HIV Transmission Via Medical Injections in Kenya - Significant Risk

Congratulations to Kenya on being one of the first African countries with a serious HIV epidemic to investigate the role of unsafe healthcare and reuse of injecting equipment in transmitting HIV. The study finds that "Men who had received ≥1 injection in the past 12 months (adjusted odds ratio, 3.2; 95% CI: 1.2 to 8.9) and women who had received an injection in the past 12 months, not for family planning purposes (adjusted odds ratio, 2.6; 95% CI: 1.2 to 5.5), were significantly more likely to be HIV infected compared with those who had not received medical injection in the past 12 months."

But these findings make the conclusion of the article all the more striking: "Injection preference [my emphasis] may contribute to high rates of injections in Kenya." If someone is infected with HIV as a result of receiving an injection, then it is the behavior of the health care practitioner that is at fault, not the 'preference' of the patient. Health facilities make more money from procedures such as injections than they do from just giving advice or handing out prescriptions, so there may be good reasons why patients 'prefer' injections; they may have been led to believe that injections are 'better'. I'd also be surprised if mere patient preference made much difference to the kind of treatment a patient received in Kenya or elsewhere in East Africa.

Those providing health services need to take responsibility for healthcare associated HIV transmission, and that includes Ministries of Health, professional bodies, and also the WHO, UNAIDS, CDC and other parties who have dominated health and HIV policy in high HIV prevalence countries for decades. Reuse of syringes, needles and other skin piercing equipment carries a very high risk of transmission of HIV, hepatitis and other pathogens. It is not enough to blame patients for their 'preferences'. Practitioners can decide what treatment a patient needs and what is the best means of administering it, if that means is available to them.

The paper recommends that "community- and facility-based injection safety strategies be integrated in disease prevention programs". If this is UN-speak for the need to accept that HIV is frequently transmitted through unsafe healthcare and these practices need to stop, then I wholeheartedly agree. This is more than thirty years too late, but it's good to hear the very mention of non-sexually transmitted HIV in the form of unsafe healthcare being taken seriously in a peer-reviewed journal. I look forward to hearing of other high HIV prevalence countries making the same 'discovery' and publicizing it, and also taking steps to reducing such transmission risks.

[To read more about HIV transmission through unsafe healthcare, have a look at the Don't Get Stuck With HIV site's Healthcare Risks for HIV pages.]

What do Media Censorship and Manipulation, Gates, the BBC and Circumcision Have in Common?

Internews describes itself as an "international non-profit organization whose mission is to empower local media worldwide to give people the news and information they need, the ability to connect and the means to make their voices heard". But one of their much trumpeted programs claims to train journalists about the 'science' behind mass male circumcision programs in Kenya and creating demand for the procedure. There's quite a difference between training journalists on the 'science' of circumcision and creating demand, and the latter generally has little to do with empowerment.

The fact that the BBC's Media Action portal, Creating Demand for Voluntary Male Medical Circumcision, which is backed by the Bill and Melinda Gates Foundation, has named the work of Internews as an example of best practice also says a lot more about the three institutions' shared biases than about empowerment. Even the URL bluntly states the bias.

A press release gushes: "Internews’ training approach illustrates the benefits of training journalists to report accurately and impartially on culturally sensitive topics, such as VMMC. The training resulted in some 100 news stories focused on this high impact HIV prevention procedure that were published or broadcast. What was notable was that the media did not carry any negative news stories about the topic during the period that Kenya was rolling out the medical procedure in Nyanza Province." Oddly, another version of this press release uses the term "falsely negative news stories"; I wonder which is correct? Or is any negative news story 'falsely negative'?

So where is the impartiality in creating demand for mass male circumcision? If people have reservations about circumcision perhaps they have good reasons to. But if the procedure is as wonderful as proponents claim it is, why should such aggressive demand creation be necessary? It is claimed that Internews training "does not prescribe to journalists what to cover" but that their main concern is accuracy. Yet their country director Ida Jooste, perhaps inadvertently, flatly contradicts this claim.

She says that a "critical article was published in Uganda about VMMC quoting a poor-quality study which attacked the credibility" of the often cited Randomised Controlled Trials that took place in Kenya, Uganda and South Africa. Without citing that 'poor-quality' study, she goes on: "Rather than wait for the Kenyan media to pick up and run the story, Internews proactively convened a round-table with journalists and VMMC experts from the National AIDS and STI Control Program, and other organizations to analyze the story and examine its scientific arguments. As a result, not a single media outlet in Kenya chose to pick up or run the sensational story."

I don't think I'd use the word 'impartial' there. Ensuring that only positive coverage is aired and that negative coverage is quashed is media censorship and control, pure and simple. This is all paid for by the US taxpayer, though it seems the UK may now have something to do with it too.

Internews also 'worked with' (should that be 'worked on'?) civil society and health agencies working in the field of mass male circumcision. When they ran a conference focusing on women's 'involvement' in mass male circumcision, "to their delight" this resulted in 25 news and feature stories. This is pure manipulation, but those involved seem to express no shame, apology or even justification for it. Joost is even cited as saying "We believe that the impact of positive media coverage, or at the very least, the absence of negative coverage, complements and reinforces traditional public campaigns aimed at creating demand and behaviour change".

The above illustrates a concerted effort by a donor (Gates), an international media outlet (the BBC, via its corporate social responsibility wing) and a well-funded US non-profit, to control the Kenyan media. These parties then openly report their successful manipulation and censorship of the media, which has resulted in completely biased coverage of a public health program that is opposed by many of those who have taken the time to inform themselves about it.

What kind of foreign donor funded public health program, only carried out on certain African populations, is so important that it is necessary to manipulate the press so that they only report positive stories and that they don't report negative stories about it? If Kenyan people had any objections to this kind of neo-imperialism, would their press even report it? If the US wanted to impose a mass male circumcision program in the UK, would the BBC also collude with Gates, PEPFAR, CDC, UNAIDS and other parties to make sure objections were not heard? This must be what is meant by 'informed consent'.

The Media in Africa: Beware of Natives

BuzzFeed has photos of 10 signs photographed in South Africa during the apartheid era and it is truly shocking to think that, as the article points out, these signs only became illegal in 1994. But that's why it should be even more shocking that instances of extreme racism and apartheid style thinking should still be so common in the international media today. I have listed a number of examples below, with links to some of the most offensive articles I've read in the past few years.

These are just the tip of the iceberg and a full study would take years. But, in no particular order, let's start with the stories about condom 'recycling' in Kenya and condom 'rental' in Tanzania. Whether the journalists who wrote these stories were bored or desperate is just one question; but what about the media outlet that published them and the public who read them?

One that goes back a few years is the 'story' about starving HIV positive people on antiretroviral drugs eating cow dung in Swaziland. Numerous media outlets echoed that one and it cropped up several times. There was even a story about a woman in Namibia who  claimed to have eaten cow dung but then admitted that she had made it up. She didn't attract anywhere near as much publicity, though.

The ever-popular notion of 'African' sexuality is a trusty tool in the journalist's store of prejudices. Although it has been debunked many times, the media picture of Africans has remained faithful to their apartheid agenda. Africans are truly 'other', that's why there are such massive HIV epidemics in some African countries, isn't it?

The UNAIDS Modes of Transmission analysis, which produces the 'science' behind the media's HIV related racism has also been criticized, but why attack the source of so many stories that everyone seems to enjoy and find so completely inoffensive? UNAIDS even recognizes the true HIV danger in African countries, unsafe healthcare. But they keep that to themselves, publishing advice about avoiding non-UN approved health facilities in a booklet for UN employees, courtesy of the sweetly named 'UN Cares' (about its own employees).

Occasionally a journalist may allude to the use of African participants as research fodder, but people are too used to hearing about the oversexed and feckless African to care very much about such abuse, especially when it can always be dressed up as 'helping'.

It's coming up to about six years since the international media 'discovered' the Tanzanian albino attacks and killings, even though they had been reported in local media for some time. The sloppy and offensive coverage that followed this great 'scoop' for the BBC continues, as do the attacks on persons with albinism. Why revise a story that has won praise and awards? Of what importance are accuracy and insight when opportunities for self-adulation are at stake?

The disgusting US Christian right story of the use of adult pampers as a result of anal sex among men who have sex with men has even done the rounds in some of the local media. We see articles about African countries claiming that homosexuality is 'brought in' by foreigners. But where did the homophobia come from?

There are sometimes instances of the kind of media friendly racism that is 'roundly' condemned, trivial matters that keep readers entertained, much easier to write about than anything that matters. But what the media writes is clearly not yet a source of offence to most people. Perhaps in years to come sites will be able to list some of the shockingly abusive things the mainstream media published about African people, who knows?

Next Year's Famine Victims Currently Being Groomed by Western Powers

If you look at the top 30 donors to the East African Famine, number one is the US. It is one of the richest countries in the world, although donations as a percentage of per capita income are nowhere near the highest.

But the US is also pretty good when it comes to land grabbing. This time it's Tanzania, where a substantial deal is being questioned by opposition MPs. But recently, it came to light that big, wealthy US educational institutions were snapping up land in various African countries that are, or have had, shortages of affordable food.

An estimated 162,000 Tanzanian smallholders stand to lose their land if the deal goes through. This means that more than half a million people would be impoverished as a result. And all so that some US energy company can produce what they refer to as food crops, but are much more likely to be used for biofuels.

'Affordable' food is the key term. There isn't a shortage of food in Tanzania as a whole (nor in Kenya or several other countries where people are starving). Indeed, some of Ethiopia's most productive land is also being grabbed, as millions there face starvation. Famines typically involve lack of access to affordable food, not lack of food.

One of the culprits mentioned in relation to Ethiopia is Italy, which also appears in the top 30 donor list, albeit at number 19. (The EC, number 2 in the list, is busy trying to ensure that India will no longer produce affordable drugs for HIV positive people by pressing them to sign an 'Economic Partnership Agreement'.)

The most generous also stand to reap far more than they sow. The UK is number 5 on the list and their history of land grabbing, which is still a huge contributor to the country's wealth, is legendary. They are one of the biggest grabbers in Africa, though they are more likely to boast about how much they 'contribute' in aid. Another big and long running land grabbing incident in Tanzania involves a British company called Sudeco.

It's interesting how a lot of the land being grabbed is being used for sugar cane. This can conveniently be referred to as a food crop but is far more likely to be used these days for biofuels. Western powers spend decades driving African sugar producers out of business by subsidizing their own producers and dumping their surplus on African markets. But now they seem to want African sugar again.

Canada is number 6 on the list. Much of Tanzania's gold, much of Africa's gold, is extracted by a Canadian company, which pays little or nothing in taxes or royalties. The US, UK and even South Africa, number 28 on the list, also extract gold at massive cost to ordinary Africans. Gold extraction puts huge tracts of land out of use, though direct contamination, water contamination and through forcibly excluding indigenous people, often people who once made a living from the gold.

Make no mistake, famines like the one currently developing in East Africa, are generally not 'natural' disasters. They occur and last because they are a consequence of large scale theft, government sponsored, multinational sponsored, philanthropic institution sponsored, even international institution sponsored, theft.

I don't wish to suggest that contributing money to the current famine is wrong, I would encourage people to contribute. But, bearing in mind what we are 'contributing' to next year's famine, giving money is not the only thing we can do. We can also ask public representatives tough questions about things that are often presented as 'business' or 'aid' or 'partnership', especially when they involve land and water use.

The majority of people in all East African countries depend very directly on land for their food and income. If that land is taken from them, or even if its use is dictated by those whose sole aim is profit, their lives and livelihoods are threatened. A famine is not an 'act of God', it's a consequence of human activities.

Aids Denialism Doesn't Make the Disease Go Away

There are many controversies surrounding HIV, development in general and various other things. So, writing a blog about these can attract some controversial remarks, in theory. In practice, I have received some comments but few that are controversial. When remarks have little or nothing to do with what I have posted, I delete them. If the post is clearly just an attempt to attract attention to some site, product, issue, service or person, I am also likely to delete them.

But a comment I received today, anonymous of course, purported to be about my most recent posting, which discusses levels of HIV transmission from unsafe medical practices. 'Anonymous' may have thought that in questioning certain aspects of HIV funding and the like, I am aligning myself with certain Aids sceptics, who deny that HIV causes Aids, or whatever. Whether this anonymous contributor represents AliveandWell.org or not is irrelevant; I do not agree with what the site stands for and I would not wish to have anything to do with a group of people whose only aim seems to be to further muddy these already turbid waters.

My approach to HIV in Kenya has been that of a general scientist. My interest is in the overall conditions in Kenya and how they changed as HIV arrived, spread and continues to spread. Therefore, I look at history, economics, social practices, lifestyles and many other things, in addition to medical and social science aspects of the virus. I do not have the scientific expertise to address all the details of the AliveandWell site. There are plenty of people who can do that, if they deem the content of the site worth the effort.

As for the idea that HIV and Aids were 'invented' by some wealthy people so they could make money (or even take over the world), I have never heard anything that could make such a hypothesis the least bit plausible. No doubt the AliveandWell site is teeming with such evidence, but I think I have more worthwhile things to spend my time on.

Some of the numerous 'experts' cited on the site may well have a great deal of expertise, I really can't say. Certainly, some of them seem to have lots of letters after their name. But people can make up qualifications, or pay for them. And plenty of well qualified people come out with utter rubbish that can be used by whoever wishes to shore up some rant that they like to call 'theory' or 'hypothesis'.

The anonymous poster says AliveandWell advocates 'scepticism' around HIV but the site is the work of a group of Aids denialists who encourage the use of 'alternative therapies' for HIV positive people. HIV positive people would be well advised to consider the fate of the woman who started the site, Christine Maggiore, who died of Aids, along with her infant daughter. Maggiore refused antiretroviral treatment for herself and for her daughter.

To adopt the stance that Maggiore and her followers recommend is not scepticism, it is idiocy. Some adults may wish to adopt such a stance, which is regrettable. But there is no justification for imposing such idiocy on people who are unable to defend themselves. There is enough disinformation about HIV/Aids in developing countries already without this sort of deception being peddled and I hope people who visit AliveandWell see the site for what it is.

Those are my thoughts on your wonderings, Anonymous.

The Aids Industry Sure Knows How to Blow its Own Trumpet

Yesterday was World Aids Day again and in Kenya you couldn't miss the copious amounts of advertising, bunting, leafleting, t-shirts, sun visors and other paraphernalia of the industry. High and not so high officials were out in strength to collect their per diem, without which, presumably, nothing important could happen. There were the mobile testing clinics in areas that already have static testing clinics and millions and millions of condoms distributed.

For all it's faults, the Aids industry has published some figures that certainly look good. Botswana, which has one of the worst HIV epidemics in the world, has the highest percentage in any African country of people on antiretroviral therapy (ART), the highest rates of HIV testing and the highest number of women on ART to prevent mother to child transmission (PMTCT). They also have the third highest percentage of children on ART.

Over several decades, the campaigns to recognise the rights of HIV positive people to receive treatment have been successful in a lot of countries. In many developing countries, a sizable percentage of HIV positive people in need of treatment are on treatment. In the West, very few babies born to HIV positive mothers are themselves HIV positive. Indeed, the percentage of HIV positive babies born to HIV positive mothers is declining in a number of developing countries too and should be relatively low by now in a country like Botswana, where such a high percentage of HIV positive mothers are receiving PMTCT.

But rights seem to be most commonly recognised for those who are already infected with HIV. If you read various developing country HIV strategic plans (which are curiously similar, despite the epidemics being very different in quality), you will notice that the word 'rights' is rarely used except in relation to HIV positive people, mainly in relation to access to treatment. The rights of those who are not yet HIV positive, and that's most people, are rarely mentioned. Yet they have a right to the things that will ensure that they remain HIV negative.

Of course, it is hard to quantify the effects of the various HIV prevention programmes that have been rolled out in Kenya and other African countryies. Most of them were run by wealthy organisations who could afford the 'research' and publicity that would make them look very successful. The reality is that very little is known about preventing HIV and, beneath the hype, few programmes have been truly successful.

I would be the first one to admit that the very idea of cutting HIV transmission is fraught with difficulties. Many things have been tried, some of them perhaps even well thought out. But in the end, there is very little money to be made out of prevention and therefore very little money put into it. Condom distribution is an exception, but where there is little or no health or science education, let alone sexual and reproductive health education, condoms haven't really taken off that well. You may have heard otherwise but there are good commercial reasons for that.

The problem with the majority of the prevention programmes that have received some of the relatively small amount of money that is available for HIV prevention is abstinence. Most programmes relied on the idea that if people would just abstain from sex, they would not be likely to be infected. The more liberal advocated abstinence until marriage, until it was noticed that more and more people are becoming infected by their spouse. But various programmes were cobbled together that, one way or another, advocated abstinence or what amounts to abstinence. People didn't abstain and most of them won't. This is not something peculiar about developing countries. Abstinence campaigns have failed where ever they have been tried.

The reason I mention the rights of people who are HIV negative is that many of them will, sooner or later, become infected with HIV because one or several of their rights are presently being denied. People, whether adults, children, male or female, have a right to health and a right to treatment when they are sick. Yet more people in Kenya and other developing countries are dying of easily treatable and curable diseases than are dying of Aids.

Children have a right to a decent education and part of that should include levels of health and science education that should give them the prerequisites to attain enough understanding of sex, sexuality and reproductive health to avoid becoming infected with HIV or other sexually transmitted diseases and to avoid unplanned pregnancies. In a word, people need education to lead healthy lives.

People have a right to a decent standard of living for themselves and their children, they have a right to adequate food and nutrition, they have a right to good standards of governance and security, water, sanitation, infrastructure and many other things. They have a right to a legal system that protects them from harm and persecution and the like. Women need to be given the same rights as men, in the workplace, in the economy, in education, in health and everywhere else. Men who have sex with men, intravenous drug users and commercial sex workers need their rights protected.

It is the denial of the sorts of rights mentioned above, along with various other rights, that leaves people vulnerable to becoming infected with HIV and suffering many other serious consequences. People in developing countries who are suffering from HIV now, and those who have died of it, were likely denied one or several of their rights. HIV is not transmitted in isolation from people's circumstances, from the conditions in which they live and work.

Those who are HIV positive and those who are HIV negative are equally entitled to their rights, though skewed funding for Aids would suggest that this is not the case. In order to avoid transmitting HIV to others and in order to remain HIV negative, everybody's rights need to be protected. In short, everyone is entitled to these rights and without them, the treatment and care programmes for people who are HIV positive will be, to a large extent, in vain; the half hearted prevention efforts will also be in vain.

Prevention has proved to be a slippery fish. But treatment and care for one disease in isolation from all the other things people can and do suffer from has also been less successful than it should have been. There is little point in treating one incurable disease and ignoring the many others that are more easily treatable and often even curable. But that is what's happening. The Aids industry is just too rich and powerful to allow people to know that.

Reconsider the Proposed 'Census of Gay People'

Apparently Kenya is going to carry out a census of its gay population. People are expected to volunteer information about their own sexuality and the sexuality of others they believe to be gay. I certainly wouldn't volunteer information about my sexuality or that of others in Kenya. The issue of homosexuality is often met with a tight-lipped silence or a rabid stream of abuse.

The National Aids/STI Control Programme (NASCOP), which intends carrying out the census, claims that it is part of an effort to 'reach out' to the gay community. This may be so, but who will protect people's right to privacy when it comes to their sexuality? Will the police protect gay people or people suspected of being gay from persecution? This seems unlikely, given the police's reputation for being behind many kinds of persecution themselves. Police here are not known for their liberal views or even their love of peace and the rule of law.

All sexually active people should have access to HIV and other sexually transmitted infection (STI) testing facilities, condoms, sexual health education, counselling and other services. But they should also have the protection of the law and this is something that is not presently guaranteed. The way commercial sex workers (CSW), and those suspected of being CSWs or accused of being CSWs, are treated is a case in point.

NASCOP is worried that some people have the mistaken view that gay sex is safer than heterosexual sex, despite the fact that it is far more risky. But heterosexual anal sex is also mistakenly thought to be safer than vaginal sex. All sexually active people, and those who will soon become sexually active, need to know things like this. Men who have sex (MSM) with men may need additional services that other sexually active groups don't need. But groups who are at higher risk of contracting HIV and other STIs, such as MSM, CSWs and intravenous drug users, are all doing something currently against the law or considered to be against the law.

If the very act of trying to bring HIV and related services to gay people is also going to expose them to even greater dangers than they currently face, the whole idea of a 'census of gay people' should be reconsidered. It could be replaced by the provision of services to all people who require them, as and when. It may seem helpful to NASCOP to approach the gay population this way but there are too many flaws in getting people to identify themselves and others as gay in Kenya.

Towards a Vaccine for Stupidity?

In an article entitled 'HIV vaccine trial results raise more questions', the recent, much reported vaccine trial results are, it is suggested, open to many interpretations. But whether a HIV vaccine is still a distant hope or already close at hand, I would argue, is not what we should be concentrating on.

Some of the reasons why many people are becoming infected with HIV and other sexually transmitted infections could be that they do not have access to good sex education or family planning, they do not use condoms, they are not always in a position to choose whether to have sex, when, with whom, how often and under what circumstances. True, many people know that HIV is a threat but there are so many threats that people just get on with their lives, HIV positive or otherwise. But this only partly explains high HIV prevalence.

Health, education and other social services are pretty much inaccessible to the majority of Kenyans and the majority of people in all developing countries. People are, effectively, denied their rights to a decent standard of living. They live in poverty and suffer from the consequences of poverty. People experience all manner of illnesses that are easily and cheaply controlled and many die unnecessarily, often at a very young age.

HIV is just one of numerous diseases that threatens the lives of people in developing countries, just one chronic disease that further impoverishes people who are already impoverished. The fact that billions of dollars are spent on finding HIV vaccines and other drugs does not make people more scared of it. Sometimes it even makes people think that a vaccine or cure is probably just around the corner.

Cures and vaccines are likely to be some way off; affordable cures and vaccines are quite another story. But, as we have seen over a period of more than two decades, people certainly don't modify their behaviour in the way that health and other professionals suggest they should. This is as true of developed countries as it is of developing countries, as true of HIV as it is of obesity, dangerous driving, drinking, various kinds of exploitation, corruption, crime and drug use.

What should we be concentrating on? Instead of putting such copious amounts of HIV funding into treating people already infected, a lot more money and effort needs to be put into preventing new infections from occurring. Much of the money currently spent on treatment and care of HIV positive people goes into intellectual property. In other words, there is existing legislation that would allow the costs to be cut, substantially, without reducing current levels of treatment and care.

As to what measures could lead to preventing HIV infections, a lot of research is needed, research that must be carried out without the biases of power politics, pseudo moral posturing, fashion and pure greed. By now, we know a lot about what doesn't work and we need to be frank in admitting that. But perhaps we also have some insights now; perhaps the promise of greater lifetime opportunities could lead to people taking fewer risks and making better decisions that relate to their health. The promise of a better standard of living, education, employment, habitation, health and social services could achieve a lot more than the patronising rubbish that has, up to now, passed as HIV prevention programming.

Most people in the world live in poverty and are denied their basic rights. They live in the majority world. Rather than putting so much of the world's aid money into a cure for one disease, some of this money could be used to change the way the minority world treats the majority of people. Indeed, much 'aid money' is used for all sorts of things aside from aid. It's used for 'technical assistance' (which usually means paying rich Western consultants and experts a little too handsomely for their advice), dumping surpluses, subsidizing the industries of rich countries, creating markets for consumer goods, etc.

Kenya and other countries not far from here are used and have long been used, as sources of cheap raw materials and labour. Much of the country's land and resources are given over to producing raw materials for the minority world. Much of its workforce receives very low pay, working in conditions that would be illegal in the West, to produce raw materials and cheap goods for the West.

Like all other diseases, HIV has a context, an environment. Countries with high HIV prevalence also have high rates of other diseases and other health and social problems. They suffer from extreme levels of deprivation and they are usually heavily exploited by rich and powerful countries. While a vaccine or cure for HIV may be a long way off, vaccines and cures for other diseases are not just available but cheap, for example treatment for intestinal parasites, which affect billions of people.

Some of the biggest killers are things like water borne diseases and acute respiratory conditions. Perhaps as much as half of the illnesses and premature deaths in developing countries could be avoided by provision of clean water and sanitation and decent places to live. That is not beyond human ingenuity, it just doesn't seem to get the same attention as a possible vaccine for one disease that affects far fewer people.

Clarification:

In a recent posting I argued that "it is not poor people in developing countries who contribute the most to global warming and environmental destruction, it is rich people in rich countries." A friend complemented me on this argument but I had to admit that it comes from an article entitled 'The Population Myth', by George Monbiot. Indeed, many of my views on development are influenced by the writings of Dr Monbiot and it was not my intention to claim credit for his work.

High Technology and Appropriate Technology

Nakuru is not far from the equator and today we travelled to Mogotio, even closer to the equator. We were there to irrigate onions, peppers and other vegetables. The irrigation process for a small shamba (smallholding) is fiddly and time consuming. The field is beside a river. The pump is petrol operated. But the process of attaching bits of pipe so that the water reaches the farthest parts of the shamba takes several people and a lot of time.

In fact, it's a process of attaching, detaching and re-attaching bits of pipe until the whole job is done. While two people add and remove pipes, two others use hoes to make furrows for the water to flow through and block furrows where adequate water has entered. Why do people not use good lengths of flexible pipe or drip irrigation?

This is a one acre shamba, the kind and size that many Kenyans own. It's for growing small amounts of produce. It's labour intensive but labour is cheap, flexible pipe and other pieces of equipment are expensive. If the shamba was bigger and more productive, we could afford drip irrigation or some other form of irrigation, but this sort of technology is beyond the means of most people here.

So I was pretty annoyed to come across an article about some 'clever' people who have developed a device which allows a farmer to SMS or call a number to turn on their irrigation system. Great, but people who can afford an irrigation system that can be switched on and off don't have to do much work on the shamba themselves. They employ people to do it. It's not the first time I have seen articles about how brilliant mobile phones are. They have their uses but most of the problems poor people suffer don't go away just because they have a mobile phone.

I also came across an article about how Uganda is using mobile phones to spread the 'message' about HIV. Do they really think their unsuccessful and very expensive programmes over the last 20 years failed because of the medium that was used? How much evidence do they need that the problem was not just with the medium?. Many people there and in other countries know all sorts of things about HIV, not all of them true. But they still engage in the sort of behaviour that is thought to spread HIV. So why should spreading the 'message' by mobile phone change anything?

Anyhow, as well as hoeing and irrigating the shamba, we were in Mogotio to demonstrate the process of solar cooking to some people there. We cooked rice, ugali (boiled maize meal) and sukuma wiki (a popular collard green). Sounds a bit starchy but Kenyans like a fair bit of starch. The result was excellent. The area is so hot that things cooked quickly. So the workers in the field were impressed at the large amount of food they were provided with and even more impressed that no charcoal or wood had been used in the cooking process.

I had my worries about the ugali. It is almost worshiped here and getting it wrong could be fatal. But it turned out pretty solid and sticky. I have tried a few other things, stew, various vegetables, even soda bread. They are very good, as long as the sun lasts. So it's time to be more adventurous and do a bit of experimenting. I have no doubt that some 'genius' will be able to invent a device that pulls a screen across the solar cooker when the food is cooked. Until then, I'll just use the time honoured process of looking at the food.

Some Things Change, Some Stay the Same

The Preliminary Report of the Kenya Aids Indicator Survey (KAIS) was released last July and was based on data collected in 2007. Prevalence was estimated to be 7.8% among 15-49 year olds (7.4% among 15-64 year olds). Many parties expressed surprise that HIV prevalence had increased since 2003, when the Demographic and Health Survey estimated prevalence to be 6.7% among 15-49 year olds.

HIV prevalence in Kenya peaked in the late 1990s and fell rapidly thereafter into the early 2000s. Prevalence fell because death rates were very high. But death rates peaked in the early to mid 2000s. If there had been few new HIV infections in the early to mid 2000s, HIV should have stabilized at a fairly low level. This didn't happen. Instead, prevalence increased.

One possible reason that HIV prevalence has been increasing throughout this decade is that antiretroviral therapy (ART) has been keeping many HIV positive people alive. However, the number of Kenyans on ART by 2005 was very small. Numbers have increased since then, although it's not yet clear what effect this will have on national prevalence figures.

Another possible reason why HIV prevalence has been increasing is that there are many people becoming newly infected every year. While huge sums of money have been poured into treatment and care for HIV positive people and their dependents, very little has been spent on prevention. What has been spent on prevention has been wasted on pointless finger-wagging about how people should and shouldn't lead their sex lives.

The final KAIS report was launched in the last few days. I can't find a copy of it online but there have been many articles about it and they all, like this one, talk about the report as if these figures are new and surprising. It is not surprising that there are more people living in rural areas infected with HIV. The vast majority of Kenyans live in rural areas. Prevalence is lower in rural areas than in urban areas but the absolute numbers are higher. This is not a new trend.

Various commentators in various articles have resolved to deal with trends noted by the KAIS report but many of these trends go back many years. Even the KAIS figures are already two years out of date. And there are likely to be quite different trends now because, in case these commentators haven't noticed, some profound changes have taken place in the lives of all Kenyans. There was a violent election campaign, a violent election and a particularly violent post election period, during which many people were killed, injured and displaced. There have been energy shortages, food shortages, water shortages, a global economic collapse, increasing unemployment and, no doubt, countless other pressures on people's lives.

Some things are not the same now as they were two years ago, when data was collected for KAIS. They are certainly not the same as they were in 2003. But the HIV prevention work that is being carried out by Kenya's health and HIV agencies is pretty much unaffected by anything that has happened in the last ten and perhaps even twenty years.

Consequently, HIV prevention continues to be given low priority and takes forms that continue to have little or no impact. That's why a recent survey of 13-19 year olds shows that, many years and tens of millions of dollars later, less than 50% understand what abstinence means. More importantly, only 20% understand what being faithful means and only 7% fully comprehend condom use. The question is, do the 48% who can say what abstinence means really understand sex and safe sex? I think the answer is clearly 'no'; all they have taken in is a definition. They will not be able to protect themselves adequately, despite being able to parrot definitions of abstinence and the like.

HIV prevention work in Kenya needs to do new things, not continue with the failed, dogmatic activities of the past. Children (and adults) need to know what sex and safe sex are, they need to know how to protect themselves and often, they need protection. There are young people pouring into Nairobi and other cities now, they are desperate for work and until they find work, countless thousands will become involved in some form of transactional sex. People's living conditions need to be changed so that they don't face such dangers.

HIV policy needs to be based on what is happening now, not what was happening, or what someone thought was happening, years ago. And policies that failed years ago need to be changed, not shored up with excuses. HIV trends can change very quickly and all Kenyans are at risk of becoming infected, though some are at higher risk than others. There is no point in just concentrating on high prevalence areas, as one Kenyan WHO representative suggests; low prevalence areas can quickly become high prevalence areas. Also, absolute numbers can be a far better indicator than percentages when it comes to describing how an epidemic is spreading.

But the Kenyan government needs also to concentrate on people's lives, livelihoods, environments and opportunities. People still need the things they have always needed, health, education, social services, infrastructure, good housing, employment and protection from harm. Relevant authorities such as the National Aids Control Council and, indeed UNAIDS, need to be able to distinguish between the things that change and the things that don't change.

Painting Pots Black

This is not to stir up the long running dispute between the pots and the kettles. We're painting pots black so we can use them with the solar cookers we purchased during the week from Solar Cookers International. We've talked to people who work with, make and research solar devices and we've talked to those who want to buy them and use them. Now it's time to go out and demonstrate them and, hopefully, persuade people to part with the $6 or so that they need to invest.

Of course, people need to invest a little time and, god forbid, they need to embrace change, just a tiny bit of change! We can make ourselves some food over the weekend and decide on the best ways to demonstrate these devices. I'm looking forward to it but I'm also a bit apprehensive. After all, much of what I believe about development could be severely tested over the next week or so.

We will be working in and around Nakuru. My colleagues have been working here for some time and they have introduced me to various community support groups. Most of these groups have grown around the need to support people who are HIV positive, people who are directly affected by HIV and, particularly, those who are on antiretroviral therapy (ART).

Some of the groups are very active, with volunteers making regular visits to those who need support of various kinds, who need to be taken to hospital, who are having problems affording school fees or rent and whatever. Many of the groups are already exploring ways of making some money, such as growing and selling fruit, vegetables, milk, eggs and the like. Others make things and sell them.

Solar cookers are a bit different from other activities these groups are involved in. If someone buys a solar cooker, they have the means of saving money they would spend on charcoal. They may save the time they spend collecting firewood. They can use the cookers to cook food, dry food and boil water, the last being particularly important for people who are HIV positive.

People who are HIV positive need to be very careful about how they live their lives, what they eat and drink, what dangers they may be exposing themselves to. Their immune system is damaged by HIV and, even though many are on treatment, they still have to be careful. It is hoped that one more way of pasteurising water will be of great help in reducing exposure to diarrhoea and other water borne diseases.

Today, my colleague and I went to a support group at the camp for internally displaced persons (IDP) just outside town. People there are just trying to get by, some doing well, some not so well. We were accompanied by a woman who works for an agency that gives microloans to help people set up small businesses. Hopefully, they will see the benefits of solar cooking and, if they can come up with the money, also buy some cookers. And maybe some of them will want to take things further and use the cookers to produce something they can cook and sell.

That's the hope, anyhow. I'll write up what happens here, even if it shatters my heartfelt beliefs!

International Policy Network Partly Right and Partly Wrong About HIV/Aids

Philip Stevens of the International Policy Network questions the wisdom of spending so much money on a single illness, HIV/Aids, and asks if this can do more harm than good. I have long been asking the same question. My feelings are that it has done very little good and has probably done a lot of harm, especially to HIV prevention efforts.

The health of a nation is unlikely to be made or broken by one, single health condition. Even when there is a serious epidemic, there are probably always more people suffering from and dying from ordinary, every day things than from that epidemic disease. Health depends on people's lifestyles, living conditions, levels of nutrition and food security, education and economic circumstances, for example.

Stevens rightly criticizes UNAIDS's prioritization of treatment over prevention. Since treatments for HIV have been developed, far more money has always been spent on that than on prevention. So while many have been treated, millions more have become infected. Greater emphasis on prevention could have made a lot of difference, although precious few effective prevention interventions have been developed and implemented in any high HIV prevalence countries.

Stevens also mentions the poor and declining state of health infrastructure in high HIV prevalence countries. Indeed, some of the major funding bodies involved in pouring money into HIV treatment and care (and a little prevention) were, at the same time, urging developing countries to reduce spending on health, education and other social services.

If it is the case that some parties have claimed that everyone in the world is at equal risk of becoming infected with HIV, then this is truly shameful. I think the message was that every sexually active person is at risk, which is true. But it is not true that everyone faces equal risk. Perhaps this message has been confused by publicists, politicians, church leaders and various money grabbers who knew nothing about health, least of all HIV, but still wanted to get on the bandwaggon for their own ends.

And Stevens is wrong to claim that UNAIDS exaggerated the numbers of people infected and were 'embarrassingly forced to revise down the estimates for dozens of countries'. Methods of estimating numbers were improved, that's why the figures went down. Many figures are still very doubtful in that they could be higher or lower than presently estimated. Kenya was one of the countries for whom figures were revised down. A short time later they had to be revised up again.

Stephens' analysis, I think, is misleading. He makes it sound as if HIV/Aids is still a problem, but less of a problem that it was. I disagree. I believe that we neither have enough data to support his view nor directly to refute it. But there is plenty of evidence that people in high HIV prevalence countries still face serious and perhaps increasing risk of becoming infected.

I hope Stevens is right that donors have finally realized the folly of directing so much money towards one disease. However, I don't think he is right. I think he has allowed himself to be fooled by all the rhetoric about strengthening primary health care and health systems. If that is ever going to happen, I'll believe it when I see it.

Solar Cookers and Cooking Baskets

Photo: An IDP camp in Molo, Rift Valley.

Yesterday, myself and two members of a local community based organisation, that I'll be revealing more about in the near future, went to a camp for internally displaced people (IDP), just outside Nakuru. This tent city was set up by the United Nations High Commission for Refugees (UNHCR) following the post election violence more than one and a half years ago. The UNHCR has now left the camp and people there are getting by as best they can.

It's disgraceful that the Kenyan government has yet to resettle people properly after all this time. Many of those in the camp find it difficult to get to services and facilities as they are an expensive bus journey away from the town. Even health facilities are hard to get at and people on antiretroviral therapy (ART) are in a particularly precarious position. ART is nominally free in Kenya but there are logistical problems relating to getting to health centres, buying other medicines and the like.

Anyhow, many people in IDP camps see themselves being there for some time. They have planted fields of fruit and vegetables and done their best to be more self reliant. Unfortunately, a herd of buffalo came recently and destroyed much of what they had grown. And the current drought doesn't help either, many crops are stunted or withered because of the lack of rain. But there are also green and flourishing gardens that must have required a lot of care and attention.

Some aid agencies have been to the IDP camp and have given some assistance. But much of that assistance is in the form of handouts of goods and money, which is not sustainable and does not allow people to be self reliant. This community based organisation are advising people on ways of saving in order to be able to access microcredit facilities. They are also advising on potential income generation schemes so that people can get some money for their work or, at least, find out about ways of spending less.

One technique we are hoping to introduce to people is the use of solar cookers for cooking food. The area gets a lot of sun and solar cookers could be used for much of the year. There are numerous advantages to using solar cookers but the advantage we want to make clearest is the cost saving. Charcoal and wood, which people use now, are expensive. They are also in short supply and becoming scarcer. Cutting the amount of smoke people inhale on a daily basis also springs to mind, and the list goes on. Oh, and it's a great way of pasteurising water!

Complementary to solar cookers would be cooking baskets, which are best explained on the Cooking in a Basket blog. These are insulated baskets that cook food which has been partially cooked, thus saving a lot of time and fuel.

In principle, it should be possible to source the materials and makers of these two tools, the solar cooker and the cooking basket, locally. That may take time and we can use ready made ones in the meantime. It may also be possible to get some of the materials free or almost free. Currently, a local sisal unit dumps large amounts of material that would make great insulation padding. But we'll spend the next few weeks working out the logistics and I'll post up our progress as we go along.

Does Everyone at the World Bank Share the Same Brain Cell?

The World Bank certainly knows how to give mixed messages. The overfed, overpaid over there now admit the dangers of climate change, especially for developing countries, and they are urging industrialised countries to reduce carbon emissions. This took many years of arguing against the climate change denialists, who dominated industry and finance, so this was no mean feat.

But the World Bank is also financing massive coal fired electricity plants in developing countries that will pump out greenhouse gases for decades. In a country like Kenya, where they don't produce coal in large quantities, this will also mean an unwanted increase in dependence on imported energy.

Dearest World Bank people, we never expected genius to emanate from among you, but nor did we expect such total idiocy. Right now, foreign governments are gagging to get their hands on Kenyan land so they can grow crops for biofuels, even though one quarter or more Kenyans face food shortages and the country is experiencing prolonged drought. This will also increase the countries carbon emissions. And there are plenty of other things happening here that are inimical to emission reduction.

Perhaps the people at the World Bank have heard of solar energy? To this piece of knowledge, perhaps they could add the fact that Kenya and other African countries get a lot of sun? Or maybe I'm overloading your thought faculties a bit? Well, there's also something here called geothermal energy, which also emits little or no carbon. There's also wind energy, which I'm sure even World Bank people would have some understanding of.

So why, with these abundant sources of renewable, not polluting energy, does the World Bank choose a non-renewable, polluting source of energy that will cripple poor countries with debt and swell their balance of payments deficit?

Would it be an exaggeration to suggest that the people at the World Bank have completely lost it and shouldn't be trusted with a piggy bank, let alone the billions they propose wasting on increasing the potential catastrophes brought about by climate change?

Good Leadership and Facing the Realities Around HIV/Aids

Still trying to familiarize myself with the area around Nakuru, the towns, villages and rural areas. More importantly, I'm trying to get a picture of the organisations and initiatives that I hope to work with, their members, leaders, qualities, interests and levels of activity.

Some are very active and productive, with keen participants and strong projects. I couldn't help agreeing with the home based care worker I met yesterday who said he thought leadership is the key. I don't believe for a moment he was talking about himself as he is a very modest man. But in Salgaa, he gives excellent leadership and gets excellent results. Leadership does appear to have a vital bearing on the success or failure of support groups and their activities.

Peter knows all of the people in his two community support groups very well because he lives near many and pays regular visits to others, travelling many kilometers every week on his bike, on a hired motorbike or on public transport. There is no substitute for covering as much of this large area as possible, as often as possible.

But the results of his work include regular meetings, high levels of support given to and given by participants; Peter and others working in the area can tell you all about each participant and they know when someone is sick or in trouble. Not everyone takes an equally active part, of course, but compared to some other support groups that don't even meet most of the time, Salgaa has a very healthy community.

Most importantly, people there who are on antiretroviral therapy (ART) are taking their medication as they should. This means they gradually become as healthy as they were before they were affected by the opportunistic infections that appear in people in advanced stages of HIV. This is one of the primary aims of the support groups and in that respect, they are doing very well.

As for HIV prevention, the area has not been so lucky. The Kenya National Aids Control Council has never really spent much time, effort or money on HIV prevention. They talk about it a lot but neither Kenya, nor any country in the world, have really implemented programmes that demonstrably reduce HIV transmission. Calling their programmes, such as they are, 'evidence based', does not mean they have had any effect.

And some organisations never learn. After many years of bleating about sexual abstinence and how it reduces transmission, even though it clearly does not, many of those involved in HIV prevention are still coming out with the same tripe.

Yes, young people need to know they can refuse those who try to persuade them to have sex. And those who are in a position to refuse either don't have sex or they only have sex under circumstances they choose. That's great for people who have freedom of choice but fails to address those who, for many reasons, don't have the choice or don't have much choice.

Children (and adults) need to know the reality of sex and choice and many other things. Abstinence campaigns, even ones that include partner reduction and condom use, do not have a history of teaching realities. There are still many adults who believe all sorts of rubbish about condoms, circumcision, reproduction and other vital matters. And there are still people who use the word 'abstain' all the time and have very little useful knowledge about what they are supposed to be abstaining from. It's sex, it's a big subject and it goes far beyond a few over used slogans.

These bogus HIV prevention campaigns demonstrate something else, besides leadership, that is missing from initiatives that fail: reality. There is plenty of money and therefore plenty of 'leadership' behind abstinence and the related sanctimonious parphenalia. But because they are not rooted in the realities of people's lives, they have little or no impact on their lives.

In Salgaa, the support groups don't just have good leadership. The groups arose from the realities of living with HIV/Aids. People need to get on with their lives, facing the same realities that may well have resulted in their becoming infected. They don't survive by refusing to accept the realities, rather, those who refuse to accept the realities become sick and die.

How Many Mobile Phones Does it Take to Change a Bandage?

Photo: This donkey is more likely to save lives than a mobile phone.

The media never tire of writing self-satisfied articles about how brilliant technology is and how so many things can be done now because of technological advances. No doubt, there have been remarkable advances and we can now do things that were never dreamed of a few decades or even a few years ago.

Despite this, there is an increasing number of poor and undernourished people. Most, if not all the Millennium Development Goals are going to be missed by most developing countries. People are dying of preventable and curable diseases. Yes, preventable and curable. They can be prevented and they can be cured but, for some reason, they are neither prevented nor cured.

There is a whole rash of articles on the use of mobile phones for HIV care and prevention, articles written with all the confidence you would expect of suit-wearing, job-holding academics and consultants. But all these articles appear to be based on anecdote rather than on comprehensive data. You can support adherence, send prevention and health messages, even diagnose diseases and perhaps issue prescriptions.

But that's only if there is some kind of infrastructure available. There's little point in issuing a prescription to people who can't afford the medicine or the trip to the pharmacy or where the pharmacy has run out of supplies or if there's no public transport or if there is no clean water to take pills or...etc, etc. Even where the infrastructure is in place, Kenya is not blessed with adequate numbers of trained health personnel.

I'm not running down technology, I agree mobile phones are great, as are handheld computers, laptops, mobile internet and anything else that can be dreamed up. But ultimately, people also need the basic things that the survival of the human race up till now has depended on.

That's what's missing, food, water, sanitation, basic health, basic education. Missing are the education, health and social service facilities and, more importantly, the trained, skilled and well equipped people who provide services.

All of the health care workers I've met recently have mobile phones. Notably, they are also all volunteers, with very little training. There are not too many people they can call, least of all skilled medical personnel, as they are in very short supply. And if someone calls them late at night, most of them don't even have a bicycle to get to the client. If the client needs to be moved, they might have a wheelbarrow or a cart to get the client to the nearest public transport vehicle. This is not a joke.

There is also a shortage of electricity here and a shortage of money for credit. Many handsets don't work or don't work very well because of the heat and dust or because they are cheap handsets that don't function for very long. True, people can use solar energy to charge their phones but most don't because this particular technology is too expensive.

Mobile services could even be paid for by the state. But the state doesn't provide the few pennies necessary to treat and prevent intestinal parasites that stunt the physical growth and mental development of vast numbers of children every year.

I'm sure people are very happy that we 'can' do all these marvelous things with technology but they'll be a whole lot happier if their immediate needs are attended to, whether they require technology or not.

The Extended Family and Other Myths

Sometimes people write about developing countries as if they are all very similar and they may throw in terms like 'extended family' and 'coping strategies', as if this makes poverty, illness and unemployment less of a burden. They write about 'incongruities', such as drought and famine, but lots of smiling children, playing happily in the dust.

Some people do 'cope', because they have no other option. Many live in large families and they do co-operate, with the sick, young and old being looked after by the able bodied. And of course, children play happily in the dust or mud or whatever.

However, such commentators may not see or may choose to ignore the children and adults lying in bed or the ones who never come out because their disabilities are too great or because they are too stigmatised, for example.

The fact is, people in developing countries have family disagreements, neighbourly jealousies, local spats and far more serious eruptions of discontent and outright violence, just as they do in other countries.

Here in Nakuru, there are differences and perceived differences that make it unlikely that some people will agree to work with some others and that community based organisations with members who see themselves as essentially different from other members can be prone to failure, sometimes quickly, sometimes slowly. Merely setting up a group that consists of members from different groups does not mean people will work happily together.

I don't believe this situation is all that different from wealthier countries. But crucially, many people in developing countries need support, perhaps many different kinds of support, right away and often for a very long period.

There is a severe shortage of most basic resources in developing countries, food, clean water, education, employment, etc. These are some of the things that allow them to be characterised as underdeveloped. When there is a shortage of resources, knowing that your neighbour has plenty when you have none is bound to cause discontent, no matter how friendly you have been in the past.

When people are under extreme pressure, they can do extreme things. Some don't, perhaps most people don't. But community based organisations and various initiatives are often set up when people are already under extreme pressure and they are therefore already precarious.

The majority of people in developing countries have been waiting for much or all of their lives for the most basic of goods. I suspect that that is why now, some people seem to grasp at anything that comes their way, even if it is intended to be shared with others. I think if I were starving, or if my children were, I would do pretty much anything to get food.

This doesn't explain why some of the richest people in the country, politicians, business people, colonials who remained after independence and various other organisations, also grab what they can. Some of them have been stealing vast sums of money and resources intended for people who were in dire need.

It doesn't explain why large multinationals exploit developing countries and see them as vast markets, why international organisations pretend to help developing countries when they are really enriching themselves at the expense of those countries, why huge 'pro-poor' initiatives are really about making rich people richer, selling arms, 'national security' or some other agenda, completely unrelated to development.

It would be nice to think that poverty is really quite a happy, fortunate state, given that the majority of people in the world live in poverty, many in absolute poverty. But it's not true. It's not true that everyone in developing countries live in 'extended families' that make sure no one 'falls through the net'. We just don't see those who fall through the net. It's not true that people 'cope', they either survive or they die, often after a lot of suffering.

Those who see and write about 'extended families' and people 'coping' may just miss or choose to miss those who have fallen through the net, because those who have fallen are no longer visible.

Free Education, For Those Who Can Afford It

If you follow the official literature and commentaries on Kenyan education, you may think that all primary school age children get free schooling. If you go into it in a little more depth, you will find that there are many hidden costs such as 'extra' tuition, which the children have to attend, shoes and uniforms, which have to be worn, exams, materials and various other items.

Therefore, many poorer children fall through the loop. Having no school fees is irrelevant for the parents who are unable to meet the additional costs. Unknown numbers of children don't go to school or don't go to school very much because their families are too poor. The Kenyan government is not too keen to admit to the existence of these children, of course. They enjoy the praise they receive from the press and from foreign donors.

Added to these children of poor families, there are orphans and other children who have been abandoned or who don't have people to provide everything they need. There are well over one million, perhaps as many as two million. There are street children, children who start school so late that they will never catch up and will drop out early, there are children who are sent out to work for much or all of the time they are supposed to be at school.

All in all, the Kenyan government is quite shy about anything that could be called bad news. The recent census may not even account for all the children in this country. It may remain difficult to know how many children are not at school or who don't receive much schooling before they become too old to attend school.

Yesterday, we were in Rhonda again, this time to visit a children's home. There are 120 children being schooled there, 20 of whom live there all the time. Because this children's home is not a public school, they receive nothing towards the children's schooling. There are many such homes around the country. No one has any idea how many, exactly. And the government will not be so keen to talk about these either.

So, for all the money that is said to be spent on 'free' primary education, if would be interesting to know how many really benefit, how many don't get anything and if it's true, as it appears to be, that only the better off get to go to school. It appears that those with least and those who are under the most pressure are also least likely to be able to afford the costs of 'free' education.

Differing Mindsets: a Goal or a Way of Life?

Western Non Governmental Organisations (NGO), funders and most Western volunteers tend to think in terms of projects, programmes, lengths of time, numbers of participants, amounts of money, outcomes, objectives, goals and targets. Of course, there needs to be accountability, there needs be a good level of monitoring and evaluation and all that. Things need to be managed.

But it's remarkable how differently local Community Based Organisations (CBO) and Kenyan volunteers work. Much of the work is never ending so things are not viewed as projects or programmes. Lengths of time are irrelevant, as are numbers and stated goals and targets. People are very pragmatic. Orphans are looked after until they grow up, sick people are looked after till they recover, if they recover, old people are looked after till they die.

There is no need to ask what a good or bad outcome is, either an intervention works, in which case it will be continued or it doesn't work, in which case it will not be continued. Of course, there are exceptions, foreign volunteers who become very pragmatic and Kenyans who become sticklers for measureable things, exclusively.

When it comes to money, attitudes vary also. Of course, people who have no money look for ways of making some. Everyone would prefer a job that is not too strenuous or stressful and one that is better paid. But some CBOs just get on with whatever it is they set out to do. Others get on with writing a proposal and waiting around for money. If they get money they may get on with the job, or they may see getting the money as an end in itself.

But some of the CBOs that just get on with the job and see funding as a longer term requirement often do amazing work before raising a single dollar. Even volunteers working for a small amount of money for a period often continue working just as hard when the money stops coming in.

Today, we interviewed four people to volunteer to work perhaps half a day, five or six days a week for six months. All of them said they would be willing to work for as long as required, a year, several years. After all, they have already worked as volunteers for three to five years. They were all asking for very little in allowances. And that's just as well because the allowance on offer is very small.

For some people, the work they volunteer to do is more of a way of life than just a job that has measurable, countable outcomes. Perhaps these differing mindsets explain some of the friction between those who always insist on targets and results and those whose aim seems to be to bring about some kind of change for the better.

Some Signs of Prosperity in Kaptembwa?

Kaptembwa is not that far from Nakuru but, for some reason, there was a more prosperous feel about some of the homesteads and fields. We were there to visit people who are HIV positive and taking antiretrovirals (ARV). But people taking ARVs can, in most cases, go back to the work they were doing before they became ill. One woman we visited kept hens, goats and sheep. She also grew maize and various vegetables and had a small shop, a hole in the side of the house, to sell food and other day to day items to neighbours. It is a long way from the nearest big shops, but that is handy for people who can be enterprising, as this woman is.

The picture is not as rosy for many people because once they have Aids, they can suffer a lot of illness. ARVs don't work as well for some people as they do for others. One family we visited had to move from a bigger house when the father and mother found they were both HIV positive and in need of treatment. The father of the family is unemployed, as is his wife. His young boy is also HIV positive and suffering from various illnesses as a result. The youngest in the family, a three month old girl, may turn out to be HIV negative, it's not always certain at that age.

It's no secret that catching HIV early, before it results in people losing their livelihoods, is something worth concentrating on. But for people who are very poor and perhaps unemployed before they become infected, an early diagnosis may not help much. The family with no income get free drugs but can't always afford trips to health centres to collect drugs and for other visits. They can't afford a good variety of food to keep themselves and the children healthy. Children need a good diet, especially. But also, people who are on ARV treatment suffer side effects if they don't have a good level of nutrition. Some suffer so badly that they just stop taking their drugs.

Much of the money spent on HIV/Aids goes to drugs but many people infected and affected by this disease need a lot more than drugs. They need good food, clean water, proper housing, health, education and social services. Some people are doing well despite being HIV positive. But some are doing no better than they were before becoming infected while most are a lot worse.