curable!
Incidentally, there are many reasons why health capacity in Kenya is so low. Several decades of structural adjustment policies emanating from the International Monetary Fund (IMF) and the World Bank (WB) have reduced capacity, especially personnel, severely.
But brain drain has also had an enormous influence. Brain drain is not just the process of trained personnel looking for work in other countries because they can't find work in their own country. They often can't find work in their own country because of aforementioned IMF and WB policies. (A cynic may suggest that, however unintended, these policies often seem to benefit wealthy countries.) And they often end up going to other countries because those countries come looking for them.
The costs of educating professional personnel plus other losses that Kenya must bear are huge. The benefits to the wealthy countries who poach them are also huge. Hence the practice of aggressively poaching personnel whenever there is a shortage in these wealthy countries. Countries that have been heavily involved in poaching doctors in large numbers include the US and the UK. Countries that have poached significant numbers of nurses include Canada, Denmark, Finland, Ireland, Portugal, UK and USA.
The UK recently published a nauseatingly sanctimonious document detailing how they did not poach personnel from developing countries. They didn't say that this was only because they discovered they had an oversupply of doctors and nurses and they no longer needed to poach so aggressively, for the moment, anyway. It could be compared to their similarly sanctimonious claim to have reduced carbon emissions when all they had done is externalised them by exporting them to developing countries. But their change of policy is too late to be of much help to Kenyan health services, regardless of their motives.
Development is not, therefore, just about figuring out 'what we can do to help developing countries'. We also need to look at policies and practices that impoverish and exploit developing countries, such as structural adjustment policies, exporting carbon emissions and aggressive poaching of skilled personnel. But these are what the title of this blog refers to, a theme I shall return to frequently.
Thursday, December 11, 2008
Who Paid for those Christmas Presents?
I will probably say this many times in one way or another on this blog:
HIV may well be mainly sexually transmitted in Kenya, but under what circumstances do people have sex? Why do some have sex frequently and with many different people? Why do they not take precautions, perhaps by using a condom, avoiding people they know to have a sexually transmitted infection (see note below about health) or people they know to be violent? Why do they agree to more dangerous sexual practices, such as anal sex or dry sex?
IRIN ran an article recently about a young woman who had to have sex with her supervisor in order to be guaranteed regular work. She works in an Export Processing Zone (EPZ). EPZs were set up with the specific intention of allowing companies to operate their production units where labour is cheap.
This is not to say that EPZs were set up with purely evil intentions. Countries with EPZs could have had strong labour laws that protected their labour force and that punished employers who flouted these laws.
But competition ensured that the country with the fewest employee protections would win the contracts. Laws in Kenya governing EPZs rarely mention employees but are pretty explicit when it comes to the companies that are flocking to the country to take advantage of the cheap labour.
The companies setting up production units in Kenya and other countries with the 'unique selling point' of cheap labour are ones that produce fashionable clothes, popular brands of watches, pharmaceuticals and other things bought by most people in developed countries, the 'minority world'.
The number of people implicated in the abuse suffered by employees of EPZs is high, taking in multinational corporations, governments and the very population driving the process: the market.
That means you and I; the people who buy sports shoes, laptops, MP3 players, mobile phones and various other things that are only affordable because of a high level of exploitation. Cheap labour ensures our access to these goods.
Don't buy the popular media reflex that developing countries are poor because of corrupt governments. Serious corruption is global.
I almost forgot to mention the part played by the organisations that are supposed to be assisting developing countries to develop: those international financial institutions whose names shall remain the World Bank and the International Monetary Fund. They loan money to desperate countries with certain conditions attached. Those countries must be 'flexible', they must deregulate, they must reduce 'barriers to trade' and public services, they must reduce the civil service...
... many civil servants being involved in the 'anticompetitive' practice of regulating employers, ensuring workers rights, inspecting companies to reduce dangerous conditions and exploitation. In fact, EPZs are not bound by the Factories Act and do not have unions because such things would seriously reduce their competitiveness. EPZs don't even make people redundant, they only 'retrench' them, which is completely different. Well, it’s far cheaper for employers, anyway.
These measures keep international financial institutions, governments, consumers and employers happy. With EPZs, the world is almost perfect.
Except for the majority world; the place where over five billion people live (out of a global population of over six billion). The people who work in these EPZs are not guaranteed work, they must accept any conditions without complaint and they cannot strike. As the Kenya Human Rights Commission say in their report 'Manufacture of Poverty', employees 'report to the factory gates every morning without pay to check whether or not there is work'.
So what makes a prospective employee more 'competitive', more likely to work today and subsequent days? Aside from being silent about flouted fire regulations and other safety measures, impossible production targets, compulsory overtime and other abuses?
Well, agreeing to sleep with the person responsible for choosing who works and who doesn't work would be a start. Sleep with the supervisor. And every time the question of who to employ comes up, the question of what price is to be paid must also be answered. The woman interviewed in IRIN's article is not the only one who suffered abuse and continues to suffer abuse in this way.
So this is a whole field of scenarios where HIV is transmitted. But the issue here is not the transmission of HIV, alone. There is a whole range of human rights being abused with impunity, with the tacit acceptance of most of the people and institutions in the world who could and who should be objecting.
So instead of criticizing people's sexual practices, perhaps we could examine our own purchasing practices.
Note about health:
The International Monetary Fund and World Bank, mentioned above, have also given loans on condition that the number of people employed by public services such as health, education and infrastructure be fixed at low levels. Spending on such services is severely limited and this has many consequences for people’s overall health.
For example, intestinal parasites are very common, as is TB, malaria and many waterborne diseases like cholera. Sexually transmitted infections are also common, especially Herpes Simplex Virus. All of these make people more susceptible to HIV. The health of Kenyans is severely compromised by these loan conditions.
The HIV ‘experts’ who implement prevention programmes do so with the expectation that existing health, education and infrastructure will ensure the success of these programmes. Even the World Bank itself funds such programmes.
So, when they find that there are very few health and education facilities and very little infrastructure in Kenya and other developing countries, one hopes they will also know who to call on to find out why: themselves.
Maybe I am hopelessly idealistic.
HIV may well be mainly sexually transmitted in Kenya, but under what circumstances do people have sex? Why do some have sex frequently and with many different people? Why do they not take precautions, perhaps by using a condom, avoiding people they know to have a sexually transmitted infection (see note below about health) or people they know to be violent? Why do they agree to more dangerous sexual practices, such as anal sex or dry sex?
IRIN ran an article recently about a young woman who had to have sex with her supervisor in order to be guaranteed regular work. She works in an Export Processing Zone (EPZ). EPZs were set up with the specific intention of allowing companies to operate their production units where labour is cheap.
This is not to say that EPZs were set up with purely evil intentions. Countries with EPZs could have had strong labour laws that protected their labour force and that punished employers who flouted these laws.
But competition ensured that the country with the fewest employee protections would win the contracts. Laws in Kenya governing EPZs rarely mention employees but are pretty explicit when it comes to the companies that are flocking to the country to take advantage of the cheap labour.
The companies setting up production units in Kenya and other countries with the 'unique selling point' of cheap labour are ones that produce fashionable clothes, popular brands of watches, pharmaceuticals and other things bought by most people in developed countries, the 'minority world'.
The number of people implicated in the abuse suffered by employees of EPZs is high, taking in multinational corporations, governments and the very population driving the process: the market.
That means you and I; the people who buy sports shoes, laptops, MP3 players, mobile phones and various other things that are only affordable because of a high level of exploitation. Cheap labour ensures our access to these goods.
Don't buy the popular media reflex that developing countries are poor because of corrupt governments. Serious corruption is global.
I almost forgot to mention the part played by the organisations that are supposed to be assisting developing countries to develop: those international financial institutions whose names shall remain the World Bank and the International Monetary Fund. They loan money to desperate countries with certain conditions attached. Those countries must be 'flexible', they must deregulate, they must reduce 'barriers to trade' and public services, they must reduce the civil service...
... many civil servants being involved in the 'anticompetitive' practice of regulating employers, ensuring workers rights, inspecting companies to reduce dangerous conditions and exploitation. In fact, EPZs are not bound by the Factories Act and do not have unions because such things would seriously reduce their competitiveness. EPZs don't even make people redundant, they only 'retrench' them, which is completely different. Well, it’s far cheaper for employers, anyway.
These measures keep international financial institutions, governments, consumers and employers happy. With EPZs, the world is almost perfect.
Except for the majority world; the place where over five billion people live (out of a global population of over six billion). The people who work in these EPZs are not guaranteed work, they must accept any conditions without complaint and they cannot strike. As the Kenya Human Rights Commission say in their report 'Manufacture of Poverty', employees 'report to the factory gates every morning without pay to check whether or not there is work'.
So what makes a prospective employee more 'competitive', more likely to work today and subsequent days? Aside from being silent about flouted fire regulations and other safety measures, impossible production targets, compulsory overtime and other abuses?
Well, agreeing to sleep with the person responsible for choosing who works and who doesn't work would be a start. Sleep with the supervisor. And every time the question of who to employ comes up, the question of what price is to be paid must also be answered. The woman interviewed in IRIN's article is not the only one who suffered abuse and continues to suffer abuse in this way.
So this is a whole field of scenarios where HIV is transmitted. But the issue here is not the transmission of HIV, alone. There is a whole range of human rights being abused with impunity, with the tacit acceptance of most of the people and institutions in the world who could and who should be objecting.
So instead of criticizing people's sexual practices, perhaps we could examine our own purchasing practices.
Note about health:
The International Monetary Fund and World Bank, mentioned above, have also given loans on condition that the number of people employed by public services such as health, education and infrastructure be fixed at low levels. Spending on such services is severely limited and this has many consequences for people’s overall health.
For example, intestinal parasites are very common, as is TB, malaria and many waterborne diseases like cholera. Sexually transmitted infections are also common, especially Herpes Simplex Virus. All of these make people more susceptible to HIV. The health of Kenyans is severely compromised by these loan conditions.
The HIV ‘experts’ who implement prevention programmes do so with the expectation that existing health, education and infrastructure will ensure the success of these programmes. Even the World Bank itself funds such programmes.
So, when they find that there are very few health and education facilities and very little infrastructure in Kenya and other developing countries, one hopes they will also know who to call on to find out why: themselves.
Maybe I am hopelessly idealistic.
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