Nicholas Kristof really knows how to pack the largest amount of conservatism into the one article. The presumptuousness of the title continues throughout the article, as well: 'The Birth Control Solution'. Kristof holds the rather naive view that underdevelopment exists because some people in some countries have too many children. The 'solution' to climate change, poverty and civil wars, and to underdevelopment in general, is birth control to limit population growth.
One result of overpopulation, according to Kristof, "is that youth bulges in rapidly growing countries like Afghanistan and Yemen makes them more prone to conflict and terrorism". All those who have spent long hours wondering why terrorism erupts in some countries should look at rapidly growing countries, with a high proportion of young people. These areas are 'prone' to conflict and terrorism, apparently.
Such populations also contribute to global poverty, we are told, and make it impossible to protect virgin forests or fend off climate change. Well that's quite a revelation to me. I always thought the biggest pressures on climate change come from rich countries. What does Kristof think virgin forests are being cut down for? To build mud huts? I am happy to let him know that the bulk of carbon emissions don't come from mud huts or from people wearing out the soles of their sandals in developing countries. There is no global shortage of food either, just a lot of people who can't afford prices that have been inflated by Western economic measures.
Kristof cites evidence that family planning works, but that is not in doubt. What's in doubt is that if you get family planning right, everything else will follow. His evidence is from India and Mexico in the 1950s and 60s. So now all Indians are rich and Mexico is peaceful? Family planning, birth control, even sexual and reproductive health, are just part of the health of a population. They need to be put into perspective.
Surprisingly, Kristof notices that the 'unmet need' for contraception is only one of many unmet needs, but he seems to think others are limited to those relating to family planning. Does he not know that there is an unmet need for access to healthcare, clean water and sanitation, education, social services and adequate infrastructure? There's nothing wrong with contraception, nor with providing more contraception, but it is just not at the top of everyone's list. It is buried inside some of those far more pressing needs.
The first thought of people planning a family (or just having a family, without any particular plans) is to have children. Then there needs to be some consideration of how to raise them. Some may wish to limit the number of children they have, but that might not come till later. What seems unlikely is that people will use contraception in order to reduce the possibility of their having an abortion. Aside from the fact that people don't think that way, abortion is illegal in many developing countries. It is just not an option. Reducing abortions is a secondary outcome of increased use of family planning methods, it is not a 'selling point'.
And those who worry about the world running out of resources tend to be those who are able to use far more of them than they need, not those who barely have access to them in the first place. Kristof seems to be thinking of his skin, and the skins of other rich Westerners. There is widespread poverty because most of the world's wealth and resources are in the hands of a few, civil wars are often fuelled by external influences (as any American journalist should know) and climate change is a result of the overconsumption of the minority world, not the sheer size of the majority world.
Showing posts with label poverty. Show all posts
Showing posts with label poverty. Show all posts
Monday, November 7, 2011
Sunday, September 12, 2010
Stealing People’s Land Can Only Impoverish Them Further
The World Bank, an institution devised to divert aid money on its way to developing countries back to the rich and powerful, seems to have woken up to the sort of negative impact that its policies have been having on developing countries. I wouldn’t get too excited, though, because the negative impacts they are concerned about follow from their policies, which they haven’t changed in any way. And no matter how they appear to equivocate, it’s always worth bearing in mind who ‘international’ financial (and other) institutions are intended to benefit.
Grabbing land goes back a long way, hundreds of years, as does using people and resources in developing countries for the enrichment of people in developed countries. The monumental disaster, the Tanganyika Groundnut Scheme, which started in the late 1940s and was abandoned in the early 1950s, is just one out of many examples. Like all of today’s land grabs, the grabbers were quick to claim numerous advantages for those who were being dispossessed of their land; employment, food security, development, mechanization, efficiency, modernization, etc. Such terminologies have changed little since the 1950s!
The flaws of the Tanzanian scheme were many and obvious from very early on, but there were those who thought they would make a lot of money from it. So vast tracts of land were destroyed and lots of equipment and other resources were wasted. Someone did make a lot of money out of the scheme, though it’s not certain who. But the losers were Tanzanians, the Tanzanian economy and the Tanzanian environment.
Land grabbing schemes of the last few years have already appropriated tens of millions of hectares, at very low cost. It is difficult to estimate how many people have been displaced and dispossessed but the number affected by the process will be enormous. ‘Investors’ will not be counting those costs, that’s for sure. They are anxious that we think of ‘feeding the starving’, even though 80% of the land hasn’t yet been used for anything. Ultimately, much of it is destined for non-food crops and for export to rich countries, though. What else would it be used for?
The World Bank has been talking about how to protect people in developing countries and their land. But they have been talking about a lot of things throughout their history. International agreements about accountability and transparency are a great idea, even better if there is some guarantee that they are upheld. But we know that all sorts of agreements are discussed, fewer are made and hardly any are ever upheld.
Land grabbing on a scale that is taking place presently is not happening despite the existence of institutions like the World Bank. On the contrary, such institutions were set up by rich and powerful countries so that they could stay rich and powerful. So we need different institutions, not the same ones saying the right thing while continuing the policies that have brought developing countries to their knees. The institutions are doing what they were intended to do, that’s why the World Bank needs to be abolished and replaced by something that genuinely represents the interests of the world.
The kind of land grabbing that is occurring at the moment will further devastate the most vulnerable communities, economies and environments in the world. People in rich countries may not be able to witness these phenomena as they occur, and the corporations currently enriching themselves are certainly not going to record them or make them publicly available. But by the time a handful of sound bites and photo opportunities are considered to be newsworthy by the world’s media, it will already be too late to reverse the damage.
Monday, August 30, 2010
Poverty Makes the World Go Round
How do you undermine the rights and autonomy of whole populations and, instead of censure, receive only praise? Simple, you just call it development. A multinational that respects little aside from money, and certainly has no time for democracy, is bad enough. Yet, when it joins forces with an institution with similar qualities, but happens to be an international 'charitable' foundation, there is very little anyone can do to rein in their actions, no matter how exploitative, destructive or manipulative they may be.
The Gates Foundation has been bullying countries into dancing to its tunes for some time now. And Monsanto's monopolistic behavior is legendary. But both these institutions recognise just how far they can go as long as they bleat on about 'helping' people, saving lives, feeding the hungry, etc. How can anyone object to such philanthropic actions, whatever their motivations? They certainly couldn't object to 'donated' food merely on the grounds that it is genetically modified (GM), could they?
Some like to make out that opposition to GM is based on a fear that the foods are damaging to people's health. Perhaps some people do have such fears. And those with an interest in pushing GM do not themselves know what effects the technology could have on health or the environment (or if they do know they have never made their findings public), so they certainly don't want anyone else to know. Because people's fears are based on lack of information, rather than availability of information, the industry can churn out any kind of deceit to defend themselves (or pay pseudo-academics to do it for them).
But others are more worried about the fact that multinationals like Monsanto want to monopolise agricultural production, from the choice of seeds, the varieties of produce, the agricultural inputs, the agricultural practices employed, all the way to what people eat, how much they know about what they eat, how much they pay for it, how food is produced and stored and anything else they can control. They are not just food facists, Monsanto runs the whole gamut of facism.
Couple this with the man who wants to do for food what he succeeded in doing for software and you've got a real threat to democracy, health, the environment, the economy and even global security. If there’s anything about facism Monsanto doesn’t know, Bill Gates and his Foundation will soon fill in the details.
People in developing countries may have been kept in the dark but they are not stupid. They know that there are reasons for high food prices and lack of access to food; they know that the prices are not necessarily high because of shortages and that lack of access to food is not necessarily because of their country's inability to produce it.
There is little secret about the fact that famines, food shortages and food insecurity, including recent instances of these, are not caused by lack of food; many countries experiencing these phenomena have plenty of food. It is obvious to many that it is people with large amounts of money who created prices beyond the means of those living in developing countries. And you don't need to be a genius to know that shortages of (edible) food can be created when most land is used for products destined for the rich; biofuel crops, flowers, luxury fruit and vegetable, tea, coffee, cocoa, rubber, sisal, animal feed (for Western animals) and the like.
One of the financial institutions that did very well out of the recent handouts to the rich, Goldman Sachs, also made a lot out of the food price speculation that created the food crisis a few years ago. They raked in an estimated billion dollars; even by Gates’ standards, that’s a lot. They do very well out of human misery, benefiting from it, as well as causing it. So who would pass up the opportunity to share in their returns? The Gates Foundation certainly wouldn't.
Is it really philanthropy to extract money from people and then give some of it back to them? We don't really know how much the Gates Foundation's ill gotten gains come from the countries that eventually 'benefit' from its 'largesse'. The Foundation, in its great (undemocratic) wisdom, decides who benefits as well as who loses and they are certainly not going to tell members of the public, especially not in developing countries. The Foundation aims to keep its wealth intact, regardless of how it achieves this. Any doubts or worries that arise can be assuaged by some pretty pictures of happy children or mention of names like ‘Kofi Annan’.
It comes as no surprise that the Foundation now has a considerable investment in Monsanto. This multinational has much to gain from developing countries and has shown that it is unscrupulous enough to do whatever is required to maximize its gains. The Foundation's sham 'Alliance for a Green Revolution in Africa' (AGRA) has never denied that it will take advantage of GM if and when it sees the benefits. Gates has been investing in Monsanto for years. Some have probably been wondering when pay day was due.
This diabolical coupling does have one feature that may not be completely negative: it brings into clear focus the intimate connection between the unscrupulous grabbing by some institutions and the equally unscrupulous ‘philanthropy’ of others. Gates and a small handful of other rich people and institutions control the means of production where the products include poverty, disease, starvation, environmental destruction and a whole lot of other ills. And where would we be without all of them?
Monday, May 10, 2010
More Assessments and a Visit to a Clinic
My trip today with Ribbon of Hope Self Help Group took us to Lomolo, about 40 minutes cycle from Mogotio and the main road. The conditions were not too bad, despite heavy rains recently. We visited three families, one of which has two orphans. As with the other villages, everyone seemed equally deserving and, no doubt, there are many other deserving families and orphans in all the places we visited.
There was a woman with twelve of her own children (two of whom are grown up) to take care of, yet she is also taking care of a teenage orphan who is doing very well at school. I really don't know how she makes her meagre income go so far! There was also a woman with no children of her own who is taking care of two orphans (who are not siblings). One of them is HIV positive, the other may be, but has not been tested. And there is a young mother who is so sick herself that she is finding it difficult to look after her one daughter.
Once we have done the assessments we can get a better idea of how we can help, especially in ways that will support the whole family. We need to find income generation activities that will give the family extra money and some of that money needs to be forthcoming very soon. Everyone we have spoken to has arrears of some kind, along with bills that soon have to be paid. People do a combination of borrowing and begging sometimes, but most very poor people don't have easy access to microfinance.
On the way to the village, we passed a man who had to make the difficult and expensive trip to Mogotio to see the area chief. Apparently, the microcredit organisation he went to insisted on him getting a letter from the chief. In addition to the time and money (including lost earnings), the chief will require some money, too. Asking someone in a position of authority just to do their job doesn't come cheap.
After the assessments, we went to see a client who is in a local clinic. He's very sick, either not responding to his antiretroviral (ARV) drugs or just not taking them. Neighbours say he was drinking a lot, which often results in people not adhering well to their drug regime, for whatever reason. The drugs are hard to hold down when you don't have enough food but also, probably, when you have a hangover.
Anyhow, we didn't get to the bottom of it because he had such a bad bout of meningitis that he looks like he is recovering from a stroke. He is finding it hard to talk and is difficult to understand. My colleague says he probably has other impairments in addition to his speech. He is emaciated and weak, which is not surprising. We can only hope that his current condition improves and he gets back to his ARV regime. But it's not a foregone conclusion.
On the subject of medical facilities, there was an article in the paper recently about an assistant health minister who visited a hospital in Bungoma, unannounced. I don't see the point in letting a hospital know you are coming as many things can be done to make conditions look better than they are. Anyhow, the man got many shocks. He saw how long people had to wait, some even dying as they waited, the arrogance with which people are treated, the conditions in the hospital and the tendency of people working there to try to cover up things. There were even the bodies of some children that had been left on a bed and he was told they were sleeping.
The man must have a fair idea of what things are like in public hospitals. If he doesn't, he should look for another job. Hospitals are underfunded, understaffed and cannot deal with the number of patients they get. The staff are often not very well trained, they don't get paid too well and they are underequipped. Drugs and other things are in scarce supply and buildings are old and crumbling. These are the conditions in which, UNAIDS claims, only 0.6% of HIV transmission comes from unsafe medical practices. Just how much evidence do they need that this claim should be reconsidered?
There was a woman with twelve of her own children (two of whom are grown up) to take care of, yet she is also taking care of a teenage orphan who is doing very well at school. I really don't know how she makes her meagre income go so far! There was also a woman with no children of her own who is taking care of two orphans (who are not siblings). One of them is HIV positive, the other may be, but has not been tested. And there is a young mother who is so sick herself that she is finding it difficult to look after her one daughter.
Once we have done the assessments we can get a better idea of how we can help, especially in ways that will support the whole family. We need to find income generation activities that will give the family extra money and some of that money needs to be forthcoming very soon. Everyone we have spoken to has arrears of some kind, along with bills that soon have to be paid. People do a combination of borrowing and begging sometimes, but most very poor people don't have easy access to microfinance.
On the way to the village, we passed a man who had to make the difficult and expensive trip to Mogotio to see the area chief. Apparently, the microcredit organisation he went to insisted on him getting a letter from the chief. In addition to the time and money (including lost earnings), the chief will require some money, too. Asking someone in a position of authority just to do their job doesn't come cheap.
After the assessments, we went to see a client who is in a local clinic. He's very sick, either not responding to his antiretroviral (ARV) drugs or just not taking them. Neighbours say he was drinking a lot, which often results in people not adhering well to their drug regime, for whatever reason. The drugs are hard to hold down when you don't have enough food but also, probably, when you have a hangover.
Anyhow, we didn't get to the bottom of it because he had such a bad bout of meningitis that he looks like he is recovering from a stroke. He is finding it hard to talk and is difficult to understand. My colleague says he probably has other impairments in addition to his speech. He is emaciated and weak, which is not surprising. We can only hope that his current condition improves and he gets back to his ARV regime. But it's not a foregone conclusion.
On the subject of medical facilities, there was an article in the paper recently about an assistant health minister who visited a hospital in Bungoma, unannounced. I don't see the point in letting a hospital know you are coming as many things can be done to make conditions look better than they are. Anyhow, the man got many shocks. He saw how long people had to wait, some even dying as they waited, the arrogance with which people are treated, the conditions in the hospital and the tendency of people working there to try to cover up things. There were even the bodies of some children that had been left on a bed and he was told they were sleeping.
The man must have a fair idea of what things are like in public hospitals. If he doesn't, he should look for another job. Hospitals are underfunded, understaffed and cannot deal with the number of patients they get. The staff are often not very well trained, they don't get paid too well and they are underequipped. Drugs and other things are in scarce supply and buildings are old and crumbling. These are the conditions in which, UNAIDS claims, only 0.6% of HIV transmission comes from unsafe medical practices. Just how much evidence do they need that this claim should be reconsidered?
Friday, February 19, 2010
Lack of Logic in the Received View of the HIV Pandemic
Something I have always found mysterious about UNAIDS' view (it's something of a received view) of the course of the HIV epidemic is that they estimate that the number of new infections peaked in Sub-Saharan Africa (SSA) some time in the mid 1990s. And they reckon that the reason new infections began to drop from then on can be put down to the success of HIV prevention and education programmes in changing the sexual behaviour of people, especially men who have sex with men (MSM), commercial sex workers (CSW), intravenous drug users (IDU) and young women.
With few exceptions, most SSA countries were doing very little to treat people with HIV or to prevent the transmission of HIV in the 1990s. Treatment was in its infancy and was inaccessible to the majority of Africans. And where prevention programmes had been implemented, they consisted of little more than mass education campaigns. They had very little influence on people's behaviour in the 1990s. And why would they have much influence? They had only started and only in a few countries, Uganda being one of the countries that started HIV prevention early. But even the nature and effectiveness of Uganda's HIV prevention campaign is still being hotly debated. Prevalence there has changed little in years and sexual behaviour indicators have long been sliding in the wrong direction.
What bothers me is that even if widespread prevention activities started in the mid 1990s, it would take many years for them to have much effect. That's if they actually had any effect at all. Ok, I can't research every country in SSA, but in the case of Kenya, very little was being done in the 1990s. It was only in the early 2000s that some serious work started, say 2002 or 2003. And the Kenya Aids Indicator Survey (KAIS) makes it quite clear that HIV prevalence, which had been dropping before 2003, actually increased and is now higher, after half a decade of HIV prevention work.
What I'm getting at is this: if rates of HIV transmission peaked in the mid nineties, then it did so for some reason other than the fact that every country had implemented widespread prevention programmes. The reason I suggest this is because prevention just wasn't a big thing then, at least, not big enough to explain why the epidemic started to 'decline'. I'm not saying that rates of transmission didn't drop, just that they didn't drop because of prevention programmes.
Another reason for thinking that prevention programmes didn't have much influence on rates of HIV transmission is because even after they did start, there is little evidence that they could have been the cause of the drop. There is plenty of evidence that most current HIV prevention programmes have little or no effect. In Kenya's case, scaling up HIV prevention programmes seem to have resulted in an increase in prevalence, the total number of people living with HIV. This doesn't tell us if transmission rates have decreased, so what about transmission? Are there still lots of people becoming newly infected?
According to the KAIS, transmission patterns are changing. Numbers infected in urban areas have dropped but numbers infected in rural areas have increased, especially among men. The majority of Kenyans, 75% or more, live in rural areas. Poorer and less well educated people are now being infected in greater numbers. The majority of poor and less well educated people live in rural areas and most Kenyans are poor and badly educated. These trends all follow what KAIS refer to as a 'rapid scale up of HIV prevention, care and treatment services'.
A recent article in AllAfrica.com quotes UNAIDS as claiming that their successful prevention and education programmes have *finally* begun to change the behaviour of those who are most at risk. If this is only happening in recent times, how can they claim that it had anything to do with a decline in incidence that began in the mid 1990s. But Kenya, along with many other SSA countries, have explicitly not targeted some of the groups who are thought to be most at risk, MSM, CSWs, IDUs and young women. The well presented 'Modes of Transmission Survey' for Kenya makes it quite clear that these groups are still being ignored.
There may be isolated signs of people's behaviour changing in some ways. All sorts of movements may have achieved great things, especially relating to HIV treatment and increasing access to treatment. I certainly wouldn't claim that all the billions that have been poured into HIV for over two decades has been wasted. But I have yet to see clear evidence that HIV transmission has declined as a result of prevention efforts. I think the epidemic has its own dynamics, like any epidemic, but I am not convinced that the enormous Aids industry has had much influence on its course. I just hope I'm wrong.
With few exceptions, most SSA countries were doing very little to treat people with HIV or to prevent the transmission of HIV in the 1990s. Treatment was in its infancy and was inaccessible to the majority of Africans. And where prevention programmes had been implemented, they consisted of little more than mass education campaigns. They had very little influence on people's behaviour in the 1990s. And why would they have much influence? They had only started and only in a few countries, Uganda being one of the countries that started HIV prevention early. But even the nature and effectiveness of Uganda's HIV prevention campaign is still being hotly debated. Prevalence there has changed little in years and sexual behaviour indicators have long been sliding in the wrong direction.
What bothers me is that even if widespread prevention activities started in the mid 1990s, it would take many years for them to have much effect. That's if they actually had any effect at all. Ok, I can't research every country in SSA, but in the case of Kenya, very little was being done in the 1990s. It was only in the early 2000s that some serious work started, say 2002 or 2003. And the Kenya Aids Indicator Survey (KAIS) makes it quite clear that HIV prevalence, which had been dropping before 2003, actually increased and is now higher, after half a decade of HIV prevention work.
What I'm getting at is this: if rates of HIV transmission peaked in the mid nineties, then it did so for some reason other than the fact that every country had implemented widespread prevention programmes. The reason I suggest this is because prevention just wasn't a big thing then, at least, not big enough to explain why the epidemic started to 'decline'. I'm not saying that rates of transmission didn't drop, just that they didn't drop because of prevention programmes.
Another reason for thinking that prevention programmes didn't have much influence on rates of HIV transmission is because even after they did start, there is little evidence that they could have been the cause of the drop. There is plenty of evidence that most current HIV prevention programmes have little or no effect. In Kenya's case, scaling up HIV prevention programmes seem to have resulted in an increase in prevalence, the total number of people living with HIV. This doesn't tell us if transmission rates have decreased, so what about transmission? Are there still lots of people becoming newly infected?
According to the KAIS, transmission patterns are changing. Numbers infected in urban areas have dropped but numbers infected in rural areas have increased, especially among men. The majority of Kenyans, 75% or more, live in rural areas. Poorer and less well educated people are now being infected in greater numbers. The majority of poor and less well educated people live in rural areas and most Kenyans are poor and badly educated. These trends all follow what KAIS refer to as a 'rapid scale up of HIV prevention, care and treatment services'.
A recent article in AllAfrica.com quotes UNAIDS as claiming that their successful prevention and education programmes have *finally* begun to change the behaviour of those who are most at risk. If this is only happening in recent times, how can they claim that it had anything to do with a decline in incidence that began in the mid 1990s. But Kenya, along with many other SSA countries, have explicitly not targeted some of the groups who are thought to be most at risk, MSM, CSWs, IDUs and young women. The well presented 'Modes of Transmission Survey' for Kenya makes it quite clear that these groups are still being ignored.
There may be isolated signs of people's behaviour changing in some ways. All sorts of movements may have achieved great things, especially relating to HIV treatment and increasing access to treatment. I certainly wouldn't claim that all the billions that have been poured into HIV for over two decades has been wasted. But I have yet to see clear evidence that HIV transmission has declined as a result of prevention efforts. I think the epidemic has its own dynamics, like any epidemic, but I am not convinced that the enormous Aids industry has had much influence on its course. I just hope I'm wrong.
Sunday, February 7, 2010
Orphanages Versus Community Based Care
Given the numbers of orphaned, abandoned and otherwise needy children in developing countries such as Kenya, the issue of whether institutional or community based care is preferable is a difficult one. There are badly run institutions and well run ones. But there are also children who face their greatest dangers in their own homes, from their parents or from their carers. From what I can see in Kenya, social services often don't get involved in cases where things go wrong, either in institutions or in community care settings.
A study with a large sample size published a couple of months ago looked at both types of care, comparing cognitive functioning, emotion, behavior, physical health, and growth. The conclusion was that community care is not better and that, for some indicators, institutions are better. The authors of the study advise against aiming to transfer as many children as possible to some kind of community care setting. This is good advice if the children are in a well run institution or if an adequate level of community care can not be guaranteed.
However, the organisation I am working with, Ribbon of Hope, does not advocate merely keeping a child in their community. We advocate for children to be cared for with the support of other people in the community, in addition to their carer or carers. We would like to see children receive any state support to which they are entitled. And we would like to help provide their carer with the means to provide for the child.
Many children in institutions have one living parent and many more have close relatives who are living. But there are also children who may not have any close relatives or whose relatives are unknown and untraceable. So I wouldn't argue that there is no need for institutions to care for children.
But there are institutions that have been set up with the express aim of making money. I don't know how many of these bogus orphanages there are compared to legitimate orphanages. I just know that several bogus orphanages have been set up in the immediate area around Nakuru. There are also institutions that cannot cope with the number of children they are trying to provide for and conditions for the children, and even the staff, are terrible.
The only well run orphanages I have seen receive very large sums of money from benefactors. It's right that institutions providing for children receive large amounts of money, of course, but most institutions are not able to attract enough money and the children can suffer as a result. Keeping children in an institution usually costs a lot more than providing assistance for them to live in a family setting. Therefore, there may be a good case for more children being raised in a family setting when that is feasible.
In addition, many of these well run orphanages are funded by private donations and are at least partly administrated by foreigners. This is not a bad thing in itself but it does suggest a lack of sustainability and a high degree of dependency. It can be difficult enough for local people to confirm that children presented to them are really orphans but for non-local people it can be impossible. Some people see orphanages as an opportunity to cut their own costs by sending one or more of their children there and claiming the children belong to a deceased relative.
So the stark dichotomy between institutions and community care for orphans is not helpful. Both settings have their advantages and disadvantages. It is quite true that institutions should not aim to transfer as many children as possible to community care. But I think there should be fewer orphanages and far more children should be cared for in a well supported environment. Some of the money available, both state, donor and private, could better be used to provide families with everything they need to give a good home to children who have been orphaned, abandoned or are otherwise in need of care. The study in question is a good one, with a sound methodology, but I don't think it took into account the scenario where the carer is actively supported in providing care.
Incidentally, people often ask about how you can tell whether an orphanage is legitimate or not. They even ask the same question about charities, philanthropic organisations, philanthropists, NGOs, CBOs and the like. I don't have a list of things but the Information in Context blog gives advice on this and other matters. The only rule of thumb I have at the moment is that when people or organisations seem to obsess about numbers, size and quantities, to the exclusion of all other criteria, this can indicate that they are more interested in raising money than in changing things for the better. That always makes me suspicious.
A study with a large sample size published a couple of months ago looked at both types of care, comparing cognitive functioning, emotion, behavior, physical health, and growth. The conclusion was that community care is not better and that, for some indicators, institutions are better. The authors of the study advise against aiming to transfer as many children as possible to some kind of community care setting. This is good advice if the children are in a well run institution or if an adequate level of community care can not be guaranteed.
However, the organisation I am working with, Ribbon of Hope, does not advocate merely keeping a child in their community. We advocate for children to be cared for with the support of other people in the community, in addition to their carer or carers. We would like to see children receive any state support to which they are entitled. And we would like to help provide their carer with the means to provide for the child.
Many children in institutions have one living parent and many more have close relatives who are living. But there are also children who may not have any close relatives or whose relatives are unknown and untraceable. So I wouldn't argue that there is no need for institutions to care for children.
But there are institutions that have been set up with the express aim of making money. I don't know how many of these bogus orphanages there are compared to legitimate orphanages. I just know that several bogus orphanages have been set up in the immediate area around Nakuru. There are also institutions that cannot cope with the number of children they are trying to provide for and conditions for the children, and even the staff, are terrible.
The only well run orphanages I have seen receive very large sums of money from benefactors. It's right that institutions providing for children receive large amounts of money, of course, but most institutions are not able to attract enough money and the children can suffer as a result. Keeping children in an institution usually costs a lot more than providing assistance for them to live in a family setting. Therefore, there may be a good case for more children being raised in a family setting when that is feasible.
In addition, many of these well run orphanages are funded by private donations and are at least partly administrated by foreigners. This is not a bad thing in itself but it does suggest a lack of sustainability and a high degree of dependency. It can be difficult enough for local people to confirm that children presented to them are really orphans but for non-local people it can be impossible. Some people see orphanages as an opportunity to cut their own costs by sending one or more of their children there and claiming the children belong to a deceased relative.
So the stark dichotomy between institutions and community care for orphans is not helpful. Both settings have their advantages and disadvantages. It is quite true that institutions should not aim to transfer as many children as possible to community care. But I think there should be fewer orphanages and far more children should be cared for in a well supported environment. Some of the money available, both state, donor and private, could better be used to provide families with everything they need to give a good home to children who have been orphaned, abandoned or are otherwise in need of care. The study in question is a good one, with a sound methodology, but I don't think it took into account the scenario where the carer is actively supported in providing care.
Incidentally, people often ask about how you can tell whether an orphanage is legitimate or not. They even ask the same question about charities, philanthropic organisations, philanthropists, NGOs, CBOs and the like. I don't have a list of things but the Information in Context blog gives advice on this and other matters. The only rule of thumb I have at the moment is that when people or organisations seem to obsess about numbers, size and quantities, to the exclusion of all other criteria, this can indicate that they are more interested in raising money than in changing things for the better. That always makes me suspicious.
Tuesday, January 12, 2010
How Long Can We Continue to Ignore Those Who Are Still HIV Negative?
I was back in Mogotio with Ribbon of Hope today, weeding the watermelon beds in our latest shamba (smallholding). There were eight of us there today, three who were getting paid for the work. Others will get payment in kind. I have to be honest, I managed to do a few hard hours under the hot equatorial sun but I had to give up at lunchtime and I'm now stiff and sore. And there was at least two thirds of the field left to weed when I left!
But it's good to see the project get off the ground because it will provide some casual employment in an area that sees little work and it will provide some good food crops at low prices at a time when food prices are particularly high. In the next few months the shamba will require a lot of looking after, weeding, irrigating and security. There will be plenty of people willing to do some of that work.
Mogotio is only about 30 kilometers out of Nakuru, so it is by no means the most isolated place you'll find. But it feels isolated. There are very few NGOs that ever visit the place and I haven't been able to find out about anything they do. I saw a World Vision four wheel drive but none of the community leaders I asked could say what the organisation does there. UNHCR has been active in the area recently because hundreds were displaced by the heavy El Nino rains. There are over one hundred white UNHCR tents just outside the village, but that's an exception.
The area is almost entirely dominated by the sisal industry. There are a few factories, most of which don't operate very much. There is little money to be made by growing sisal and people who live in these areas don't make much of that money anyway, it's mostly made by the estate owner, who lives in Nairobi and rarely visits the area. Some of the people who work for or have worked for the factories are owed wages going back many years. Every now and again they get some money, but just a fraction of what they are owed.
Like a lot of parts of Kenya, HIV is widespread here but it receives little attention. Most NGOs are based in the cities and bigger towns. They work in or close to wealthy suburbs and rarely leave those areas for long. When they do, it's like a state visit, a convoy of huge, air conditioned, white, oversized vehicles, stirring up the dust and little else. HIV spreads more slowly in rural areas and that may be one of the reasons that less attention is paid to them than to urban areas. However, the majority of Kenyans, over 80%, live in rural areas.
And many more people in rural areas don't go to school or don't go to school very much, many don't have access to mainstream media, they don't have access to health or other social services and they have little or no connection with the benefits of the cities and towns. They are more isolated than their distance can explain. Every now and again something comes their way, probably not much, then the project or organisation leaves and loses touch.
But even some of these isolated areas have access to some HIV testing and counseling facilities and even the HIV drugs that most people are supposed to receive for free. They usually don't have access to any other kind of drugs and they are lucky if they can stay healthy, but it's a start. But treating more and more HIV positive people every year has little impact on reducing HIV transmission. Many more people become infected for every one person who gets treatment.
And HIV prevention really is a strange animal. In all the time HIV has been around, few methods of HIV prevention have been developed. A fraction of the money that goes into HIV goes towards prevention, less than 25% in Kenya. About half of that goes on prevention of mother to child transmission and the 12% that's left is spent on rather dubious projects that are known to be of little or no benefit.
A series of findings were presented at the 2006 Aids Conference that demonstrated that most kinds of HIV prevention programmes have a very small effect, some have a negative effect and the majority don't do anything. Consider the list: Voluntary Counseling and Testing, Condom Social Marketing, Mass Media, Abstinence-Based Interventions, Peer Education, Family Planning Counseling for HIV-Infected Women, Needle Exchange Programs, and the Effect of HIV Treatment on Risk Behavior.
The only one in the above list that has proved itself is needle exchange programmes. These have been known to be effective for a long time but they are strongly disapproved of by many funders, especially US funders, who feel that they increase drug use. They don't increase drug use, they reduce it and they have an impact on HIV transmission. But such programmes are of little relevance in Kenya as a whole and of virtually no relevance in a place like Mogotio.
The majority of HIV infections in Kenya come from heterosexual intercourse. A sizeable percentage comes from male to male intercourse. A debatable, possibly high percentage, comes from medical treatment, such as injections. But in rural areas, like Mogotio, people are in need of good education, health services, ordinary health services, not vertical interventions that treat HIV (or something else) alone, basic social services, infrastructure and things like that. There is no mystery about HIV transmission that makes its reduction intractable. People need a reasonable standard of living, they need security in their lives, especially food security, they need work, for which they get paid; just basic things that people in developed countries take for granted.
Yet more and more money continues to be poured into programmes that are unlikely to work or even ones that have been demonstrated not to work. In the case of Mogotio, of course, they don't even get these programmes most of the time. Money intended for the constituency appears to get stuck elsewhere and people are forced to plod along without even the most basic of their rights being realized. As long as people have so many problems in their lives and so little to aspire to, HIV will continue to be low on their list of priorities. If HIV is low on their list of priorities, even effective prevention programmes, if effective programmes exist, are destined to fail.
But it's good to see the project get off the ground because it will provide some casual employment in an area that sees little work and it will provide some good food crops at low prices at a time when food prices are particularly high. In the next few months the shamba will require a lot of looking after, weeding, irrigating and security. There will be plenty of people willing to do some of that work.
Mogotio is only about 30 kilometers out of Nakuru, so it is by no means the most isolated place you'll find. But it feels isolated. There are very few NGOs that ever visit the place and I haven't been able to find out about anything they do. I saw a World Vision four wheel drive but none of the community leaders I asked could say what the organisation does there. UNHCR has been active in the area recently because hundreds were displaced by the heavy El Nino rains. There are over one hundred white UNHCR tents just outside the village, but that's an exception.
The area is almost entirely dominated by the sisal industry. There are a few factories, most of which don't operate very much. There is little money to be made by growing sisal and people who live in these areas don't make much of that money anyway, it's mostly made by the estate owner, who lives in Nairobi and rarely visits the area. Some of the people who work for or have worked for the factories are owed wages going back many years. Every now and again they get some money, but just a fraction of what they are owed.
Like a lot of parts of Kenya, HIV is widespread here but it receives little attention. Most NGOs are based in the cities and bigger towns. They work in or close to wealthy suburbs and rarely leave those areas for long. When they do, it's like a state visit, a convoy of huge, air conditioned, white, oversized vehicles, stirring up the dust and little else. HIV spreads more slowly in rural areas and that may be one of the reasons that less attention is paid to them than to urban areas. However, the majority of Kenyans, over 80%, live in rural areas.
And many more people in rural areas don't go to school or don't go to school very much, many don't have access to mainstream media, they don't have access to health or other social services and they have little or no connection with the benefits of the cities and towns. They are more isolated than their distance can explain. Every now and again something comes their way, probably not much, then the project or organisation leaves and loses touch.
But even some of these isolated areas have access to some HIV testing and counseling facilities and even the HIV drugs that most people are supposed to receive for free. They usually don't have access to any other kind of drugs and they are lucky if they can stay healthy, but it's a start. But treating more and more HIV positive people every year has little impact on reducing HIV transmission. Many more people become infected for every one person who gets treatment.
And HIV prevention really is a strange animal. In all the time HIV has been around, few methods of HIV prevention have been developed. A fraction of the money that goes into HIV goes towards prevention, less than 25% in Kenya. About half of that goes on prevention of mother to child transmission and the 12% that's left is spent on rather dubious projects that are known to be of little or no benefit.
A series of findings were presented at the 2006 Aids Conference that demonstrated that most kinds of HIV prevention programmes have a very small effect, some have a negative effect and the majority don't do anything. Consider the list: Voluntary Counseling and Testing, Condom Social Marketing, Mass Media, Abstinence-Based Interventions, Peer Education, Family Planning Counseling for HIV-Infected Women, Needle Exchange Programs, and the Effect of HIV Treatment on Risk Behavior.
The only one in the above list that has proved itself is needle exchange programmes. These have been known to be effective for a long time but they are strongly disapproved of by many funders, especially US funders, who feel that they increase drug use. They don't increase drug use, they reduce it and they have an impact on HIV transmission. But such programmes are of little relevance in Kenya as a whole and of virtually no relevance in a place like Mogotio.
The majority of HIV infections in Kenya come from heterosexual intercourse. A sizeable percentage comes from male to male intercourse. A debatable, possibly high percentage, comes from medical treatment, such as injections. But in rural areas, like Mogotio, people are in need of good education, health services, ordinary health services, not vertical interventions that treat HIV (or something else) alone, basic social services, infrastructure and things like that. There is no mystery about HIV transmission that makes its reduction intractable. People need a reasonable standard of living, they need security in their lives, especially food security, they need work, for which they get paid; just basic things that people in developed countries take for granted.
Yet more and more money continues to be poured into programmes that are unlikely to work or even ones that have been demonstrated not to work. In the case of Mogotio, of course, they don't even get these programmes most of the time. Money intended for the constituency appears to get stuck elsewhere and people are forced to plod along without even the most basic of their rights being realized. As long as people have so many problems in their lives and so little to aspire to, HIV will continue to be low on their list of priorities. If HIV is low on their list of priorities, even effective prevention programmes, if effective programmes exist, are destined to fail.
Sunday, June 28, 2009
HIV Treatment is Necessary but not Sufficient for Eradication
The HIV in Kenya blog has covered many aspects of development in Kenya and other African countries because HIV is a symptom of underdevelopment, poor health systems, inadequate education and few, if any, social services. However, it has been primarily concerned with prevention of HIV, as opposed to treatment and care for those already infected with HIV. This is not because I consider treatment and care to be unimportant or because it is already over funded. On the contrary, treatment and care for people with HIV and Aids should be a vital part of any country's approach to reducing the spread of HIV.
If people who are HIV positive have no expectation of treatment or care, there is no reason why they should bother being tested. If people don't get tested and don't know their status, they could continue having sex with HIV negative people and thus spread HIV further. People who are found to be HIV positive can be advised on how to take precautions against spreading HIV. They can also receive antiretroviral therapy (ART), which, when they respond to it, makes them less likely to transmit HIV.
At present, many tens of thousands of people are on ART in Kenya. Most of them are able to live a healthy life, to work and provide for themselves and their families. Many of them have been provided with conditions that can reduce the probability of their transmitting HIV to their partners.
Admittedly, some treatment and care programmes are better than others. The programmes are very expensive and require a delicate balance, so treatment can be interrupted for many reasons, such as civil disturbance, financial problems, various disasters, food shortages, etc. The majority of people who are HIV positive and requiring treatment are still not receiving it, but there are also many people who would not be alive or healthy today if they were not receiving treatment.
This is good for HIV positive people, who may number as much as 1.5 million, sexually active people. In a population of around 40 million people, that's no small feat because these 1.5 million adults would have many dependents. Many millions of people are less directly affected by HIV but would be at far greater risk if they didn't have a parent, sibling or guardian to provide for them. When you add in dependents, maybe a quarter of the population of Kenya or more need ART to be rolled out to everyone who needs it.
But even if everyone who needed ART were to receive it, this would not cut the rate of HIV transmission to a level where the epidemic will eventually 'fizzle out'. Tens of thousands of people are being infected every year, more than are being put on ART every year. The epidemic may be bumping along, with prevalence lower than it was 10 years ago, when it peaked at 10%. But this is not a good situation, this is not something to celebrate. Prevalence dropped in the early 2000s because death rates were very high. Now that death rates are lower, prevalence is going up.
Treating and caring for people who are HIV positive is only one part of preventing people from becoming infected and, eventually, reducing infection to so low a level that the epidemic will cease to be the serious threat to the country that it is now and will be for the foreseeable future. At the moment, the amount of money spent on HIV prevention is estimated to be less than 25% of total spending. And much of the money being spent on HIV prevention seems to be having very little effect.
Much more money needs to be spent on researching and implementing viable prevention programmes. Treatment and care can only be a part of a country's overall HIV eradication programme. The disease won't just go away and, right now, the number of people requiring treatment, which they will need for the rest of their lives, is going up. Kenya can't afford to keep treating people at the rate that people are becoming newly infected; the world can't afford to keep treating people at the rate that people are becoming infected, globally.
HIV will not just die out unless new infections are reduced radically. Treatment and care programmes are very necessary but, on their own, are not sufficient to eradicate HIV.
If people who are HIV positive have no expectation of treatment or care, there is no reason why they should bother being tested. If people don't get tested and don't know their status, they could continue having sex with HIV negative people and thus spread HIV further. People who are found to be HIV positive can be advised on how to take precautions against spreading HIV. They can also receive antiretroviral therapy (ART), which, when they respond to it, makes them less likely to transmit HIV.
At present, many tens of thousands of people are on ART in Kenya. Most of them are able to live a healthy life, to work and provide for themselves and their families. Many of them have been provided with conditions that can reduce the probability of their transmitting HIV to their partners.
Admittedly, some treatment and care programmes are better than others. The programmes are very expensive and require a delicate balance, so treatment can be interrupted for many reasons, such as civil disturbance, financial problems, various disasters, food shortages, etc. The majority of people who are HIV positive and requiring treatment are still not receiving it, but there are also many people who would not be alive or healthy today if they were not receiving treatment.
This is good for HIV positive people, who may number as much as 1.5 million, sexually active people. In a population of around 40 million people, that's no small feat because these 1.5 million adults would have many dependents. Many millions of people are less directly affected by HIV but would be at far greater risk if they didn't have a parent, sibling or guardian to provide for them. When you add in dependents, maybe a quarter of the population of Kenya or more need ART to be rolled out to everyone who needs it.
But even if everyone who needed ART were to receive it, this would not cut the rate of HIV transmission to a level where the epidemic will eventually 'fizzle out'. Tens of thousands of people are being infected every year, more than are being put on ART every year. The epidemic may be bumping along, with prevalence lower than it was 10 years ago, when it peaked at 10%. But this is not a good situation, this is not something to celebrate. Prevalence dropped in the early 2000s because death rates were very high. Now that death rates are lower, prevalence is going up.
Treating and caring for people who are HIV positive is only one part of preventing people from becoming infected and, eventually, reducing infection to so low a level that the epidemic will cease to be the serious threat to the country that it is now and will be for the foreseeable future. At the moment, the amount of money spent on HIV prevention is estimated to be less than 25% of total spending. And much of the money being spent on HIV prevention seems to be having very little effect.
Much more money needs to be spent on researching and implementing viable prevention programmes. Treatment and care can only be a part of a country's overall HIV eradication programme. The disease won't just go away and, right now, the number of people requiring treatment, which they will need for the rest of their lives, is going up. Kenya can't afford to keep treating people at the rate that people are becoming newly infected; the world can't afford to keep treating people at the rate that people are becoming infected, globally.
HIV will not just die out unless new infections are reduced radically. Treatment and care programmes are very necessary but, on their own, are not sufficient to eradicate HIV.
Wednesday, April 8, 2009
IMF: a Sixty Year Old Limping Contradiction
I don't know if it is a coincidence but last year the Americans have finally said they would allow someone other than an American to hold the position of president of the IMF (International Monetary Fund), which they have dominated for 60 years. Will the Europeans also allow a non-European to be Managing Director? At the same time, many developing countries, recipients of IMF loans, have decided that the conditions attached to the loans cause more harm than good. So they have paid back their loans (Thailand, Brazil, Venezuela, Argentina, Indonesia). If this trend continues, the IMF could cease to exist.
Is it possible that the Americans see the IMF as an obsolescent institution? Well, perhaps not. Although the IMF appears to have been limping along for some time, the global financial crisis has prompted the G20 to add half a trillion dollars to its funds. The people who are tasked with dealing with the consequences of financial and banking liberalization are also promoting them, one of the IMF's favourite conditions being financial and banking liberalization.
Contradictions have never been a problem for the IMF or the World Bank. They give loans to countries to assist 'development' at the same time as they oversee the reduction of health, education, social services and infrastructure in the same countries. These are the very areas that are in need of development but if you've got the money, you get to decide on the ‘best’ route to development; even if that route is in the opposite direction to anything that could be described as development.
It's vaguely possible that the IMF, similar institutions and donor countries will one day start listening to their recipients. After all, many recipients have had clearer insights into what they need in order to achieve development that benefits their own people. But given their behaviour to date, it seems unlikely that these unwieldy institutions will change much for the better. One might almost think that they are not designed to benefit their recipients. (Remember the Goldenberg scandal in Kenya? Ok, it’s a bit of an easy target!)
A recent issue of Africa Focus (Africa: Global Economic Crisis 1-3) makes the point that developing countries have long been worried about the subsidies that developed countries paid to its farmers (while stipulating the removal of subsidies in developing countries as a condition of receiving loans). Now they also need to worry about subsidies being paid to financial institutions and the possible subsidies to be paid to manufacturing industries, such as the automotive industry. But those who have the money, again, get to make all the rules. Worse still, they also get to break the rules they later find they don't like.
The fiscal stimulus package is designed to favour American (and perhaps Western) interests, goods and services. The fact that Americans and Westerners own or have an interest in financial and other institutions, goods and services in developing countries does not mean that those developing countries will benefit from the package. Developing countries are not allowed to protect themselves, developed countries are.
It is almost laughable that one of the conditions the IMF and World Bank like to apply is an increase in democratic accountability and good governance. These institutions have no democratic accountability and their governance has been demonstrated to be flawed over and over again. Almost laughable, but the poorest people in the world suffer from these jokers’ repeated cock-ups.
Those responsible for the way international finance works have screwed up, badly. Yet the same people and institutions are also responsible for addressing these problems and they seem to be applying the same tired and failed solutions. The IMF is supposed to continue to give loans to developing countries with the same conditions that have been so destructive in the past. Even countries who have made some progress in reducing their indebtedness will now go back to where they were, at best.
The first and most practical thing the IMF and other donors can do is to cancel debts. Really cancel them, not just tinker around with the figures. These debts stem from loans that had impossible conditions attached to them. The recipients of these loans usually end up poorer as a result of the loans and, in reality, have paid them back many times over.
It's not developing countries that need to reform, it's institutions like the IMF. If they are to be in a position to assist developing countries, they need to face up to the reality of the mess they have made. They need to be more representative, they need good governance. Or perhaps the IMF has is finished? Perhaps the IMF now realises that is is an experiment that went on sixty years too long.
Is it possible that the Americans see the IMF as an obsolescent institution? Well, perhaps not. Although the IMF appears to have been limping along for some time, the global financial crisis has prompted the G20 to add half a trillion dollars to its funds. The people who are tasked with dealing with the consequences of financial and banking liberalization are also promoting them, one of the IMF's favourite conditions being financial and banking liberalization.
Contradictions have never been a problem for the IMF or the World Bank. They give loans to countries to assist 'development' at the same time as they oversee the reduction of health, education, social services and infrastructure in the same countries. These are the very areas that are in need of development but if you've got the money, you get to decide on the ‘best’ route to development; even if that route is in the opposite direction to anything that could be described as development.
It's vaguely possible that the IMF, similar institutions and donor countries will one day start listening to their recipients. After all, many recipients have had clearer insights into what they need in order to achieve development that benefits their own people. But given their behaviour to date, it seems unlikely that these unwieldy institutions will change much for the better. One might almost think that they are not designed to benefit their recipients. (Remember the Goldenberg scandal in Kenya? Ok, it’s a bit of an easy target!)
A recent issue of Africa Focus (Africa: Global Economic Crisis 1-3) makes the point that developing countries have long been worried about the subsidies that developed countries paid to its farmers (while stipulating the removal of subsidies in developing countries as a condition of receiving loans). Now they also need to worry about subsidies being paid to financial institutions and the possible subsidies to be paid to manufacturing industries, such as the automotive industry. But those who have the money, again, get to make all the rules. Worse still, they also get to break the rules they later find they don't like.
The fiscal stimulus package is designed to favour American (and perhaps Western) interests, goods and services. The fact that Americans and Westerners own or have an interest in financial and other institutions, goods and services in developing countries does not mean that those developing countries will benefit from the package. Developing countries are not allowed to protect themselves, developed countries are.
It is almost laughable that one of the conditions the IMF and World Bank like to apply is an increase in democratic accountability and good governance. These institutions have no democratic accountability and their governance has been demonstrated to be flawed over and over again. Almost laughable, but the poorest people in the world suffer from these jokers’ repeated cock-ups.
Those responsible for the way international finance works have screwed up, badly. Yet the same people and institutions are also responsible for addressing these problems and they seem to be applying the same tired and failed solutions. The IMF is supposed to continue to give loans to developing countries with the same conditions that have been so destructive in the past. Even countries who have made some progress in reducing their indebtedness will now go back to where they were, at best.
The first and most practical thing the IMF and other donors can do is to cancel debts. Really cancel them, not just tinker around with the figures. These debts stem from loans that had impossible conditions attached to them. The recipients of these loans usually end up poorer as a result of the loans and, in reality, have paid them back many times over.
It's not developing countries that need to reform, it's institutions like the IMF. If they are to be in a position to assist developing countries, they need to face up to the reality of the mess they have made. They need to be more representative, they need good governance. Or perhaps the IMF has is finished? Perhaps the IMF now realises that is is an experiment that went on sixty years too long.
Monday, April 6, 2009
A Short History of HIV in Kenya
[UPDATE: August 10 2014 - I am completely revising this short history and posting the new version in parts, on this blog and on my other blogs, Blogtivist.and Don't Get Stuck With HIV - Part I Part II Part III Part IV]
In response to a recent blog post on the history of the HIV epidemic in South Africa, I would like to provide a brief history of the HIV epidemic in Kenya.
Kenya had a very different history from South Africa. In fact, the histories of most African countries may share similarities but are also subtly different. Therefore, each country is now experiencing very different HIV epidemics and need different sets of HIV prevention interventions.
Following independence in the early 60s, Kenya under Kenyatta saw many changes, some good and some bad. Spending on education, health, infrastructure and various social services increased. The country underwent a transformation and enjoyed a level of prosperity that was unmatched, before or since.
The early independence period was not perfect, of course. Some gained, some remained in the position they had always been in. In general, many people were employed and social and economic indicators showed improvement. But at the same time, those in the Kenyatta government had already started the process of enriching themselves from the public purse.
It is important to note an advantage that Kenya had over some other African countries. They opposed the soviet regime and were well rewarded for the part they played in the cold war. Kenya continues to support the current ‘war against terror’ and appears to be generally sympathetic to US aggression. It is probably not an accident, therefore, that they currently receive the tenth highest share of US aid money.
So, while health, education and other social infrastructures were being built up during the 70s, politics and governance were taking shape to eventually undermine many of the earlier gains. Kenyatta died and was replaced by Moi in 1978. (The current president, Mwai Kibaki, held senior cabinet posts in the Kenyatta and Moi regimes, so there is a high level of continuity between the early independence years and the present decade.)
HIV probably first reached Kenya in the late 1970s, coming from the Western Equatorial region via Uganda and perhaps via Tanzania. This was still some years before it would be identified, though some health professionals working in Kenya at the time retrospectively noted an unusual health situation characterised by acute versions of relatively common conditions.
1980: retrospective tests of blood samples from Nairobi commercial sex workers (CSW) show zero HIV prevalence (the percentage found to be HIV positive), but a sexually transmitted infection (STI) programme was established. So the virus may well have already been present in other areas because in 1981, retrospective tests show a prevalence of 4%. Around this time the US Center for Disease Control (CDC) noted a new disease that affected gay men.
Kenya had been receiving loans from the International Monetary Fund (IMF) and the World Bank for some years but it was in the 1980s that these institutions started to build conditionality into its loans. ‘Structural Adjustment Policies’ (SAP), which resulted in reduced spending on education, health, infrastructure and social services, had an enormous impact on the country. When HIV prevention efforts started, belatedly, they were seriously curtailed by these SAPs.
These SAPs continue to this day, sometimes under different names. This is despite clear evidence that their effects are almost entirely destructive. They play a major part in what can only be described as retrogressive development and the sooner they are reformed the better. As long as developing countries are compelled to reduce health, education and other services, they will be unable to develop or, therefore, to reduce the spread of HIV.
1982: AIDS is named and vertical (mother to child) and heterosexual transmission are recognised. The following year a virus is identified that is suspected of causing AIDS. It is later named HIV and World Health Organisation (WHO) HIV surveillance starts. In 1984 the first case of HIV in Kenya is identified and in the following year the National AIDS Committee is established.
For the whole of the 1980s and 1990s, even into the 2000s, Kenyan leaders persisted in denying the existence of HIV. There was plenty of evidence that HIV was a serious problem in Nairobi because prevalence among CSWs there peaked at 81%. Prevalence subsequently declined, despite the fact that HIV prevention efforts were not very widespread until many years later. In fact, it remains unclear why prevalence peaked so early among CSWs and then declined.
1987: the WHO formed the Global Programme on AIDS. The following year, Kenya’s Ministry of Health issues guidelines stating that patients should be told their HIV status. In 1989, President Moi is said to have ordered the quarantining of people with HIV/AIDS but the order was quietly ignored. By 1990, there were an estimated 7.5 million people living with HIV, globally.
Without the Kenyan government substantially moving from their position of denial, HIV incidence (the number of new infections per year) peaked at 2%. Prevalence in one province, Rift Valley, peaks at 14% in the same year. At this time, Moi publicly refused to admit that the HIV epidemic had become national in scope. Prevalence peaks in Western Province at 17% in 1994 and the government as a whole recognises HIV as a critical issue.
But in 1995, the Kenyan government still seems uninterested in the epidemic. Donor funds are not distributed or go missing and, although the countries blood stocks are found to be unsafe, the government denies that this poses a major problem. At this time 17.5 million people are living with AIDS, globally. Prevalence in Nairobi peaks at 17% and national prevalence is estimated at between 10 and 14%.
1996: Highly Active Anti-Retroviral Therapy is developed (HAART). In the same year, a Kenyan cardinal condemns the use of condoms to prevent HIV infection. The following year, HIV prevalence peaks. Early prevalence figures were subsequently revised and it is now thought that HIV prevalence peaked at 9 or 10% in the late 1990s.
1997: UNAIDS (Joint United Nations Programme on HIV/AIDS) is formed. The Kenyan Parliament approves a 15 year national AIDS policy and forms the National AIDS Council. Moi bows to election year pressure from religious leaders and shelves sex education plans.
1998: incidence is thought to have peaked globally at around 3.4%. A large number of Kenyan public sector employees die as a result of AIDS. The Great Lakes Initiative on AIDS (GLIA) is established. The following year, HIV in the last of Kenya’s provinces peaks; North Western Province peaks at a relatively low rate, 6%, although this and other figures are often questioned.
In the same year, Moi declares AIDS a national disaster but is still reluctant to do anything about it. He says he feels it would be improper to encourage the use of condoms in schools and colleges. However, the National AIDS Control Council was formed and is still in operation.
2000: an estimated 27.5 million people are living with AIDS, globally. Kenya develops a five year National AIDS Strategic Plan and plans AIDS education for all schools and colleges. The Millennium Development Goals (MDG) are adopted by the international community and reducing the spread and impact of HIV are include in this initiative.
2001: the Global Fund to Fight AIDS, TB and Malaria (Global Fund) is formed by the World Bank. Moi, in the run up to another election, publicly expresses reluctance to spend public money on condoms. He recommends abstinence as protection against AIDS. Christian and Muslim leaders join him in opposing condoms.
2002: the new president, Mwai Kibaki, declares ‘Total War on AIDS’. However, the following year, Global Fund grants are withheld because of corruption allegations. Widespread corruption, misuse and disappearance of funds are discovered and, unusually, some people are held accountable.
2003: Kenya’s prevalence is found to have dropped to 6.7% and the death rate peaks at 120,000 per year. These are highly significant milestones. As HIV incidence peaked in 1993 and declined thereafter, it would follow that prevalence would peak some years later, around the end of the 90s, say. A few years after that, it follows that many people would die of AIDS and prevalence would drop dramatically. The first wave of the HIV epidemic ended in the early 2000s.
2005: globally, 37 million people are living with HIV. AIDS deaths peak at around 2.2 million. Kenyan prevalence is said to stand at around 6.1%. A new five year strategic plan, due to run up to 2010, is published. The following year, Kenyan prevalence is said to have fallen again, to around 5.1%.
2007: global prevalence is revised downwards as a result of improved reporting methods. HIV figures are confusing, but data collected in Kenya suggest that prevalence had been rising since 2004 and had reached 7.8%. This is despite the previous assumption that prevalence had been falling continuously since the late 90s and had dropped to about 5.1%
The data published in 2008 show rising prevalence and my interpretation is that this may indicate a ‘new wave’ of the HIV epidemic. On the other hand, it may indicate no such thing. Estimations are very imprecise and predictions are dangerous. Some say HIV in Kenya is declining, some say otherwise. Personally, given the apparent connections between the spread of HIV and the country’s history, I would suggest that that Kenya is in a worse state now than it was in the 1980s and is therefore experiencing another serious HIV epidemic.
Holding a pessimistic position when everyone wants something to be optimistic about is hazardous; people want you to be wrong. But, as I have said elsewhere on this blog, I too would like to be wrong. I am not an epidemiologist, I could well be ignoring many factors and exaggerating the effects of others. No doubt it will be some years before the true picture is known. It is to be hoped, in the meantime, that some effort is made to improve health, education, social services and governance. These are in serious need of attention, regardless of what the HIV epidemic is doing at present.
In response to a recent blog post on the history of the HIV epidemic in South Africa, I would like to provide a brief history of the HIV epidemic in Kenya.
Kenya had a very different history from South Africa. In fact, the histories of most African countries may share similarities but are also subtly different. Therefore, each country is now experiencing very different HIV epidemics and need different sets of HIV prevention interventions.
Following independence in the early 60s, Kenya under Kenyatta saw many changes, some good and some bad. Spending on education, health, infrastructure and various social services increased. The country underwent a transformation and enjoyed a level of prosperity that was unmatched, before or since.
The early independence period was not perfect, of course. Some gained, some remained in the position they had always been in. In general, many people were employed and social and economic indicators showed improvement. But at the same time, those in the Kenyatta government had already started the process of enriching themselves from the public purse.
It is important to note an advantage that Kenya had over some other African countries. They opposed the soviet regime and were well rewarded for the part they played in the cold war. Kenya continues to support the current ‘war against terror’ and appears to be generally sympathetic to US aggression. It is probably not an accident, therefore, that they currently receive the tenth highest share of US aid money.
So, while health, education and other social infrastructures were being built up during the 70s, politics and governance were taking shape to eventually undermine many of the earlier gains. Kenyatta died and was replaced by Moi in 1978. (The current president, Mwai Kibaki, held senior cabinet posts in the Kenyatta and Moi regimes, so there is a high level of continuity between the early independence years and the present decade.)
HIV probably first reached Kenya in the late 1970s, coming from the Western Equatorial region via Uganda and perhaps via Tanzania. This was still some years before it would be identified, though some health professionals working in Kenya at the time retrospectively noted an unusual health situation characterised by acute versions of relatively common conditions.
1980: retrospective tests of blood samples from Nairobi commercial sex workers (CSW) show zero HIV prevalence (the percentage found to be HIV positive), but a sexually transmitted infection (STI) programme was established. So the virus may well have already been present in other areas because in 1981, retrospective tests show a prevalence of 4%. Around this time the US Center for Disease Control (CDC) noted a new disease that affected gay men.
Kenya had been receiving loans from the International Monetary Fund (IMF) and the World Bank for some years but it was in the 1980s that these institutions started to build conditionality into its loans. ‘Structural Adjustment Policies’ (SAP), which resulted in reduced spending on education, health, infrastructure and social services, had an enormous impact on the country. When HIV prevention efforts started, belatedly, they were seriously curtailed by these SAPs.
These SAPs continue to this day, sometimes under different names. This is despite clear evidence that their effects are almost entirely destructive. They play a major part in what can only be described as retrogressive development and the sooner they are reformed the better. As long as developing countries are compelled to reduce health, education and other services, they will be unable to develop or, therefore, to reduce the spread of HIV.
1982: AIDS is named and vertical (mother to child) and heterosexual transmission are recognised. The following year a virus is identified that is suspected of causing AIDS. It is later named HIV and World Health Organisation (WHO) HIV surveillance starts. In 1984 the first case of HIV in Kenya is identified and in the following year the National AIDS Committee is established.
For the whole of the 1980s and 1990s, even into the 2000s, Kenyan leaders persisted in denying the existence of HIV. There was plenty of evidence that HIV was a serious problem in Nairobi because prevalence among CSWs there peaked at 81%. Prevalence subsequently declined, despite the fact that HIV prevention efforts were not very widespread until many years later. In fact, it remains unclear why prevalence peaked so early among CSWs and then declined.
1987: the WHO formed the Global Programme on AIDS. The following year, Kenya’s Ministry of Health issues guidelines stating that patients should be told their HIV status. In 1989, President Moi is said to have ordered the quarantining of people with HIV/AIDS but the order was quietly ignored. By 1990, there were an estimated 7.5 million people living with HIV, globally.
Without the Kenyan government substantially moving from their position of denial, HIV incidence (the number of new infections per year) peaked at 2%. Prevalence in one province, Rift Valley, peaks at 14% in the same year. At this time, Moi publicly refused to admit that the HIV epidemic had become national in scope. Prevalence peaks in Western Province at 17% in 1994 and the government as a whole recognises HIV as a critical issue.
But in 1995, the Kenyan government still seems uninterested in the epidemic. Donor funds are not distributed or go missing and, although the countries blood stocks are found to be unsafe, the government denies that this poses a major problem. At this time 17.5 million people are living with AIDS, globally. Prevalence in Nairobi peaks at 17% and national prevalence is estimated at between 10 and 14%.
1996: Highly Active Anti-Retroviral Therapy is developed (HAART). In the same year, a Kenyan cardinal condemns the use of condoms to prevent HIV infection. The following year, HIV prevalence peaks. Early prevalence figures were subsequently revised and it is now thought that HIV prevalence peaked at 9 or 10% in the late 1990s.
1997: UNAIDS (Joint United Nations Programme on HIV/AIDS) is formed. The Kenyan Parliament approves a 15 year national AIDS policy and forms the National AIDS Council. Moi bows to election year pressure from religious leaders and shelves sex education plans.
1998: incidence is thought to have peaked globally at around 3.4%. A large number of Kenyan public sector employees die as a result of AIDS. The Great Lakes Initiative on AIDS (GLIA) is established. The following year, HIV in the last of Kenya’s provinces peaks; North Western Province peaks at a relatively low rate, 6%, although this and other figures are often questioned.
In the same year, Moi declares AIDS a national disaster but is still reluctant to do anything about it. He says he feels it would be improper to encourage the use of condoms in schools and colleges. However, the National AIDS Control Council was formed and is still in operation.
2000: an estimated 27.5 million people are living with AIDS, globally. Kenya develops a five year National AIDS Strategic Plan and plans AIDS education for all schools and colleges. The Millennium Development Goals (MDG) are adopted by the international community and reducing the spread and impact of HIV are include in this initiative.
2001: the Global Fund to Fight AIDS, TB and Malaria (Global Fund) is formed by the World Bank. Moi, in the run up to another election, publicly expresses reluctance to spend public money on condoms. He recommends abstinence as protection against AIDS. Christian and Muslim leaders join him in opposing condoms.
2002: the new president, Mwai Kibaki, declares ‘Total War on AIDS’. However, the following year, Global Fund grants are withheld because of corruption allegations. Widespread corruption, misuse and disappearance of funds are discovered and, unusually, some people are held accountable.
2003: Kenya’s prevalence is found to have dropped to 6.7% and the death rate peaks at 120,000 per year. These are highly significant milestones. As HIV incidence peaked in 1993 and declined thereafter, it would follow that prevalence would peak some years later, around the end of the 90s, say. A few years after that, it follows that many people would die of AIDS and prevalence would drop dramatically. The first wave of the HIV epidemic ended in the early 2000s.
2005: globally, 37 million people are living with HIV. AIDS deaths peak at around 2.2 million. Kenyan prevalence is said to stand at around 6.1%. A new five year strategic plan, due to run up to 2010, is published. The following year, Kenyan prevalence is said to have fallen again, to around 5.1%.
2007: global prevalence is revised downwards as a result of improved reporting methods. HIV figures are confusing, but data collected in Kenya suggest that prevalence had been rising since 2004 and had reached 7.8%. This is despite the previous assumption that prevalence had been falling continuously since the late 90s and had dropped to about 5.1%
The data published in 2008 show rising prevalence and my interpretation is that this may indicate a ‘new wave’ of the HIV epidemic. On the other hand, it may indicate no such thing. Estimations are very imprecise and predictions are dangerous. Some say HIV in Kenya is declining, some say otherwise. Personally, given the apparent connections between the spread of HIV and the country’s history, I would suggest that that Kenya is in a worse state now than it was in the 1980s and is therefore experiencing another serious HIV epidemic.
Holding a pessimistic position when everyone wants something to be optimistic about is hazardous; people want you to be wrong. But, as I have said elsewhere on this blog, I too would like to be wrong. I am not an epidemiologist, I could well be ignoring many factors and exaggerating the effects of others. No doubt it will be some years before the true picture is known. It is to be hoped, in the meantime, that some effort is made to improve health, education, social services and governance. These are in serious need of attention, regardless of what the HIV epidemic is doing at present.
Wednesday, March 25, 2009
UNAIDS: a Development Paradox
A recent UNAIDS newsletter demonstrates the paradox of the existence of such an institution as UNAIDS, whose brief is a single, sexually transmitted virus, HIV. The newsletter concentrates on homophobia, harm reduction programmes for drug users, sex work and the role of condoms in reducing HIV transmission (and, presumably, other sexually transmitted infections and unwanted pregnancies).
The paradox stems from the reflection that all these issues predate HIV, they will probably all continue after the HIV pandemic has subsided, if that ever happens, and they are all very important issues in themselves. That is, their importance goes well beyond their connection with the transmission of HIV. Therefore, there were already programmes to address these issues before HIV was even heard of, so where does UNAIDS fit in?
Homophobia, for example, is abhorrent and an infringement on human rights. There are organisations all over the world fighting homophobia. Does the arrival of UNAIDS add to the work that these organisations are doing or does it water the message down? The message seems to become 'homophobia is bad because it plays a part in spreading HIV'. Homophobes may even see this as an endorsement of their position. Perhaps I'm wrong, perhaps UNAIDS strengthens these organisations and has a genuine role to play.
Harm reduction for drug users is another issue that has been associated with HIV transmission. Yet, evidence that harm reduction programmes work for injecting drug users has been around for a long time. It's only political pragmatism that has prevented such programmes from being implemented in many countries. Does relating these programmes to HIV reduction strengthen or weaken advocacy for harm reduction programmes?
UNAIDS have embraced the view that there is no single approach to HIV, that each country needs to gather detailed data on how HIV spread in their country and implement different approaches as appropriate to that context. I am one hundred percent in agreement with them as this is one of my own findings. But I saw that as an indication that UNAIDS may therefore be superfluous, however well intended. I think of all development issues are addressed, HIV reduction will not be such an intractable problem.
Commercial sex work (or transactional sex) is surrounded by numerous factors in the transmission of HIV. Sex workers are vulnerable because they are poor, or poorer than their clients, they are unprotected by the law and perhaps even victims of abuse by officers of the law, they are stigmatised by the public, they have little access to health and other social services, stemming from their poverty, lack of those services, their legal position, etc.
Sex workers suffer terribly, they have multiple vulnerabilities and, as a result, they often play an important part in the transmission of HIV. But they have suffered abuse and been denied their rights for as long as anyone can remember. This relates to HIV but HIV transmission stems from many other problems that are not just about HIV. Where does UNAIDS fit in here? Do they become advocates for the decriminalisation of sex work? This would be great but should they join other organisations already involved in such advocacy or is there a niche for them, somewhere?
The (male) condom is something of a symbol of the fight against HIV. They appear on websites about HIV, in particular, on UNAIDS's site. But condoms have been around for a long time and played a significant part in the decades of work carried out by those who believed that development simply meant population control. Those organisations, FHI (Family Health International), PSI (Population Services International), TFGI (The Futures Group International), and others, were spectacularly unsuccessful in getting condoms accepted. However, they were considered the most deserving recipients of hundreds of millions of the dollars that were subsequently ploughed into HIV reduction.
Is UNAIDS going to become one of them, a family planning organisation? There is no doubt that sexual and reproductive health are very important issues; they are also an important part of the fight against HIV but I think UNAIDS see themselves as playing all of the above roles. Yet they are playing all of those roles in an importantly qualified way. It seems that they are playing those roles to the extent that this will reduce HIV transmission.
Every single factor in the transmission of HIV needs to be addressed but also, every single factor that I can think of needs to be addressed, irrespective of its part in HIV transmission. Each factor in the transmission of HIV is also an area of underdevelopment. HIV spread in places where there are high levels of economic and gender inequality, poverty, poor health, low standards of education, low levels of social services, poor infrastructure, especially in the area of water and sanitation. Governance, legal institutions and civil society are also factors in the transmission of HIV.
UNAIDS have some of the best personnel in the HIV world, they have some of the best resources and they have access to pots of money. But I'm still at a loss to understand why HIV has been singled out from all other diseases and development problems and given this special UN institution. Especially as many of these other diseases and development problems played a crucial part in the spread of HIV.
I suppose the paradox is that there is a sense in which UNAIDS is concerned with all of these issues but is, at the same time, only concerned with HIV.
The paradox stems from the reflection that all these issues predate HIV, they will probably all continue after the HIV pandemic has subsided, if that ever happens, and they are all very important issues in themselves. That is, their importance goes well beyond their connection with the transmission of HIV. Therefore, there were already programmes to address these issues before HIV was even heard of, so where does UNAIDS fit in?
Homophobia, for example, is abhorrent and an infringement on human rights. There are organisations all over the world fighting homophobia. Does the arrival of UNAIDS add to the work that these organisations are doing or does it water the message down? The message seems to become 'homophobia is bad because it plays a part in spreading HIV'. Homophobes may even see this as an endorsement of their position. Perhaps I'm wrong, perhaps UNAIDS strengthens these organisations and has a genuine role to play.
Harm reduction for drug users is another issue that has been associated with HIV transmission. Yet, evidence that harm reduction programmes work for injecting drug users has been around for a long time. It's only political pragmatism that has prevented such programmes from being implemented in many countries. Does relating these programmes to HIV reduction strengthen or weaken advocacy for harm reduction programmes?
UNAIDS have embraced the view that there is no single approach to HIV, that each country needs to gather detailed data on how HIV spread in their country and implement different approaches as appropriate to that context. I am one hundred percent in agreement with them as this is one of my own findings. But I saw that as an indication that UNAIDS may therefore be superfluous, however well intended. I think of all development issues are addressed, HIV reduction will not be such an intractable problem.
Commercial sex work (or transactional sex) is surrounded by numerous factors in the transmission of HIV. Sex workers are vulnerable because they are poor, or poorer than their clients, they are unprotected by the law and perhaps even victims of abuse by officers of the law, they are stigmatised by the public, they have little access to health and other social services, stemming from their poverty, lack of those services, their legal position, etc.
Sex workers suffer terribly, they have multiple vulnerabilities and, as a result, they often play an important part in the transmission of HIV. But they have suffered abuse and been denied their rights for as long as anyone can remember. This relates to HIV but HIV transmission stems from many other problems that are not just about HIV. Where does UNAIDS fit in here? Do they become advocates for the decriminalisation of sex work? This would be great but should they join other organisations already involved in such advocacy or is there a niche for them, somewhere?
The (male) condom is something of a symbol of the fight against HIV. They appear on websites about HIV, in particular, on UNAIDS's site. But condoms have been around for a long time and played a significant part in the decades of work carried out by those who believed that development simply meant population control. Those organisations, FHI (Family Health International), PSI (Population Services International), TFGI (The Futures Group International), and others, were spectacularly unsuccessful in getting condoms accepted. However, they were considered the most deserving recipients of hundreds of millions of the dollars that were subsequently ploughed into HIV reduction.
Is UNAIDS going to become one of them, a family planning organisation? There is no doubt that sexual and reproductive health are very important issues; they are also an important part of the fight against HIV but I think UNAIDS see themselves as playing all of the above roles. Yet they are playing all of those roles in an importantly qualified way. It seems that they are playing those roles to the extent that this will reduce HIV transmission.
Every single factor in the transmission of HIV needs to be addressed but also, every single factor that I can think of needs to be addressed, irrespective of its part in HIV transmission. Each factor in the transmission of HIV is also an area of underdevelopment. HIV spread in places where there are high levels of economic and gender inequality, poverty, poor health, low standards of education, low levels of social services, poor infrastructure, especially in the area of water and sanitation. Governance, legal institutions and civil society are also factors in the transmission of HIV.
UNAIDS have some of the best personnel in the HIV world, they have some of the best resources and they have access to pots of money. But I'm still at a loss to understand why HIV has been singled out from all other diseases and development problems and given this special UN institution. Especially as many of these other diseases and development problems played a crucial part in the spread of HIV.
I suppose the paradox is that there is a sense in which UNAIDS is concerned with all of these issues but is, at the same time, only concerned with HIV.
Friday, January 30, 2009
No Such Number
Out of the eight provinces in Kenya, the two most disadvantaged, using a range of about 50 indicators, are North Eastern and Coast. The two most advantaged are Central and Nairobi. When you compare HIV prevalence, the two provinces with the highest rates are Nyanza and Nairobi and the two with the lowest are North Eastern and Central.
A broad range of advantages does not necessarily mean low HIV prevalence and a broad range of disadvantages does not necessarily mean high HIV prevalence. This is why it is important to look at development as a whole, rather than obsessing about HIV; it's just one disease and for many people, it is not even the worst thing that can happen.
If you look more closely at some districts you get even clearer insights into serious instances of underdevelopment. If you compare urban populations, they appear to have a lot of advantages over rural populations. But if you look at slums, and there are many in Kenya, you get a completely different picture. An estimated 71% of urban dwellers in Kenya live in slums (probably around 2.8 million people in Nairobi alone).
Some of the social indicators (health, education, infrastructure, etc) for slum areas are even poorer than they are in rural areas. Slums are growing, especially now as many IDPs are moving to urban areas. Others are moving from rural areas to find work, so there is particular pressure on urban areas right now.
A report published last year on the burden of disease in two of Nairobi's slums, Korogocho and Viwandani, list many features of these areas that differ from Nairobi as a whole. Although the report does not have the scope to measure HIV prevalence, it suggests that it, too, is higher there than in other parts of the country. Prevalence fell slightly in Nairobi between 2003 and 2008 but this is unlikely to reflect the situation in slums.
The report measures mortality in years of life lost to premature mortality (YLL). It found that under fives had four times the mortality rate of the rest of the population (standing at 692 years per 1,000 person years). The chief causes of death are pneumonia (22.8%) and diarrhoeal diseases (19.5%). It is notable that these two causes can be addressed, in part, by introducing intermediate technologies such as solar cookers and other techniques for sterilising water.
Infant mortality was 96.0, 82.6 and 81.8 per 1,000 live births for the years 2003, 2004 and 2005 respectively (compared to 79 per 1,000 nationally in 2005 and 96 per 1,000 in 1970). Under five mortality is 139.1, 119.1 and 121.4 per 1,000 live births (compared to 120 per 1,000 nationally in 2005 and 156 per 1,000 in 1970). Malnutrition is known to be an underlying cause for more than half of childhood deaths but may be underestimated by this survey methodology. Malnutrition and anaemia account for 8.4% of YLL.
In Nairobi province 20.3% of children are stunted, 6.3% of under fives are underweight and 2.1% suffer from wasting. Poor health and nutrition in children can be related to low maternal education, poverty, lack of food security, etc. Only 69.2% of children have full childhood immunisation. This suggests weak and inaccessible health systems and poor attendance at ante-natal clinics.
It is clear that nearly forty years of development has had little impact on infant and child mortality in Kenya. In fact these figures have mainly been disimproving nationally since the 1970s in Kenya. The HIV epidemic may have had some part in this but the trend started before HIV would have had much impact.
Among those over five years of age, around 50% of mortality is caused by HIV/AIDS and TB. TB has been counted with HIV because deaths caused by either are difficult to distinguish. Mortality in the population as a whole is 205 YLL per 1,000 person years.
Other findings are equally appalling: population density in this area is estimated to be 60,000 per square kilometre. Homicide is the second most common contributor to mortality (12.1%) in those over 5 years old. Road traffic accidents are the third most common (5.8%). These figures are higher than for Sub Saharan Africa as a whole
The ratio of males to females in these areas is similar to much of Nairobi and a large part of the population consists of those from productive age groups. Between the ages of 20 and 35, males outnumber females considerably. Where there are a lot of men relative to women, this can result in high levels of commercial/transactional sex. Nairobi had a particularly high ratio of males to females in the 1980s, a time when HIV was known to have spread very rapidly.
Health systems, clearly, are poor in these slum areas. Most people die outside the formal health care system. Verbal autopsy was used for the report in question but this has its limitations. Official death certificates are not common. For Nairobi as a whole, life expectancy is 57; 54.1 for men and 59.8 for women. 40% of people are not expected to survive to over 40, the worst figure for this indicator in the country. 54% of people have poor access to a qualified doctor.
The Human Development Index, a composite index widely used and recognised by the development community, is currently the highest in the country for Nairobi province. But this hides many problems faced by a huge number of the city’s population. The fact that many of the richest people in the country have a residence in Nairobi must distort many of the figures.
Slums are sometimes politely referred to as informal urban settlements or by some similar construction. They are barely alluded to by politicians and few official statistics exist to allow proper evaluation. But they are a reality for an increasing number of Kenyans, a reality that needs to be addressed now.
A broad range of advantages does not necessarily mean low HIV prevalence and a broad range of disadvantages does not necessarily mean high HIV prevalence. This is why it is important to look at development as a whole, rather than obsessing about HIV; it's just one disease and for many people, it is not even the worst thing that can happen.
If you look more closely at some districts you get even clearer insights into serious instances of underdevelopment. If you compare urban populations, they appear to have a lot of advantages over rural populations. But if you look at slums, and there are many in Kenya, you get a completely different picture. An estimated 71% of urban dwellers in Kenya live in slums (probably around 2.8 million people in Nairobi alone).
Some of the social indicators (health, education, infrastructure, etc) for slum areas are even poorer than they are in rural areas. Slums are growing, especially now as many IDPs are moving to urban areas. Others are moving from rural areas to find work, so there is particular pressure on urban areas right now.
A report published last year on the burden of disease in two of Nairobi's slums, Korogocho and Viwandani, list many features of these areas that differ from Nairobi as a whole. Although the report does not have the scope to measure HIV prevalence, it suggests that it, too, is higher there than in other parts of the country. Prevalence fell slightly in Nairobi between 2003 and 2008 but this is unlikely to reflect the situation in slums.
The report measures mortality in years of life lost to premature mortality (YLL). It found that under fives had four times the mortality rate of the rest of the population (standing at 692 years per 1,000 person years). The chief causes of death are pneumonia (22.8%) and diarrhoeal diseases (19.5%). It is notable that these two causes can be addressed, in part, by introducing intermediate technologies such as solar cookers and other techniques for sterilising water.
Infant mortality was 96.0, 82.6 and 81.8 per 1,000 live births for the years 2003, 2004 and 2005 respectively (compared to 79 per 1,000 nationally in 2005 and 96 per 1,000 in 1970). Under five mortality is 139.1, 119.1 and 121.4 per 1,000 live births (compared to 120 per 1,000 nationally in 2005 and 156 per 1,000 in 1970). Malnutrition is known to be an underlying cause for more than half of childhood deaths but may be underestimated by this survey methodology. Malnutrition and anaemia account for 8.4% of YLL.
In Nairobi province 20.3% of children are stunted, 6.3% of under fives are underweight and 2.1% suffer from wasting. Poor health and nutrition in children can be related to low maternal education, poverty, lack of food security, etc. Only 69.2% of children have full childhood immunisation. This suggests weak and inaccessible health systems and poor attendance at ante-natal clinics.
It is clear that nearly forty years of development has had little impact on infant and child mortality in Kenya. In fact these figures have mainly been disimproving nationally since the 1970s in Kenya. The HIV epidemic may have had some part in this but the trend started before HIV would have had much impact.
Among those over five years of age, around 50% of mortality is caused by HIV/AIDS and TB. TB has been counted with HIV because deaths caused by either are difficult to distinguish. Mortality in the population as a whole is 205 YLL per 1,000 person years.
Other findings are equally appalling: population density in this area is estimated to be 60,000 per square kilometre. Homicide is the second most common contributor to mortality (12.1%) in those over 5 years old. Road traffic accidents are the third most common (5.8%). These figures are higher than for Sub Saharan Africa as a whole
The ratio of males to females in these areas is similar to much of Nairobi and a large part of the population consists of those from productive age groups. Between the ages of 20 and 35, males outnumber females considerably. Where there are a lot of men relative to women, this can result in high levels of commercial/transactional sex. Nairobi had a particularly high ratio of males to females in the 1980s, a time when HIV was known to have spread very rapidly.
Health systems, clearly, are poor in these slum areas. Most people die outside the formal health care system. Verbal autopsy was used for the report in question but this has its limitations. Official death certificates are not common. For Nairobi as a whole, life expectancy is 57; 54.1 for men and 59.8 for women. 40% of people are not expected to survive to over 40, the worst figure for this indicator in the country. 54% of people have poor access to a qualified doctor.
The Human Development Index, a composite index widely used and recognised by the development community, is currently the highest in the country for Nairobi province. But this hides many problems faced by a huge number of the city’s population. The fact that many of the richest people in the country have a residence in Nairobi must distort many of the figures.
Slums are sometimes politely referred to as informal urban settlements or by some similar construction. They are barely alluded to by politicians and few official statistics exist to allow proper evaluation. But they are a reality for an increasing number of Kenyans, a reality that needs to be addressed now.
Sunday, January 4, 2009
Rights and Responsibilities
There is little doubt that a free press is vital to democracy, if that free press keeps people informed about what is going on in the country and in the world. If the free press chooses to print only what they deem newsworthy and seldom bothers to investigate anything that comes their way, it's hard to see how they could be so vital.
So I'm assuming that the Kenyan press has done at least some of the things that they should have been doing. Over the past year, there was certainly no shortage of things to report on. The press duly covered the issues and, in addition to covering the post election violence and political manoeuvrings, raised questions about water shortages, food shortages, MPs not paying taxes, fuel shortages and various other excesses.
They even went further than that. They suggested that some of the various shortages in the country were connected with certain politicians. The country needs more of this, and the press is to be congratulated. Perhaps they have improved from the time when coverage of issues concerning the HIV epidemic were sensationalist, moralising, inaccurate and slavishly copied from whatever source happened to be available.
Now, no one could accuse Mwai Kibaki of being inexperienced in politics or in his handling of the press. He held senior positions under Kenyatta and Moi and I assume he learned a lot during that period. He also seems to be putting some of that experience into practice by signing the 2008 Amendment to the Communications Bill of 1998. I wonder was his attitude towards Aids also influenced by that of Moi?
In 1989, it is said that Moi ordered the quarantining of all people found to be HIV positive. Thankfully, those receiving the order quietly failed to act on it. In 1993, he refused to accept that the epidemic had become national in scope. Yet later estimates suggest that nearly one million people were infected by 1993. It was also the year when the rate of new infections peaked and many thousands had already died.
In the mid 90s, the Kenyan government recognised Aids as a critical issue, but major donors were bypassing the government because they were not felt to be reliable when it came to spending the money. In 1997, the year the Kenyan parliament approved a 15 year national Aids policy, Moi, on this election year, gave in to religious leaders and dropped school sex education plans. By 1999 the man was willing to acknowledge that Aids was a national disaster but still felt it improper to encourage the use of condoms in schools and colleges. In 2001, still keeping step with religious leaders, he still spoke out against the use of public money to provide condoms.
By 2002, when the newly elected Kibaki declared total war on Aids, prevalence had already dropped to 6.6%, the lowest it had been since 1993. By the time either he or his predecessor had got around to being the leaders they were elected to be, it was too late for the tens of thousands who had already died and the approximately 1,600,000 who were HIV positive.
Of course, you can't blame Kibaki for that, he had only just been elected; the decline in HIV prevalence from the late 1990s was, to a large extent, due to a high death rate. As death rates declined, prevalence started to rise again. But in the years following Kibaki's presidency, large amounts of donor money continued to be unaccounted for. Eventually, people were found to be siphoning off the money for themselves and some of them have been convicted. But it's hard to detect any big change in HIV policy. Perhaps Kibaki, like Moi, was worried about the effect that the epidemic would have on the Kenyan tourist industry.
The current Kenyan National HIV/Aids Strategic Plan was published in 2005. It is due to run until 2010. However, it is largely based on the previous strategic plan, despite conditions being very different then. These two plans cover the period when HIV declined for a while, only to increase again. The prevention programmes seem to have had little effect. So it is to be hoped that the next plan is being researched at the moment and will be significantly different from the last two.
This gives the media time to do some investigative reporting, rather than waiting till the next strategic plan comes out and then merely noting its highlights. If they are to play a part in keeping people informed about how this government is doing in the fight against HIV, they need to do their research and constantly update people. It's not enough to blast out a few articles around World Aids Day, echo sensationalist rubbish from the international press or cover visits by bloated celebrities who are currently on the HIV bandwagon.
I believe there are some intelligent people working for the Kenyan press. I hope we see more evidence of that when it comes to coverage of issues such as poverty, especially rural poverty, rural neglect and lack of access to social services, inequality, especially gender inequalities, sexual and gender related violence and abuse and labour related practices that compromise human rights. The list is not exhaustive but it's a good start.
Perhaps it is because the government got away with ignoring the plight of some of the most vulnerable people in the country for so long that they thought gagging the press would be relatively easy.
So I'm assuming that the Kenyan press has done at least some of the things that they should have been doing. Over the past year, there was certainly no shortage of things to report on. The press duly covered the issues and, in addition to covering the post election violence and political manoeuvrings, raised questions about water shortages, food shortages, MPs not paying taxes, fuel shortages and various other excesses.
They even went further than that. They suggested that some of the various shortages in the country were connected with certain politicians. The country needs more of this, and the press is to be congratulated. Perhaps they have improved from the time when coverage of issues concerning the HIV epidemic were sensationalist, moralising, inaccurate and slavishly copied from whatever source happened to be available.
Now, no one could accuse Mwai Kibaki of being inexperienced in politics or in his handling of the press. He held senior positions under Kenyatta and Moi and I assume he learned a lot during that period. He also seems to be putting some of that experience into practice by signing the 2008 Amendment to the Communications Bill of 1998. I wonder was his attitude towards Aids also influenced by that of Moi?
In 1989, it is said that Moi ordered the quarantining of all people found to be HIV positive. Thankfully, those receiving the order quietly failed to act on it. In 1993, he refused to accept that the epidemic had become national in scope. Yet later estimates suggest that nearly one million people were infected by 1993. It was also the year when the rate of new infections peaked and many thousands had already died.
In the mid 90s, the Kenyan government recognised Aids as a critical issue, but major donors were bypassing the government because they were not felt to be reliable when it came to spending the money. In 1997, the year the Kenyan parliament approved a 15 year national Aids policy, Moi, on this election year, gave in to religious leaders and dropped school sex education plans. By 1999 the man was willing to acknowledge that Aids was a national disaster but still felt it improper to encourage the use of condoms in schools and colleges. In 2001, still keeping step with religious leaders, he still spoke out against the use of public money to provide condoms.
By 2002, when the newly elected Kibaki declared total war on Aids, prevalence had already dropped to 6.6%, the lowest it had been since 1993. By the time either he or his predecessor had got around to being the leaders they were elected to be, it was too late for the tens of thousands who had already died and the approximately 1,600,000 who were HIV positive.
Of course, you can't blame Kibaki for that, he had only just been elected; the decline in HIV prevalence from the late 1990s was, to a large extent, due to a high death rate. As death rates declined, prevalence started to rise again. But in the years following Kibaki's presidency, large amounts of donor money continued to be unaccounted for. Eventually, people were found to be siphoning off the money for themselves and some of them have been convicted. But it's hard to detect any big change in HIV policy. Perhaps Kibaki, like Moi, was worried about the effect that the epidemic would have on the Kenyan tourist industry.
The current Kenyan National HIV/Aids Strategic Plan was published in 2005. It is due to run until 2010. However, it is largely based on the previous strategic plan, despite conditions being very different then. These two plans cover the period when HIV declined for a while, only to increase again. The prevention programmes seem to have had little effect. So it is to be hoped that the next plan is being researched at the moment and will be significantly different from the last two.
This gives the media time to do some investigative reporting, rather than waiting till the next strategic plan comes out and then merely noting its highlights. If they are to play a part in keeping people informed about how this government is doing in the fight against HIV, they need to do their research and constantly update people. It's not enough to blast out a few articles around World Aids Day, echo sensationalist rubbish from the international press or cover visits by bloated celebrities who are currently on the HIV bandwagon.
I believe there are some intelligent people working for the Kenyan press. I hope we see more evidence of that when it comes to coverage of issues such as poverty, especially rural poverty, rural neglect and lack of access to social services, inequality, especially gender inequalities, sexual and gender related violence and abuse and labour related practices that compromise human rights. The list is not exhaustive but it's a good start.
Perhaps it is because the government got away with ignoring the plight of some of the most vulnerable people in the country for so long that they thought gagging the press would be relatively easy.
Thursday, December 4, 2008
HIV: Exceptional or Exceptionalised?
Controversy can often lead to a polarisation of views, where neither version is particularly tenable. Some people take the view that HIV is just a result of poverty. Others point to the fact that wealthier people in Kenya are infected in larger numbers than the less well off. Still others may take the view that the truth is somewhere in the middle, but this fails to put a finger on the part that wealth and poverty play in the transmission of HIV.
If a single man goes to a bar, almost any bar in Nairobi, Dar es Salaam, Kisumu, Kigoma, Mumias, Tanga, probably anywhere in East Africa, he will soon be approached by a woman or even two or three women. They could directly ask for a drink or just make idle conversation before the suggestion or implication of sex comes up.
The term 'commercial sex work' (well, there are far worse terms) can be used for this phenomenon. But it would be a mistake to think that money is always involved or that there is always a one for one transaction.
Anyhow, casual sex of any kind carries the risk of the transmission of HIV and other sexually transmitted diseases. It also carries other risks, stigmatisation, violence and abuse, even imprisonment, though these risks are usually experienced disproportionately by women.
Many pronouncements on HIV and how it should be prevented concentrate on casual sex, multiple sex partners, sex without condoms and the rest. In a sense, they are right, these are factors in the spread of HIV. But how about the reasons why large numbers of women (usually women), young and not so young, spend evenings in bars and nights with strangers?
HIV is, I would suggest, not spread merely because of low moral standards. At least, it is not the moral standards of these 'commercial sex workers' that should be in question. There may be people who are quite happy to do sex work but people here that I have talked to only do it because they have to. Being poor is not immoral, neither is being desperate.
On the other hand, the sort of danger, stigma and discrimination faced by people involved in commercial sex work, or reputed to be involved in commercial sex work, should be seriously questioned. There are also some men involved in, what is by definition, a transaction. Yet it is the commercial sex workers that are condemned by the moralists, punished by the law, denied protection and denied health care by the state.
If the moralists find transactional sex so repulsive, why are there not campaigns to give work or financial support to people who otherwise have no alternative? HIV prevention campaigns are all very well, but when you're down and out you'll do anything. You will not 'abstain' or 'be faithful' and you will probably not have the choice about whether to use a condom or not.
So there go the ABC campaigns we hear so much about, to say nothing of the abstinence only campaigns.
In fact, as economic conditions get worse, people engaged in commercial sex work need to take more risks, have more partners and probably use condoms less. Ok, if everyone suffers from worsening economic conditions, even the over paid and under taxed politicians, there will also be fewer customers, or each customer will pay less. But then the sex worker needs to work even harder and do whatever guarantees some money rather than none.
So, what is the relationship between wealth or poverty and HIV transmission? Commercial sex workers are, generally, poor. Their clients can be rich or not so rich, influential or not so influential. If you are rich you have many choices; if you are poor you have few choices. If you are a commercial sex worker, you have probably made the last choice you can make.
Some of the women who work in the bars in Kenya work in the informal sector, perhaps selling something in the market, some work in poorly paid jobs and some are unemployed or have too many dependents to think of working outside the home during the day. Even if they have an income, it may not be enough to pay the rent or various costs, such as healthcare or materials for children's schooling or food.
The money needs to come from somewhere, banks here are not falling over themselves to give out loans to the very poor.
In Kenya, most people are very poor, probably equally poor. In other words, about half the people live on an income that is below the poverty line.
Very few people are very rich. However, if wealth quintiles are compared, sure enough, HIV prevalence is higher in the highest quintile. Maybe it is to some extent the very level of inequality that is associated with high HIV rates.
Nairobi is one of the wealthiest provinces in Kenya. This is despite having some of the biggest and worst slums in Africa. Nairobi also has very high levels of wealth inequality and high rates of HIV. North Eastern province has the lowest HIV prevalence in Kenya and low levels of inequality. In North Eastern province, most people are poor, equally poor.
In contrast to this, Central province also has high levels of inequality and low HIV, so the relationship between inequality and HIV is as difficult to define as that between absolute wealth and poverty and HIV.
Whatever people's economic status, it is difficult to legislate over or even indicate how they should behave. Sex is not a crime. And if transactional sex is a crime, it should be a crime that has two (at least) culprits per instance. Perhaps countries like Kenya feel they should go down the route of curbing transactional sex, however they think are going to achieve that. They haven't done so well to date.
But perhaps they will go down the route of figuring out why there are so many poor, vulnerable, desperate people, especially women. Perhaps they will think about the human rights of women and their entitlement to the same rights as those enjoyed by men and by wealthier people.
Poverty and wealth inequalities existed before HIV; if a cure was found for HIV today, there would still be poverty and wealth inequalities, bad health, low levels of education and low levels of social services. These all pertain to human rights and if people feel moral repugnance, it should at the denial of these rights to so many people for so long. People’s rights to these benefits are not conditional on that reducing the spread of HIV.
I don’t know exactly what the relationship is between wealth and poverty and HIV. I think poverty, inequality and HIV are all worth fighting. I also think we know a lot more about fighting poverty and inequality, so maybe we could concentrate on them, rather than on seeing HIV as this extraordinary disease, the first ever disease to be completely independent of all social and economic conditions.
If a single man goes to a bar, almost any bar in Nairobi, Dar es Salaam, Kisumu, Kigoma, Mumias, Tanga, probably anywhere in East Africa, he will soon be approached by a woman or even two or three women. They could directly ask for a drink or just make idle conversation before the suggestion or implication of sex comes up.
The term 'commercial sex work' (well, there are far worse terms) can be used for this phenomenon. But it would be a mistake to think that money is always involved or that there is always a one for one transaction.
Anyhow, casual sex of any kind carries the risk of the transmission of HIV and other sexually transmitted diseases. It also carries other risks, stigmatisation, violence and abuse, even imprisonment, though these risks are usually experienced disproportionately by women.
Many pronouncements on HIV and how it should be prevented concentrate on casual sex, multiple sex partners, sex without condoms and the rest. In a sense, they are right, these are factors in the spread of HIV. But how about the reasons why large numbers of women (usually women), young and not so young, spend evenings in bars and nights with strangers?
HIV is, I would suggest, not spread merely because of low moral standards. At least, it is not the moral standards of these 'commercial sex workers' that should be in question. There may be people who are quite happy to do sex work but people here that I have talked to only do it because they have to. Being poor is not immoral, neither is being desperate.
On the other hand, the sort of danger, stigma and discrimination faced by people involved in commercial sex work, or reputed to be involved in commercial sex work, should be seriously questioned. There are also some men involved in, what is by definition, a transaction. Yet it is the commercial sex workers that are condemned by the moralists, punished by the law, denied protection and denied health care by the state.
If the moralists find transactional sex so repulsive, why are there not campaigns to give work or financial support to people who otherwise have no alternative? HIV prevention campaigns are all very well, but when you're down and out you'll do anything. You will not 'abstain' or 'be faithful' and you will probably not have the choice about whether to use a condom or not.
So there go the ABC campaigns we hear so much about, to say nothing of the abstinence only campaigns.
In fact, as economic conditions get worse, people engaged in commercial sex work need to take more risks, have more partners and probably use condoms less. Ok, if everyone suffers from worsening economic conditions, even the over paid and under taxed politicians, there will also be fewer customers, or each customer will pay less. But then the sex worker needs to work even harder and do whatever guarantees some money rather than none.
So, what is the relationship between wealth or poverty and HIV transmission? Commercial sex workers are, generally, poor. Their clients can be rich or not so rich, influential or not so influential. If you are rich you have many choices; if you are poor you have few choices. If you are a commercial sex worker, you have probably made the last choice you can make.
Some of the women who work in the bars in Kenya work in the informal sector, perhaps selling something in the market, some work in poorly paid jobs and some are unemployed or have too many dependents to think of working outside the home during the day. Even if they have an income, it may not be enough to pay the rent or various costs, such as healthcare or materials for children's schooling or food.
The money needs to come from somewhere, banks here are not falling over themselves to give out loans to the very poor.
In Kenya, most people are very poor, probably equally poor. In other words, about half the people live on an income that is below the poverty line.
Very few people are very rich. However, if wealth quintiles are compared, sure enough, HIV prevalence is higher in the highest quintile. Maybe it is to some extent the very level of inequality that is associated with high HIV rates.
Nairobi is one of the wealthiest provinces in Kenya. This is despite having some of the biggest and worst slums in Africa. Nairobi also has very high levels of wealth inequality and high rates of HIV. North Eastern province has the lowest HIV prevalence in Kenya and low levels of inequality. In North Eastern province, most people are poor, equally poor.
In contrast to this, Central province also has high levels of inequality and low HIV, so the relationship between inequality and HIV is as difficult to define as that between absolute wealth and poverty and HIV.
Whatever people's economic status, it is difficult to legislate over or even indicate how they should behave. Sex is not a crime. And if transactional sex is a crime, it should be a crime that has two (at least) culprits per instance. Perhaps countries like Kenya feel they should go down the route of curbing transactional sex, however they think are going to achieve that. They haven't done so well to date.
But perhaps they will go down the route of figuring out why there are so many poor, vulnerable, desperate people, especially women. Perhaps they will think about the human rights of women and their entitlement to the same rights as those enjoyed by men and by wealthier people.
Poverty and wealth inequalities existed before HIV; if a cure was found for HIV today, there would still be poverty and wealth inequalities, bad health, low levels of education and low levels of social services. These all pertain to human rights and if people feel moral repugnance, it should at the denial of these rights to so many people for so long. People’s rights to these benefits are not conditional on that reducing the spread of HIV.
I don’t know exactly what the relationship is between wealth and poverty and HIV. I think poverty, inequality and HIV are all worth fighting. I also think we know a lot more about fighting poverty and inequality, so maybe we could concentrate on them, rather than on seeing HIV as this extraordinary disease, the first ever disease to be completely independent of all social and economic conditions.
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