What Has Gates Learned About Development Since Last Year?

Bill Gates' 'Annual Letter' always makes depressing reading. That someone so single minded about making money and controlling as much as possible [good article in the English Guardian on this issue] should understand so little about development is not as surprising  as the fact that, for all his money, he doesn't appear to be able to find advisors who have the balls to stand up to him and get him to at least fake an understanding.

Yet again, to Gates and his cronies, 'innovation' in agriculture in developing countries means wresting the little control left to small farmers out of their hands and putting it in the hands of multinationals, who can squeeze whatever blood is left in the farmers that hasn't already been squeezed out by other means. Technology, as Gates knows, is the preserve of the rich; the rich benefit from it, the poor pay for it. Genetically modified organisms (GMO) and various other technologies that impress Gates so much, and I don't believe he is unaware of this, are not designed to benefit small farmers in developing countries, nor will they ever do so.

In health, also, Gates obsesses about technologies, such as vaccines, single, headline-grabbing diseases such as polio and HIV and issues such as family planning. Yet, over and over again, research shows that it is not just technologies that allow substantial reductions in transmission of common preventable diseases, it is also things like sanitation, water and living conditions. There is no mention in his speech of sanitation and the only mention of water is in relation to GMOs. Polio, which Gates hopes to get credit for 'eradicating', is an example of a disease that will not go away just because everyone is immunized; people need access to clean water and good sanitation. That will help eradicate a whole host of diseases, not just the fashionable ones.

Gates, like a large chunk of the development industry as a whole, thinks that reducing birth rates in developing countries will magically mean that everyone has enough money and enough food. But people need a decent standard of living, gainful employment and food sovereignty. His policies of flying in technologies, whether in health or agriculture, actually increase dependency, poverty and insecurity. If lower birth rates are to occur at all, they will occur as a result of better health, a better economy, better education and the like, not the other way around. And talking of education, Gates is silent on the matter, except for education in the US.

As for HIV, the connection between this disease and enormous profits for Big Pharma is pretty obvious, even to Gates. His foundation has been instrumental in setting up a parallel health infrastructure for this, instead of trying to comprehend how existing conditions in health facilities in high prevalence countries, which are appalling, may have a lot of influence on how the virus spreads. Much of the foundation's money has gone into facilitating the sale of drugs and other technologies and much of the money has never left the US, except to go to US institutions, purpose built in high prevalence countries. Sometimes, the foundation sticks some of the few well qualified health professionals to be found in African countries into a Gates funded institution, just to make the whole thing more African. (For a good example, check out AGRA, the Alliance for a Green Revolution in Africa).

Against the above technocentricity, it's difficult to see why the man should share the HIV industry's obsession with male circumcision. But Gates does mention things like PrePex and the Shang Ring, which will make fat profits for a couple of medical device companies. He seems to think that male circumcision reduces HIV transmission by 'up to 70%', but I think even the most rabid circumcision enthusiasts wouldn't claim that; most would even concede that the up to 60% figure  claimed by the HIV industry is from carefully controlled trial conditions with carefully massaged results (though they might not use the word 'massage').

In addition to advocating male circumcision in countries where conditions in health facilities are dreadful and where there are many far higher priorities, Gates goes on to advocate technologies such as injectible hormonal contraceptives, which have also been associated with increased HIV transmission (male circumcision has been associated with higher HIV transmission in as many countries as it has with lower). Unsurprisingly, genuine improvements in health facilities are not part of the Gates Final Solution. And just to demonstrate his fragile grasp on public health, on the subject of antiretroviral drugs to reduce HIV transmission, he says "In studies where the patients used the tool as they were supposed to, the results were quite good." If people don't 'use the tool as they are supposed to', maybe the problem is with the tool.

And the letter goes on and on, with Gates demonstrating his global imperialist ambitions in every sentence, as well as his ignorance of the lives of the people who will suffer as a result. It seems like every year that passes other institutions with imperialist ambitions, such as the UN, World Bank and WTO, also align themselves with this man. Don't expect too many changes over the next year.

Without Addressing Determinants of Health, Technical Fixes May be Useless

There is an interesting conflict between the findings of two different pieces of malaria research. One piece from Tanzania claims that mosquito numbers have decreased over a number of years to such an extent that fewer and fewer people are being infected.

Whereas scientists in Kenya agree, but claim that malaria infections are lower because of public health measures, such as "well-managed control programmes which involved distribution of nets, effective medicines and vector suppression".

It looks as if there will have to be a meta-study to resolve the issue: has malaria declined because of successful public health measures, because malaria spreading mosquitos are in decline (for one or more reasons), or is malaria prevalence merely cyclical, as has been found with some other diseases?

The Tanzanian-Danish study is adamant that the decline in malaria is not attributable to human interventions, apparently. This conclusion is unlikely to be popular among public health donors, who tend to attribute success to their efforts and failures to something that can remain quite mysterious.

Rumors about the possible influence of climate change have arisen, predictably, but that's a pretty amorphous determinant, at best. But, as scientists, they have to say something.

Despite the claims about distribution of nets in countries such as Kenya and Tanzania, I have talked to many who do not have nets, do not have enough nets, can't afford insecticide treated nets, or don't live in conditions that make nets useful, for example, they don't sleep in a bed or share the bed with so many people the net is useless.

Other articles have mentioned the fact that nets are often used for things far removed from their intended purposes. And so called 'free' nets are often sold, sometimes at too high a cost for the most needy.

And when it comes to drugs, there have been many articles lately, bemoaning the fact that 'fake' drugs (a term that fails to distinguish between generic versions of drugs, counterfeits and placebos) are responsible for sickness, death and resistant strains of malaria. Clearly, the drug industry wants public money to be used to ensure that they extract as much as they can from those living in the greatest poverty.

So all these scientists and experts really do have themselves in a tangle. Declines in numbers of mosquitoes have been equally sharp in villages without mosquito nets, though some articles would make you think there was no such thing as a village that didn't have nets.

Interestingly, a long way from East Africa, insecticide resistance has been linked to an increase in malaria in Senegal. Apparently, mosquitoes have become resistant to the insecticide used on bednets and malaria incidence is now higher than it was before the reduction campaign.

In addition to resistance in the mosquitoes, older children and adults are becoming more susceptible to the disease, which is an entirely separate matter. People's immune response is increased by frequent exposure to malaria, but it then drops once exposure is reduced. This research also acknowledges that the increase in the disease had been forseen for some time.

Sometimes these 'vertical' public health programs, ones that aim to address only one disease, seem a bit futile. For example, attempts to eradicate polio by using an improved vaccination without improving people's living conditions, especially their access to clean water and good sanitation, seem like a bit of a loser.

Similarly with malaria, many people who are most at risk from malaria live in areas with a lot of stagnant water and little control over waste disposal. The same people risk numerous water borne, hygiene related and other diseases, not just the economically viable ones. Perhaps the obsession with technical fixes, yet again, is getting in the way of providing people with what is vital for their survival and their health: decent living conditions.

Literacy as a Source of Ignorance

A review of a film entitled 'Shame in the time of cholera' mentions, as so many articles do, the role of illiteracy in such epidemics and how high levels of illiteracy make it difficult to disseminate information on how to avoid cholera.

High levels of illiteracy are a disgrace in the 21st century and make efforts to improve health conditions very difficult. But it is worth comparing illiteracy in poor areas with the sort of priorities rich and powerful people make about the health of those in poor areas.

Telling people to wash their hands, keep their houses clean, be careful about sanitation and personal hygiene, etc, is like a sick joke when there is little or no access to clean water or basic sanitation facilities (I'm not criticizing the film maker or the reviewer here).

And there may well be all sorts of stories about cholera coming from the wind, witchcraft, miasmas, etc, but there is also the story about cholera epidemics being prevented by drugs and technology and other great human feats.

But are people supposed to take these drugs and use these technologies in the absence of improvements in water, hygiene and sanitation? If so, the exercise will fail. Cholera and other water borne conditions were eradicated in Western countries, not by drugs, but by clean water, modern water infrastructures and sanitation facilities.

Some people and insititutions seem to think that they can pick out a few diseases, such as cholera and polio, and produce vaccines for them. They think that distributing these drugs far and wide will reduce morbidity and mortality, but they are wrong.

People treated for a handful of diseases will simply suffer from, and some will die from, other water borne diseases unless the whole issue of water and sanitation is addressed (and, of course, nutrition, health in general, education, social services, etc).

A name (of a person and an institution) that springs to mind is Gates. Bill has put a small amount of money into water and sanitation projects, but the main thrust of his spending is on vaccines. He even boasts about this.

His wife has talked abut how much we can learn from Coca Cola, because they have a distribution system for their destructive product. I know Coca Cola like to wave their products about in famine and drought areas, but people don't need bottled water, which wastes far more water than it produces. They need a sustainable supply of clean water, unlike what those living in Kerala and other parts of India experienced when they happened to be close to a Coke factory.

Myths are not exclusive to poor, undereducated people suffering from bad health. The sort of myths emanating from Gates (the people and the foundation) are far more harmful, because the media, that great purveyor of myths, blasts them around the world, and so many powerful people seem anxious to repeat myths from the powerful Gateses.

Drugs, scientific breakthroughs, technology and things that the likes of Gates are interested in are not a priority; clean water and sanitation, along with basic health and education are priorities. This is not new, but the message doesn't seem to have reached the literate.