Don't Blame the Poor for Diseases of Poverty

Diabetes is often referred to as a disease of the relatively affluent because it can be caused by some of the habits that are common in better off, urbanized areas. It can be associated with foods that have high levels of sugar, often highly processed foods, along with a sedentary lifestyle.

However, it can also be a disease of the very poor, those who have little choice over which staple food they rely on for almost all of their nutritional needs. In Tanzania and Kenya, for example, many people rely on staples that are high in starch, and little else. Maize, white rice, white bread and a small number of other foods can make up the bulk of the daily diet of most people.

An article in the New York Times may give the impression that there are lots of Africans suffering from diseases of affluence. I'm not sure why this article is about such a small sector of the East African population, though it may well be true that there are more wealthy people now than before. But diabetes is far more common than affluence.

I accept that the article is quite clearly about the African middle class, but the association of diabetes with increasing wealth is disingenuous. There are people suffering from diabetes who are neither affluent, urbanized nor sedentary. Are we supposed to see people in such circumstances as being responsible for their suffering from the disease?

The same article mentions lung cancer. One of the biggest killers in developing countries is acute respiratory conditions. This is not because most people smoke cigarettes, live close to a polluting but highly lucrative (for them) industry, live in a city or do anything else that relates to affluence. It is because they are exposed to living conditions that render them susceptible to serious lung problems. It is also because health facilities are poor and inaccessible.

In fact, if any generalization can be made about diarrhea, water-borne diseases in general, nutritional deficiencies and acute respiratory conditions, it is that they affect more babies and infants than adults. In adults, respiratory conditions affect women more than men. Also women and children are far more likely to be living in poverty than men.

The majority of people do not have access to private transport, some don't even have access to public transport. Most do not work in offices, most don't even have formal jobs of any kind. Most still have to walk to health facilities and social services, or even do without them. There are, presumably, risk factors for cancer, heart disease and strokes that relate to poverty as well as to affluence.

Urbanization has been a trend for a long time but it is unlikely to contribute that much to diseases of affluence in East Africa. Urban dwelling poor people are probably even more deprived than rural dwelling poor people and they face additional health hazards that those in rural areas don't face. These hazards include air quality, pollution, road traffic accidents, occupational hazards, violence and others.

I don't wish to belittle common health conditions, regardless of who suffers from them. But it is poor people who need better and more accessible health services, whether urban or rural dwelling. And many people are suffering from preventable and curable conditions that relate to their diet, their environment, their economic circumstances and adverse social conditions, not just from their 'lifestyle'.

An article about health in Zimbabwe illustrates the point: "70% of diseases and deaths in the country, caused by malnutrition, diarrhea, malaria and pregnancy-related complications, are preventable." Similar figures can be found for Kenya and Tanzania. It's a popular game in the press, in development and in politics to deflect attention from the problems people face that are beyond their control and to concentrate on issues that are, ostensibly, a matter of individual responsibility. There is a lot of public health work that needs to be done. Poor countries are not 'like' rich countries when it comes to health.

A New Orphan Project (and Another Grumble About Pills)

I recently blogged about the tendency to medicalise problems that have very simple and cheap solutions. For example, if people are suffering from nutritional deficiencies, they need a good balanced diet and therefore access to adequate food. So many companies, especially multinationals, are weighing in with their very expensive food supplements and 'biofortified' versions of various seeds. If people don't have the money for even their meager diet, they certainly can't afford these overpriced supplements and fortified seeds.

But as myself and my colleagues from Ribbon of Hope Self Help Group sat in a restaurant having a meeting yesterday, a woman came up to us to sell us some nutritional supplements which had all manner of stuff in them, according to the colourful label. But they were to be taken three a day for seven days to relieve just about any ailment that could possibly relate to nutritional deficiency. And the course cost as much as more than two weeks of staple food for four or five people.

If people had this sort of money, they could just buy good food. They would be ill advised to spend it on pills that some woman who approached them in a restaurant tried to sell them. But people do buy all sorts of rubbish that promises to sort out all their children's or their own problems. This is a terrible form of exploitation and the stuff being sold is often produced by very big, powerful, wealthy companies. We tried to persuade her that what she was saying couldn't be true. But you can't blame her for trying to make a living in a country where most people don't have jobs. After all, she's been conned too.

Anyhow, today we went to a small village called Majani Mingi to assess some orphans so their families can be supported to send the orphans to school and look after them, along with the rest of their family. Majani Mingi is near Mogotio, about 50 kilometres North of Nakuru. In fact, you can't get to Majani Mingi most of the time and the best way to get there is by motor bike. It's about 10 kilometres from the main road but, despite this, you never leave the massive sisal estate that is 'owned' by a Greek man who can't even be bothered to pay his employees and suppliers most of the time.

With this in mind, we visited four households, taking in 5 orphans in all. All of them had lost both of their parents and all were being cared for by families that were already stretched for the means to keep providing themselves with the basics. Most people in the village have some connection, direct or indirect, with the sisal factory, either as employees or people who are dependent on employees. I think it is safe to say that pretty much all the people living in these sisal dominated villages are very needy, so it's hard to assess children and families when your finances will only stretch to four children.

We can put together the information we have received, along with similar information for four other villages and then make a decision. I suspect that families themselves will have to decide how to use any support they get because when money is in short supply, so is everything else. You can't very well ask a family of thirteen to give food, clothes and schooling to the one orphan and leave the others without. I really don't know how these decisions are made at the family level. I hope to gain some insight into this over the next few months.

There can be a tendency to associate orphans and other vulnerable children with orphanages. But thankfully, Ribbon of Hope is not interested in such institutions, they are beyond our scope. They cost so much money to run and the children do not get the sort of care they could get in a family. And so many orphanages have been hotbeds of corruption and deceit, where often children get very little and those running the orphanages make a very comfortable living. Of course, they are not all like that, but finding out which are genuine and which are not is just too time and resource consuming. As the orphan and vulnerable children project gets up and running, I'll report progress here.

Immediate Needs Sidelined by HIV

Wildly exaggerated estimations of how many lives could be saved by mass male circumcision or universal HIV testing and treatment grab the headlines. But stories about being able to save two million children a year who are dying from diarrhoea don't seem to attract so much attention. The treatment for the acute diarrhoea that kills children, an oral rehydration solution of a pinch of salt and a handful of clean water (CLEAN water!), just doesn't jingle the way expensive programmes and drugs do.

Another thing that doesn't grab headlines is something like a nutrition programme that targets starving children. Free meals in a school in Tanzania has had the effect of increasing attendance and allowing almost all children to graduate from primary to secondary school. Before the programme started, pupils who made it to school were too tired and undernourished to concentrate and most failed to finish primary school. Mainstream media has a taste for good news sometimes, but this seems to lack the high sugar content that appeals to them.

If children just turned up at school to be fed and then left or didn't bother to do any work, this programme would be disappointing. But the fact that they were enabled to go on to secondary school means that the programme could have many benefits aside from nutritional and educational. According to the most recent figures, fewer children go to secondary school in Tanzania than in Kenya or Uganda. And only around 1% go to tertiary level education.

One of the problems with current HIV prevention programmes, the ones that are implemented in schools, anyhow, is that the general level of education in the country is low. I have met people who, at the age of 15, started having sex, usually with an older partner. That's not the surprising bit; the surprising bit is that they didn't know what sex was or if they did, they didn't know that that's what they were indulging in.

I came across a paper about reproductive awareness among adolescent girls (10-19 years) in Bangladesh and many had incorrect knowledge or misperceptions about reproduction, the fertile period, STIs and HIV. This is often connected with the educational status of girls or that of their mother. 18 out of 20 married adolescents who had recently given birth didn't understand why they had become pregnant. Most had never heard of STIs and while 40% had heard of HIV, only 20% had knowledge about how HIV is transmitted.

Many girls experience sex of some kind in their teens, whether they chose it or not. Most of them know so little about sex that they don't know how to avoid doing what someone is coercing them into doing, they don't know how to negotiate precautions, such as using a condom, they may not even know what condoms are, where to buy them or how to use them. To understand what safe sex is, children need to understand what sex is. There is no evidence that teaching children about sex encourages them to try it, all the evidence is to the contrary.

Many school based programmes have had little effect except to give people a superficial ability to answer questionnaires about sex in the required manner. Well educated young people are ones who can make decisions, negotiate, relate to other people at a level other than a reflex level, where they simply say things like 'sex is bad' or 'abstinence is the safest sex' or whatever brainless platitude is the current favourite. People need to learn to think, not just repeat what they are told to think.

Even adults are confused about the 'ABC' strategy, Abstain, Be faithful, use a Condom. The word ‘abstain’ is widely misunderstood, or ignored where it is understood (I certainly ignore it); being faithful is sometimes understood as meaning that it is ok to have other partners as long as your main partner doesn't know; and condoms are a somewhat exotic commodity that used to be really common a few years ago. You can still get condoms free of charge sometimes but, apparently, the free ones are not as common as they used to be. (A packet of three condoms made in Tanzania costs the price of a small bottle of soda. A packet of three produced in rich countries cost about four times that much. Some splash out for the local brands but others spend the money on soda.)

Children (and adults) have rights, that are enshrined in the Universal Declaration of Human Rights, to a good level of nutrition, water and sanitation, health and education. There is nothing in the declaration that says they only have the right to remain HIV negative and to other rights only insofar as they maintain a HIV negative status. HIV is just one aspect of development and underdevelopment. To many, it doesn't even matter that much compared to the urgent need for something that the lack of will kill them very quickly.

HIV has deflected attention from vital areas of development. In fact, many HIV prevention and care programmes have poor results because most areas of development, such as health, education, social services, infrastructure, governance, human rights and equality, have been ignored.