In many developing countries, a substantial majority of people live in rural areas. The majority of rural dwellers depend, directly or indirectly, on agriculture of some kind. And most of those engaged in agriculture are smallholders, producing food for their families, their local market and perhaps a bit beyond that. Even a lot of people who don't depend on agriculture grow some food for their own use. Small scale food crops, fodder crops and stock keeping is so widespread in Kenya, where over 80% of the population lives in rural areas, that it would be difficult to estimate their value in the overall economy.
On the other hand, 'aid' from the UK's Department for International Development (DfID), seems to assume that the best way to help poor people in developing countries is to give the bulk of their money to large and wealthy sectors of agriculture. DfID favour large-scale agriculture, high use of expensive, environmentally destructive technologies, such as fertilizer, pesticide, various pharmaceutical products, heavy machinery and genetically modified organisms (GMO).
Small farmers, who can't afford these technologies and who are stuck with relatively undestructive farming methods that preserve biodiversity are therefore denied the opportunity to investigate ways of increasing their yields in sustainable ways. DfID seems particularly opposed to the production of food crops and stocks, spending only 3% of their of aid on food (.3% in Sub-Saharan Africa). MPs are calling for the figure to be raised to 10%.
DfID probably hasn't realised that these small farmers produce most of the food that people live on in Kenya. Many of the rich farmers in Kenya produce for export, things such as tea and coffee and a lot of non-food crops such as flowers and sisal. A lot of land is even being used to produce crops for biofuel, which, whether for export or the domestic market, is not going to help starving people very much. DfID even supports programmes that 'donate' food aid, which is just a form of dumping that suits Western countries but serves only to destroy local markets in developing countries and leaves many of the putative recipients worse off than they were before.
Any institution that supports GMOs has no right to call itself an 'aid' agency. GMOs are the prerogative of wealthy and rapacious multinationals who want to control the food market in order to maximize their profits. Such institutions also have no regard for the importance of biodiversity, which is under serious enough threat but will be even more rapidly destroyed by widespread use of GMOs. An example is the current attempt to introduce genetically modified aubergine (eggplant, brinjal) into India, where there are currently several thousand varieties. If these modified aubergines are introduced, all others will either die out or become contaminated.
Every few weeks there is an article about some kind of crop that will supposedly save a country or reduce levels of malnutrition or increase yields or whatever. These articles don't usually say so, but if you check further, you'll often find that the crop in question is genetically modified. The article may even talk about biodiversity and sustainability and all sorts of lovely things. But if GM is involved, then neither biodiversity nor sustainability are involved.
There are many reasons why GMOs should not be grown anywhere, yet some GMOs now dominate in a few countries, such as cotton in India and maize and soya in the US. Many farmers in countries like India, the US and Canada are now regretting the fact that they bought into GM but it's very hard to get back out again. Yet the industry still churns out its lies about GM being high yielding, uses less pesticides and herbicides, is more drought resistant, grows well in marginal land, etc. It's hard to understand why so many seem to fall for their lies.
But DfID, with all its money and expertise, could not possibly be in the dark about the dangers of GM or even the inappropriateness of funding only large scale, industrial agriculture in developing countries. The question is, who has nobbled them and what are they getting out of supporting the biotechnology and other industries that stand to profit from their big spending?
Showing posts with label retrogressive development. Show all posts
Showing posts with label retrogressive development. Show all posts
Monday, February 8, 2010
Friday, May 22, 2009
How to Save a Failing Church
A Nigerian bishop, the Archbishop of Ibadan, recently became one of the many defenders of the pope’s infamously garbled pronouncement on condoms. The fact that the pope’s statement was garbled makes it easy for people to either reinterpret it in a favourable light or in an unfavourable light, whatever suits their purposes. But the problem is that the statement did not give the sort of clarity that many people seek.
Previously, the pope has opposed the use of condoms under any circumstances and advocated abstinence and fidelity as a response to the HIV pandemic. Christians sought clarification because they felt that abstinence and fidelity were great in theory but were not feasible for many people. And even if they were achievable for some, they were not necessarily achievable for their partners, for sex workers, for victims of sexual assault, etc.
Some Catholics and Christians went even further and preached that condoms had holes that allowed HIV virus through or that condoms are very unreliable or that they often burst.
So the guidance that people received from the church ranged from unfeasible to vague to untrue. It’s little wonder that Catholics and Christians were left to do what most of them have been doing for generations: using their own interpretation and doing the best they could.
But there are people who take what they hear from church leaders rather more literally, either because they feel that’s what it is to be a Catholic or Christian or because that particular course of action suits them. So there are people who waited till they were married before having sex only to be infected by their partner. Others ended up with more children than they could provide for. Others didn’t have any choice about whether to have sex, when or with whom.
The Nigerian bishop claims that the pope’s statement is about people’s sexual behaviour and that people’s sexual behaviour is behind the HIV pandemic. But if the bishop (and the pope) were to think about it a little more carefully, they would see that sexual behaviour does not occur in a vacuum. People’s behaviour and sexual behaviour are determined by other circumstances. Just as TB is airborne, you don’t prevent transmission of TB by telling people to stop breathing, so you won’t reduce HIV transmission by merely trying to legislate over people’s sexual behaviour.
For example (and it is only one example), there are many women who have no option but to have sex in exchange for money or other benefits, because they have no job or because they have too low an income; they are desperate and need the money immediately; they don’t want to have sex with strange men and expose themselves to all sorts of dangers, they have no option. Do the church leaders understand any of this?
Some women find that if they apply for jobs they have to pay a substantial amount of money to secure a position. Others find that they are expected to sleep with their boss in order to be selected for a job, to keep a job or to improve their income, sometimes very slightly. Is this even a viable alternative to commercial sex work? I don’t think so.
So if church leaders are concerned about people’s behaviour, sexual or otherwise, they should take a look at people’s circumstances, the way people live. No matter how devout people are, they need to provide for their family, for their dependents and for themselves. To criticize the pope and other church leaders for failing to see this is not polemic. Preachings that are manufactured in one of the richest states in the world have little relevance to the lives of people in the poorest states in the world.
Church leaders, firstly, take a look at the realities of people’s lives, engage with the real problems, not the ones you wish to prognosticate over; secondly, make your prognostications clear and unambiguous; thirdly, engage with debates honestly, don’t resort to the lies and fabrication which you have relied on for so long.
If you want the respect and obedience of your followers you have to earn it.
The Nigerian bishop also makes a comment about Africa being used as “a guinea pig of foreign business ventures”. This is a valid point but Africa is just as much a ‘market’ and a ‘business venture’ for the churches, too. The churches also come up with slogans and marketing campaigns because they are also businesses who stand to gain or lose large amounts of money. They compete with other business, though they may see themselves as being above business and commerce.
Finally, the bishop makes the often made remark about distributing condoms increasing the “sexual waywardness of the continents’ [sic] youth who have access to it” and promoting “sexual recklessness”. Despite the claims of various churches, distributing condoms, teaching children about sex and safe sex and various other measures, does not give rise to higher levels of unsafe sexual behaviour. On the contrary, children who know about sex and safe sex delay having sex for the first time and are more likely to take precautions when they do have sex.
If the churches really have compassion, if they really care about the welfare of their followers, they need to look at how people live, how their behaviour and sexual behaviour are determined. Human dignity is not about doctrine and dogma, it is about basic human rights. People are being denied their rights and the church would do well to address this issue, rather than shoring up their dubious philosophies with pseudo scientific claptrap.
Of course, church leaders could lead by example, observing vows of poverty, chastity and obedience, for instance. But many seem to have chosen to live in wealth. Their chastity has often been open to question. And their obedience often appears to be to political interests, commercial interests and even human desires for power, sexual gratification, etc, rather than to any spiritual authority.
Church leaders, come and live like the majority of human beings and you’ll find yourselves rewriting your vast tomes in a language that most people will readily understand.
Previously, the pope has opposed the use of condoms under any circumstances and advocated abstinence and fidelity as a response to the HIV pandemic. Christians sought clarification because they felt that abstinence and fidelity were great in theory but were not feasible for many people. And even if they were achievable for some, they were not necessarily achievable for their partners, for sex workers, for victims of sexual assault, etc.
Some Catholics and Christians went even further and preached that condoms had holes that allowed HIV virus through or that condoms are very unreliable or that they often burst.
So the guidance that people received from the church ranged from unfeasible to vague to untrue. It’s little wonder that Catholics and Christians were left to do what most of them have been doing for generations: using their own interpretation and doing the best they could.
But there are people who take what they hear from church leaders rather more literally, either because they feel that’s what it is to be a Catholic or Christian or because that particular course of action suits them. So there are people who waited till they were married before having sex only to be infected by their partner. Others ended up with more children than they could provide for. Others didn’t have any choice about whether to have sex, when or with whom.
The Nigerian bishop claims that the pope’s statement is about people’s sexual behaviour and that people’s sexual behaviour is behind the HIV pandemic. But if the bishop (and the pope) were to think about it a little more carefully, they would see that sexual behaviour does not occur in a vacuum. People’s behaviour and sexual behaviour are determined by other circumstances. Just as TB is airborne, you don’t prevent transmission of TB by telling people to stop breathing, so you won’t reduce HIV transmission by merely trying to legislate over people’s sexual behaviour.
For example (and it is only one example), there are many women who have no option but to have sex in exchange for money or other benefits, because they have no job or because they have too low an income; they are desperate and need the money immediately; they don’t want to have sex with strange men and expose themselves to all sorts of dangers, they have no option. Do the church leaders understand any of this?
Some women find that if they apply for jobs they have to pay a substantial amount of money to secure a position. Others find that they are expected to sleep with their boss in order to be selected for a job, to keep a job or to improve their income, sometimes very slightly. Is this even a viable alternative to commercial sex work? I don’t think so.
So if church leaders are concerned about people’s behaviour, sexual or otherwise, they should take a look at people’s circumstances, the way people live. No matter how devout people are, they need to provide for their family, for their dependents and for themselves. To criticize the pope and other church leaders for failing to see this is not polemic. Preachings that are manufactured in one of the richest states in the world have little relevance to the lives of people in the poorest states in the world.
Church leaders, firstly, take a look at the realities of people’s lives, engage with the real problems, not the ones you wish to prognosticate over; secondly, make your prognostications clear and unambiguous; thirdly, engage with debates honestly, don’t resort to the lies and fabrication which you have relied on for so long.
If you want the respect and obedience of your followers you have to earn it.
The Nigerian bishop also makes a comment about Africa being used as “a guinea pig of foreign business ventures”. This is a valid point but Africa is just as much a ‘market’ and a ‘business venture’ for the churches, too. The churches also come up with slogans and marketing campaigns because they are also businesses who stand to gain or lose large amounts of money. They compete with other business, though they may see themselves as being above business and commerce.
Finally, the bishop makes the often made remark about distributing condoms increasing the “sexual waywardness of the continents’ [sic] youth who have access to it” and promoting “sexual recklessness”. Despite the claims of various churches, distributing condoms, teaching children about sex and safe sex and various other measures, does not give rise to higher levels of unsafe sexual behaviour. On the contrary, children who know about sex and safe sex delay having sex for the first time and are more likely to take precautions when they do have sex.
If the churches really have compassion, if they really care about the welfare of their followers, they need to look at how people live, how their behaviour and sexual behaviour are determined. Human dignity is not about doctrine and dogma, it is about basic human rights. People are being denied their rights and the church would do well to address this issue, rather than shoring up their dubious philosophies with pseudo scientific claptrap.
Of course, church leaders could lead by example, observing vows of poverty, chastity and obedience, for instance. But many seem to have chosen to live in wealth. Their chastity has often been open to question. And their obedience often appears to be to political interests, commercial interests and even human desires for power, sexual gratification, etc, rather than to any spiritual authority.
Church leaders, come and live like the majority of human beings and you’ll find yourselves rewriting your vast tomes in a language that most people will readily understand.
Thursday, May 14, 2009
Islands of Deception
Are the president, prime minister and sitting MPs of Kenya aware that there are things happening in Kenya that are far more important than the ownership of a small island in Lake Victoria? In Uganda, too, this island is not really a priority. Both countries have large numbers of poor people, internally displaced people, sick people, children out of school, environmental problems and numerous other problems.
For example, both countries have a serious and worsening HIV epidemic. Prevalence stands at over 7% in Kenya and has been increasing for several years. Prevalence is under 6% in Uganda but there signs that it is increasing and the safe sex messages of the nineties are being forgotten.
Kenya and Uganda rank 127th and 132nd in the gender development index, suggesting that they have done little to improve the status and conditions of women and girls. In Kenya, only 7% of parliament seats were held by women in 2007. The figure was nearly 30% in Uganda. But the gap between female and male earnings is bigger in Uganda.
Health in general is poor in both countries. Expenditure on health is 1.8% in Kenya and 2.5% in Uganda, both figures well below an ideal target of 15% of GDP. There are hundreds of thousands of children still not receiving immunisation to TB and childhood diseases. The figures are especially high for the poorest Kenyans and Ugandans.
Infant mortality and under five morality are very high. These figures have only reduced a little since the nineteen seventies and, in some cases, have increased after an initial drop. Life expectancy is around 50 or below in both countries, despite showing improvements after independence. Again, the situation is far worse for the poorest people.
There are 14 doctors per 100,000 people in Kenya, only 8 in Uganda. 20% or fewer births are attended by skilled health personnel in the poorest sectors of society. Unsurprisingly, percentages of low birthweight, underweight and underheight children are high, as is undernourishment.
Uganda fares a bit better than Kenya in that only 37% of the population lives below the poverty line compared to over 50% in Kenya. But the level of inequality, the difference between the rich and poorest people, is higher in Uganda as well. In terms of gross domestic product and human development, Kenya fares better than Uganda but neither countries have much good news for the majority of their citizens.
Military expenditure is higher than health expenditure in both countries, despite both countries being, nominally, not at war. But Kenya has its simmering disputes, such as the ongoing battles among pastoralists in the north, the land disputes around Mount Elgon in the West and the various tribal disagreements. Although there is technically no war in Kenya, the police act as judge, jury and executioner; shootings and beatings are very common but how common is hard to say. No one is counting.
Both Kenya an Uganda have adult and youth literacy problems. For various reasons, many children are not at school or their attendance is poor. The aim to send every child to school is not being matched by adequate numbers of teachers or resources and many families cannot afford the costs. Some cannot afford to have all their children at school and some of them have to work. The ones who go out to work or stay at home to work are almost always female.
Many people, especially women, have little regular access to media such as TV, radio or newspapers. Access to mobile phones is often good and highly publicised, but access to electricity can be low. As for credit, many carry phones that can receive, if they have friends who have credit. Internet use is very low, despite much publicised increases. Infrastructure is too weak and people's knowledge of and access to technology is low.
Improvements in technology, communications and other things would be great but no one is worrying as long as they have no access to clean water and good sanitation. People who are dying of easily prevented and treated conditions, such as diarrhoea, have little use for high technology. As access to electricity is low for both countries, technology is almost irrelevant to many. Ok, many have access to electricity, but only in between the frequent power cuts.
If these overpaid, undertaxed Kenyans and Ugandans can't find things to do with their time, perhaps they should be introduced to their electorate. They don't seem to know much about them. But ordinary Kenyans and Ugandans will be able to find enough work to keep them occupied until the next elections. There probably isn't enough work to justify their inflated salaries but I think they could gain a lot of good will, perhaps even the confidence of their electorate.
For example, both countries have a serious and worsening HIV epidemic. Prevalence stands at over 7% in Kenya and has been increasing for several years. Prevalence is under 6% in Uganda but there signs that it is increasing and the safe sex messages of the nineties are being forgotten.
Kenya and Uganda rank 127th and 132nd in the gender development index, suggesting that they have done little to improve the status and conditions of women and girls. In Kenya, only 7% of parliament seats were held by women in 2007. The figure was nearly 30% in Uganda. But the gap between female and male earnings is bigger in Uganda.
Health in general is poor in both countries. Expenditure on health is 1.8% in Kenya and 2.5% in Uganda, both figures well below an ideal target of 15% of GDP. There are hundreds of thousands of children still not receiving immunisation to TB and childhood diseases. The figures are especially high for the poorest Kenyans and Ugandans.
Infant mortality and under five morality are very high. These figures have only reduced a little since the nineteen seventies and, in some cases, have increased after an initial drop. Life expectancy is around 50 or below in both countries, despite showing improvements after independence. Again, the situation is far worse for the poorest people.
There are 14 doctors per 100,000 people in Kenya, only 8 in Uganda. 20% or fewer births are attended by skilled health personnel in the poorest sectors of society. Unsurprisingly, percentages of low birthweight, underweight and underheight children are high, as is undernourishment.
Uganda fares a bit better than Kenya in that only 37% of the population lives below the poverty line compared to over 50% in Kenya. But the level of inequality, the difference between the rich and poorest people, is higher in Uganda as well. In terms of gross domestic product and human development, Kenya fares better than Uganda but neither countries have much good news for the majority of their citizens.
Military expenditure is higher than health expenditure in both countries, despite both countries being, nominally, not at war. But Kenya has its simmering disputes, such as the ongoing battles among pastoralists in the north, the land disputes around Mount Elgon in the West and the various tribal disagreements. Although there is technically no war in Kenya, the police act as judge, jury and executioner; shootings and beatings are very common but how common is hard to say. No one is counting.
Both Kenya an Uganda have adult and youth literacy problems. For various reasons, many children are not at school or their attendance is poor. The aim to send every child to school is not being matched by adequate numbers of teachers or resources and many families cannot afford the costs. Some cannot afford to have all their children at school and some of them have to work. The ones who go out to work or stay at home to work are almost always female.
Many people, especially women, have little regular access to media such as TV, radio or newspapers. Access to mobile phones is often good and highly publicised, but access to electricity can be low. As for credit, many carry phones that can receive, if they have friends who have credit. Internet use is very low, despite much publicised increases. Infrastructure is too weak and people's knowledge of and access to technology is low.
Improvements in technology, communications and other things would be great but no one is worrying as long as they have no access to clean water and good sanitation. People who are dying of easily prevented and treated conditions, such as diarrhoea, have little use for high technology. As access to electricity is low for both countries, technology is almost irrelevant to many. Ok, many have access to electricity, but only in between the frequent power cuts.
If these overpaid, undertaxed Kenyans and Ugandans can't find things to do with their time, perhaps they should be introduced to their electorate. They don't seem to know much about them. But ordinary Kenyans and Ugandans will be able to find enough work to keep them occupied until the next elections. There probably isn't enough work to justify their inflated salaries but I think they could gain a lot of good will, perhaps even the confidence of their electorate.
Saturday, April 18, 2009
Mixed Views About Male Circumcision for HIV Prevention
Has anyone come across evidence that access to adequate food supplies reduces acute malnutrition? How about access to good health services reducing illness or good education reducing illiteracy? Should we believe that good water and sanitation reduces water borne diseases or that a clean environment can help to reduce acute respiratory infections?
The answers to the above questions are all 'yes'; there is overwhelming evidence for an affirmative answer to each one. But does Kenya or any other developing country have any of these benefits? Well, no, that is why they are called developing countries. Underdevelopment and retrogressive development are not new and these issues have been discussed in one form or other for many decades.
But just recognising their desirability doesn't give rise to development. The knowledge that these are all good things, necessary for development and for the insurance of human rights, has not given rise to their promotion. So when I see an article entitled '[Male c]ircumcision does reduce the risk of HIV, say researchers' I am pleased to hear it. But which developing country has the facilities, resources and personnel to carry out millions of circumcisions safely and to continue to circumcise all newborn males (either shortly after birth or later, when informed consent is possible)?
Kenya does not have presently have the health capacity required. Evidence has shown that the level of adverse effects relating to circumcision is nearly 20% when the operation is carried out in a clinical setting and around 35% in traditional settings. Those who presently don't go for circumcision, usually for reasons associated with the traditions of their tribe, may be more likely to choose a clinical setting. But with statistics like that they could be forgiven for opting to remain uncircumcised.
Kenya does not have the capacity required to control most of the infectious diseases that are endemic in the country, diseases that kill more people and diseases that have been around for far longer than HIV. If Kenya had good health, education and other social services, the HIV epidemic would never have got so out of control and some of the expensive prevention measures that are being carried out might have achieved some success by now.
In fact, the problem here is not the Cochrane Collaboration publication, entitled Male Circumcision for Prevention of Heterosexual Acquisition of HIV in Men, it's the newspaper article that reports on the original publication. The newspaper article only adds in the final sentence that policy makers need to consider the culture and environment in which MMC is carried out. This is crucial and the Cochrane abstract makes this clear, asking if "[a]t a local level, further research will be needed to assess whether implementing the intervention is feasible, appropriate, and cost-effective in different settings."
One might conclude from the newspaper article that because male circumcision can reduce the risk of HIV, that mass male circumcision (MMC) is a good thing, especially in countries that have high HIV prevalence. Circumcision may also protect against herpes simplex virus (HSV), which increases susceptibility to HIV, human papilloma virus (HPV) and various other sexually transmitted infections (STI). But the Cochrane review notes that incidence of adverse events was low in the trials they examined. One would expect the incidence of adverse events to be low, these were randomised controlled trials! The review concludes that circumcision "under these conditions" is a safe procedure.
The Cochrane review may have found the evidence conclusive and that could eventually be very significant. But the studies they refer to still raise many unanswered questions. I will not rehearse the various problems with the circumcision trials in question. A quick search of other sites and blogs will give you as much information as you could possibly want. (I haven't had access to the full Cochrane paper, although I am familiar with some of the literature and trials involved.)
Mass Male Circumcision (MMC) will not be carried out in ideal conditions in Kenya, not given the present state of Kenyan health services. If there were ideal conditions in Kenya it is unlikely that the country would have need to implement such a huge and costly project as MMC.
But a second objection to MMC is the problem of 'disinhibition'. Some circumcised people think they are, more or less, immune to HIV. People have told me that they don't need to use condoms because they are circumcised or even that condoms don't work because they are circumcised. There is a worry that MMC could result in a large number of people believing that they don't need condoms or that they don't need to be careful because they are circumcised. This will not be an easy problem to deal with.
There’s often a ‘eureka!’ quality to articles about MMC as a means of reducing transmission of HIV. Why not the same cry with regard to development issues where the solutions are more obvious, such food and food security for the starving, healthcare for the sick and healthy, alike, education for all, safe water and sanitation and a healthy environment? The Cochrane report also concludes with a need for further research. Let's hope policy makers are not as selective as journalists in what they glean from scientific papers.
The answers to the above questions are all 'yes'; there is overwhelming evidence for an affirmative answer to each one. But does Kenya or any other developing country have any of these benefits? Well, no, that is why they are called developing countries. Underdevelopment and retrogressive development are not new and these issues have been discussed in one form or other for many decades.
But just recognising their desirability doesn't give rise to development. The knowledge that these are all good things, necessary for development and for the insurance of human rights, has not given rise to their promotion. So when I see an article entitled '[Male c]ircumcision does reduce the risk of HIV, say researchers' I am pleased to hear it. But which developing country has the facilities, resources and personnel to carry out millions of circumcisions safely and to continue to circumcise all newborn males (either shortly after birth or later, when informed consent is possible)?
Kenya does not have presently have the health capacity required. Evidence has shown that the level of adverse effects relating to circumcision is nearly 20% when the operation is carried out in a clinical setting and around 35% in traditional settings. Those who presently don't go for circumcision, usually for reasons associated with the traditions of their tribe, may be more likely to choose a clinical setting. But with statistics like that they could be forgiven for opting to remain uncircumcised.
Kenya does not have the capacity required to control most of the infectious diseases that are endemic in the country, diseases that kill more people and diseases that have been around for far longer than HIV. If Kenya had good health, education and other social services, the HIV epidemic would never have got so out of control and some of the expensive prevention measures that are being carried out might have achieved some success by now.
In fact, the problem here is not the Cochrane Collaboration publication, entitled Male Circumcision for Prevention of Heterosexual Acquisition of HIV in Men, it's the newspaper article that reports on the original publication. The newspaper article only adds in the final sentence that policy makers need to consider the culture and environment in which MMC is carried out. This is crucial and the Cochrane abstract makes this clear, asking if "[a]t a local level, further research will be needed to assess whether implementing the intervention is feasible, appropriate, and cost-effective in different settings."
One might conclude from the newspaper article that because male circumcision can reduce the risk of HIV, that mass male circumcision (MMC) is a good thing, especially in countries that have high HIV prevalence. Circumcision may also protect against herpes simplex virus (HSV), which increases susceptibility to HIV, human papilloma virus (HPV) and various other sexually transmitted infections (STI). But the Cochrane review notes that incidence of adverse events was low in the trials they examined. One would expect the incidence of adverse events to be low, these were randomised controlled trials! The review concludes that circumcision "under these conditions" is a safe procedure.
The Cochrane review may have found the evidence conclusive and that could eventually be very significant. But the studies they refer to still raise many unanswered questions. I will not rehearse the various problems with the circumcision trials in question. A quick search of other sites and blogs will give you as much information as you could possibly want. (I haven't had access to the full Cochrane paper, although I am familiar with some of the literature and trials involved.)
Mass Male Circumcision (MMC) will not be carried out in ideal conditions in Kenya, not given the present state of Kenyan health services. If there were ideal conditions in Kenya it is unlikely that the country would have need to implement such a huge and costly project as MMC.
But a second objection to MMC is the problem of 'disinhibition'. Some circumcised people think they are, more or less, immune to HIV. People have told me that they don't need to use condoms because they are circumcised or even that condoms don't work because they are circumcised. There is a worry that MMC could result in a large number of people believing that they don't need condoms or that they don't need to be careful because they are circumcised. This will not be an easy problem to deal with.
There’s often a ‘eureka!’ quality to articles about MMC as a means of reducing transmission of HIV. Why not the same cry with regard to development issues where the solutions are more obvious, such food and food security for the starving, healthcare for the sick and healthy, alike, education for all, safe water and sanitation and a healthy environment? The Cochrane report also concludes with a need for further research. Let's hope policy makers are not as selective as journalists in what they glean from scientific papers.
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.
Monday, March 30, 2009
The Cherry Picking Theory of HIV Programming
When HIV started spreading across Africa, it hit more densely populated areas first. This is not surprising, given that it is primarily a sexually transmitted infection (STI). It was noticed early on that mobile populations were at particularly high risk, which is also not surprising.
But mobile people come into contact with less mobile people. People in densely populated areas move to, or move to and from, less densely populated areas. Those living in less densely populated areas are likely to be infected later in an epidemic and at a slower rate. But this also means that they are probably not going to be targeted by specific prevention campaigns and they are less likely to be exposed to media and other messages about HIV.
Coupled with this, people in more remote areas are less likely to have access to health, education or other social services. The poor infrastructure and isolation that, at first, gave them protection, now means that they are more likely to be infected with HIV and other STIs without knowing and with less likelihood of finding out.
The fact that they are living in less densely populated areas does not mean that they are not vulnerable. One of their vulnerabilities also turns out to be their relative isolation. This is not a contradiction. Over time, the once protective effect of isolation turns out to imply a whole host of vulnerabilities.
This is one of the reasons why I would argue that HIV is a factor of underdevelopment (and retrogressive development). HIV spreads best where there are multiple vulnerabilities. The virus is also hardest to prevent in these same areas. It is the vulnerabilities that need to be targeted, not the people assumed to be vulnerable.
At present in Kenya, Tanzania and other countries, HIV is spreading in more isolated areas. But health facilities and social services tend to be concentrated in urban and semi urban areas. Between 80 and 85% of these populations live in rural areas. This is changing, many people are moving to urban centres. But this is not a reason to continue to deny the vast majority of people the services they need.
Of course, the process of moving to urban areas, or moving to and from urban areas, exposes people to a new set of vulnerabilities as well. Prevention programmes are not keeping up with changes, nor do they even seem to be aware of trends that have been evident for some time. So there have been many articles recently about HIV infecting isolated populations in greater numbers and these usually express surprise at the trend.
The fact that some people seem less vulnerable now does not mean that this will always be so. Things change. Also, the fact that HIV spreads slower in less dense populations doesn't mean that these populations are ok; HIV spreads among vulnerable people. Prevention programmes need to aim to slow down the spread of HIV. Targeting so called vulnerable groups can often miss people, indeed, the population in general, who are considered not vulnerable enough.
Northern Kenya, which is very sparsely populated, has nomadic people who were once assumed to be safe from HIV. Prevalence there is very low and has been for some time. But HIV is there. Low prevalence can become high prevalence. In fact, people in Northern Kenya are probably the most vulnerable, taken as a whole. Few people have access to health or other social services, education and literacy levels are among the lowest in the country. Now that the HIV community have noticed the problem, they will find that there is very little infrastructure and most programmes will run up against things like lack of attendance in schools and low levels of health and education.
HIV arrived in a very underdeveloped country in the 1980s and has experienced retrogressive development since then. 25 years later, solutions to HIV are still appropriate to a short term emergency. For HIV prevention to work, people need to be well educated, they need a good level of health, water and sanitation and the rest. In other words, they need development. HIV continues to deflect attention from all these other problems which are factors in the spread of HIV. The result of this serious underdevelopment is that the very facilitators of any subsequent prevention programmes are missing.
If aid agencies are just realising that pastoralists and other groups are not 'safe', they have been ignoring evidence that has been around for a long time. They have made a lot of unwarranted assumptions. Everyone is vulnerable to HIV and this been the case for a long time. Whatever the utility in targeting groups, we should forget that people who don't belong to those groups are also in need of attention.
When it looked as if HIV could be eradicated purely by such targeting, these approaches may have been justified, but that was a long time ago. 'Remote' communities are also very mobile and this should have hinted at their relative vulnerability.
At one time, it appeared odd that Northeastern Province was, in many ways, the least developed province. Yet it had the lowest prevalence in the country, at around 1%. That's lower than Senegal, Washington DC and Ukraine, for example. But there is no reason why HIV should stay low, there or in other places where there are a lot of vulnerable people. For example, it should be borne in mind that female genital mutilation is higher there than anywhere else. Young girls marry very young, usually to much older men. These are other worrying issues but these two factors are very significant and they need attention, regardless of the rate at which HIV is spreading.
It’s fashionable to say that HIV is spread by lots of people being promiscuous and careless but only some HIV is spread this way. Many others are infected because they are vulnerable, for numerous reasons. No amount of pure HIV programming will address their vulnerabilities but this is one of the reasons why much of the pure HIV programming to date has been so unsuccessful.
But mobile people come into contact with less mobile people. People in densely populated areas move to, or move to and from, less densely populated areas. Those living in less densely populated areas are likely to be infected later in an epidemic and at a slower rate. But this also means that they are probably not going to be targeted by specific prevention campaigns and they are less likely to be exposed to media and other messages about HIV.
Coupled with this, people in more remote areas are less likely to have access to health, education or other social services. The poor infrastructure and isolation that, at first, gave them protection, now means that they are more likely to be infected with HIV and other STIs without knowing and with less likelihood of finding out.
The fact that they are living in less densely populated areas does not mean that they are not vulnerable. One of their vulnerabilities also turns out to be their relative isolation. This is not a contradiction. Over time, the once protective effect of isolation turns out to imply a whole host of vulnerabilities.
This is one of the reasons why I would argue that HIV is a factor of underdevelopment (and retrogressive development). HIV spreads best where there are multiple vulnerabilities. The virus is also hardest to prevent in these same areas. It is the vulnerabilities that need to be targeted, not the people assumed to be vulnerable.
At present in Kenya, Tanzania and other countries, HIV is spreading in more isolated areas. But health facilities and social services tend to be concentrated in urban and semi urban areas. Between 80 and 85% of these populations live in rural areas. This is changing, many people are moving to urban centres. But this is not a reason to continue to deny the vast majority of people the services they need.
Of course, the process of moving to urban areas, or moving to and from urban areas, exposes people to a new set of vulnerabilities as well. Prevention programmes are not keeping up with changes, nor do they even seem to be aware of trends that have been evident for some time. So there have been many articles recently about HIV infecting isolated populations in greater numbers and these usually express surprise at the trend.
The fact that some people seem less vulnerable now does not mean that this will always be so. Things change. Also, the fact that HIV spreads slower in less dense populations doesn't mean that these populations are ok; HIV spreads among vulnerable people. Prevention programmes need to aim to slow down the spread of HIV. Targeting so called vulnerable groups can often miss people, indeed, the population in general, who are considered not vulnerable enough.
Northern Kenya, which is very sparsely populated, has nomadic people who were once assumed to be safe from HIV. Prevalence there is very low and has been for some time. But HIV is there. Low prevalence can become high prevalence. In fact, people in Northern Kenya are probably the most vulnerable, taken as a whole. Few people have access to health or other social services, education and literacy levels are among the lowest in the country. Now that the HIV community have noticed the problem, they will find that there is very little infrastructure and most programmes will run up against things like lack of attendance in schools and low levels of health and education.
HIV arrived in a very underdeveloped country in the 1980s and has experienced retrogressive development since then. 25 years later, solutions to HIV are still appropriate to a short term emergency. For HIV prevention to work, people need to be well educated, they need a good level of health, water and sanitation and the rest. In other words, they need development. HIV continues to deflect attention from all these other problems which are factors in the spread of HIV. The result of this serious underdevelopment is that the very facilitators of any subsequent prevention programmes are missing.
If aid agencies are just realising that pastoralists and other groups are not 'safe', they have been ignoring evidence that has been around for a long time. They have made a lot of unwarranted assumptions. Everyone is vulnerable to HIV and this been the case for a long time. Whatever the utility in targeting groups, we should forget that people who don't belong to those groups are also in need of attention.
When it looked as if HIV could be eradicated purely by such targeting, these approaches may have been justified, but that was a long time ago. 'Remote' communities are also very mobile and this should have hinted at their relative vulnerability.
At one time, it appeared odd that Northeastern Province was, in many ways, the least developed province. Yet it had the lowest prevalence in the country, at around 1%. That's lower than Senegal, Washington DC and Ukraine, for example. But there is no reason why HIV should stay low, there or in other places where there are a lot of vulnerable people. For example, it should be borne in mind that female genital mutilation is higher there than anywhere else. Young girls marry very young, usually to much older men. These are other worrying issues but these two factors are very significant and they need attention, regardless of the rate at which HIV is spreading.
It’s fashionable to say that HIV is spread by lots of people being promiscuous and careless but only some HIV is spread this way. Many others are infected because they are vulnerable, for numerous reasons. No amount of pure HIV programming will address their vulnerabilities but this is one of the reasons why much of the pure HIV programming to date has been so unsuccessful.
Monday, March 23, 2009
Belt and Braces but no Trousers
On a number of occasions on this blog, I have expressed scepticism about technical solutions to the HIV epidemic. Such solutions include mass male circumcision (MMC), universal testing and treatment (UTT) and universal condom distribution. I am not suggesting that these technical solutions do not work, on the contrary, they are effective. But there are two major problems; no single solution is likely to work on its own and structural conditions in developing countries mean that technical solutions face serious, often insurmountable, barriers to success.
Even condom distribution requires some level of infrastructure, education and communications. MCC faces the problem of seriously scarce, under funded and understaffed health facilities. Large scale testing has been dogged by the fact that many facilities are static and centralised, whereas the majority of Kenyans live in rural areas. Recently, it was demonstrated that many people are receiving incorrect results, either false positives or false negatives. This results from lack of training and quality control and probably many other things. And treatment has had problems as a result of disruptions such as food shortages, civil disturbances and economic problems.
A recent survey carried out in Bungoma, Western Kenya, showed that even in clinical settings, around 17% of people circumcised suffered adverse effects. The figure was about double that for circumcisions carried out in traditional settings. So this would not make circumcision a tempting option for Kenyans unless a huge amount of money is spent on developing health facilities. I don't oppose circumcision as long as it is an elective operation but I don't think circumcision in traditional settings will ever be a wise option.
Testing facilities in Kenya, as well as being in short supply, are just not reaching enough people. Some Kenyan policy documents mention mobile testing units, but they don't seem to be common yet. There continues to be a problem with testing facilities being in urban and semi urban areas. This means that many will not be able to access them, for various reasons. Cost is one factor but people are also less likely to know about HIV and testing when they are isolated from what are highly centralised and relatively inaccessible services. There is also talk about door to door testing and similar methods but this has only been carried out to a limited extent so far.
Those already being treated for HIV have, in many cases, had their treatment interrupted because of post election violence in Kenya, because of ongoing civil disputes in Zimbabwe, because of an economic crisis in Botswana, because of political disputes in South Africa and because of war in Sudan. There are, doubtless, many other instances where treatment has been shown to lack sustainability and this is often a problem with technical solutions.
The history of the epidemic in Kenya shows that there were many factors in the spread of HIV, relating to health, the economy, the environment, infrastructure, labour practices, gender and many other areas. Given this, it is no wonder that a single solution will have little chance of reducing HIV transmission. Condoms will remain in warehouses or on shelves, stay unused or be used incorrectly. Drugs, too, will be unused or misused because lack of support, education or other enabling conditions.
All of these technical solutions are good and together, along with any other strategies, could see HIV decline significantly in the next few decades. But if we ignore the overall development of countries like Kenya, each solution will have little success, perhaps none. Kenya is suffering from underdevelopment, many development indicators are moving in the wrong direction. This has been going on for decades and has been obvious for decades.
Developing health, education and other social services may seem too expensive or too difficult. But this is not an optional extra, it is a prerequisite to the success of any of the currently popular technical solutions.
Even condom distribution requires some level of infrastructure, education and communications. MCC faces the problem of seriously scarce, under funded and understaffed health facilities. Large scale testing has been dogged by the fact that many facilities are static and centralised, whereas the majority of Kenyans live in rural areas. Recently, it was demonstrated that many people are receiving incorrect results, either false positives or false negatives. This results from lack of training and quality control and probably many other things. And treatment has had problems as a result of disruptions such as food shortages, civil disturbances and economic problems.
A recent survey carried out in Bungoma, Western Kenya, showed that even in clinical settings, around 17% of people circumcised suffered adverse effects. The figure was about double that for circumcisions carried out in traditional settings. So this would not make circumcision a tempting option for Kenyans unless a huge amount of money is spent on developing health facilities. I don't oppose circumcision as long as it is an elective operation but I don't think circumcision in traditional settings will ever be a wise option.
Testing facilities in Kenya, as well as being in short supply, are just not reaching enough people. Some Kenyan policy documents mention mobile testing units, but they don't seem to be common yet. There continues to be a problem with testing facilities being in urban and semi urban areas. This means that many will not be able to access them, for various reasons. Cost is one factor but people are also less likely to know about HIV and testing when they are isolated from what are highly centralised and relatively inaccessible services. There is also talk about door to door testing and similar methods but this has only been carried out to a limited extent so far.
Those already being treated for HIV have, in many cases, had their treatment interrupted because of post election violence in Kenya, because of ongoing civil disputes in Zimbabwe, because of an economic crisis in Botswana, because of political disputes in South Africa and because of war in Sudan. There are, doubtless, many other instances where treatment has been shown to lack sustainability and this is often a problem with technical solutions.
The history of the epidemic in Kenya shows that there were many factors in the spread of HIV, relating to health, the economy, the environment, infrastructure, labour practices, gender and many other areas. Given this, it is no wonder that a single solution will have little chance of reducing HIV transmission. Condoms will remain in warehouses or on shelves, stay unused or be used incorrectly. Drugs, too, will be unused or misused because lack of support, education or other enabling conditions.
All of these technical solutions are good and together, along with any other strategies, could see HIV decline significantly in the next few decades. But if we ignore the overall development of countries like Kenya, each solution will have little success, perhaps none. Kenya is suffering from underdevelopment, many development indicators are moving in the wrong direction. This has been going on for decades and has been obvious for decades.
Developing health, education and other social services may seem too expensive or too difficult. But this is not an optional extra, it is a prerequisite to the success of any of the currently popular technical solutions.
Thursday, March 12, 2009
When is Development Development?
The issue of foreign aid crops up frequently in the development literature. People ask why aid doesn’t seem to be working even after large amounts of money have been donated over long periods of time. These are difficult questions to answer, there’s no denying that.
But there are other questions that may be less difficult. For example, in Tanzania, there doesn’t seem to be much evidence that aid money has been spent on setting up manufacturing outlets. Almost all manufactured goods seem to come from other, very expensive, countries.
Things around the house are either manufactured elsewhere or manufactured by companies that are foreign owned. In Kenya, tea and sugar are among the top products. But even when they are processed in Kenya, they are often processed by foreign companies. The cut flower industru has become one of the countries main exporters. But the outlets producing flowers pay little or no tax, either in Kenya or in their own (developed) country.
Those ‘investing’ in Tanzanian gold mines get years of tax breaks, they can import what they want without restriction and all under the understanding that they are bringing much needed investment to the country. But they don’t leave much behind. Employment conditions are terrible, pay is low, huge social problems develop around the mining industry and when the incentives cease, the mining companies go home. That is, unless they can find other ways of extracting the commodity without having to pay very much in return.
Actually, it’s not fair to say mining companies leave little behind when they have got as much as they can out of a country. They leave behind unhealthy former employees, ghost towns and environmental degradation. The mercury, cyanide and other poisons that they leave behind will slowly kill people, animals and other forms of life, it will poison the water and the soil for the foreseeable future.
When such foreign companies arrive they are given the rights to do whatever they deem necessary to fulfil their objectives. Tanzanians, who struggle to get enough water for their daily needs, find their supply further curtailed. The companies who have come to ‘invest’ in their future have brought their inaccessibly expensive technology to gather water and people already living in the area have to compete for the dwindling supply.
There have been articles in the papers recently about nasty Tanzanians tapping into water pipes belonging to various manufacturers and other commercial interests. Such activities are referred to as acts of vandalism and are entirely unanalysed by commentators. The commercial interests have been assured by the government that they will have unrestricted access to whatever they want. The fact that there are Tanzanians who need water to survive and that the commercial interests are preventing them from getting this water is rarely mentioned.
A large amount of aid money seems to be spent on the continuation of what is already a serious development problem in countries like Kenya and Tanzania: the production of raw materials for rich countries. As long as earnings from the main exports from these countries are dwarfed by what they have to spend on basic (but manufactured) goods that come from rich countries, it’s hard to see aid money having much effect.
For a start, anyhow, much of what is called ‘aid’ comes in the form of loans, loans that must be paid back with interest. The fact that the loans very often can’t be paid back doesn’t mean that the interest doesn’t continue to mount up. But generally, the money that creates unrepayable debts in developing countries never leaves the ‘donor’ country. The money is spent on goods produced in the donor country, transported using the donor country’s transportation networks, handled by the donor country’s employees or it pays for the donor country’s technical expertise.
As a result, the ‘recipient’ country is merely building up a debt in order to buy up the donor country’s surpluses, give business to their service industries and employ their people, often people working in big, foreign NGOs. Vast amounts of money go to NGOs that are based in and administrated by the donor countries. It is in the interest of donor countries that they continue to ‘donate’ aid money, they themselves benefit, they are stimulating the growth and prosperity of their own country.
I’m sure there are lots of reasons why billions of dollars of aid money seem to go to developing countries without having much effect. Worse, many developing countries are regressing. But it could be asked if donors really spend money on developing countries or if donations, to a large extent, fit in with their own commercial interests. To what extent are donations even intended to benefit the recipient?
Countries like Zambia and Botswana depend heavily on their mining industries. When times are good they do relatively well, but doing relatively well is not development. They are always dependent on conditions being favourable in the developed countries who buy the raw materials they produce. Now, conditions are not favourable, and Zambia and Botswana are beginning to suffer. Now that things are difficult, it is apparent that during the ‘good times’ aid money was not used to increase sustainability or self-reliance.
So neither country has developed much in the last couple of decades, despite their great mineral wealth. How much aid money has gone towards developing their ability to produce something other than raw materials? And I’m not talking about money and technology to achieve greater yields from marginal mining outlets. I mean, to what extent has ‘development’ ever meant reducing the extent to which developing countries are completely dependent on developed countries to reach a position that really only constitutes just getting by?
But there are other questions that may be less difficult. For example, in Tanzania, there doesn’t seem to be much evidence that aid money has been spent on setting up manufacturing outlets. Almost all manufactured goods seem to come from other, very expensive, countries.
Things around the house are either manufactured elsewhere or manufactured by companies that are foreign owned. In Kenya, tea and sugar are among the top products. But even when they are processed in Kenya, they are often processed by foreign companies. The cut flower industru has become one of the countries main exporters. But the outlets producing flowers pay little or no tax, either in Kenya or in their own (developed) country.
Those ‘investing’ in Tanzanian gold mines get years of tax breaks, they can import what they want without restriction and all under the understanding that they are bringing much needed investment to the country. But they don’t leave much behind. Employment conditions are terrible, pay is low, huge social problems develop around the mining industry and when the incentives cease, the mining companies go home. That is, unless they can find other ways of extracting the commodity without having to pay very much in return.
Actually, it’s not fair to say mining companies leave little behind when they have got as much as they can out of a country. They leave behind unhealthy former employees, ghost towns and environmental degradation. The mercury, cyanide and other poisons that they leave behind will slowly kill people, animals and other forms of life, it will poison the water and the soil for the foreseeable future.
When such foreign companies arrive they are given the rights to do whatever they deem necessary to fulfil their objectives. Tanzanians, who struggle to get enough water for their daily needs, find their supply further curtailed. The companies who have come to ‘invest’ in their future have brought their inaccessibly expensive technology to gather water and people already living in the area have to compete for the dwindling supply.
There have been articles in the papers recently about nasty Tanzanians tapping into water pipes belonging to various manufacturers and other commercial interests. Such activities are referred to as acts of vandalism and are entirely unanalysed by commentators. The commercial interests have been assured by the government that they will have unrestricted access to whatever they want. The fact that there are Tanzanians who need water to survive and that the commercial interests are preventing them from getting this water is rarely mentioned.
A large amount of aid money seems to be spent on the continuation of what is already a serious development problem in countries like Kenya and Tanzania: the production of raw materials for rich countries. As long as earnings from the main exports from these countries are dwarfed by what they have to spend on basic (but manufactured) goods that come from rich countries, it’s hard to see aid money having much effect.
For a start, anyhow, much of what is called ‘aid’ comes in the form of loans, loans that must be paid back with interest. The fact that the loans very often can’t be paid back doesn’t mean that the interest doesn’t continue to mount up. But generally, the money that creates unrepayable debts in developing countries never leaves the ‘donor’ country. The money is spent on goods produced in the donor country, transported using the donor country’s transportation networks, handled by the donor country’s employees or it pays for the donor country’s technical expertise.
As a result, the ‘recipient’ country is merely building up a debt in order to buy up the donor country’s surpluses, give business to their service industries and employ their people, often people working in big, foreign NGOs. Vast amounts of money go to NGOs that are based in and administrated by the donor countries. It is in the interest of donor countries that they continue to ‘donate’ aid money, they themselves benefit, they are stimulating the growth and prosperity of their own country.
I’m sure there are lots of reasons why billions of dollars of aid money seem to go to developing countries without having much effect. Worse, many developing countries are regressing. But it could be asked if donors really spend money on developing countries or if donations, to a large extent, fit in with their own commercial interests. To what extent are donations even intended to benefit the recipient?
Countries like Zambia and Botswana depend heavily on their mining industries. When times are good they do relatively well, but doing relatively well is not development. They are always dependent on conditions being favourable in the developed countries who buy the raw materials they produce. Now, conditions are not favourable, and Zambia and Botswana are beginning to suffer. Now that things are difficult, it is apparent that during the ‘good times’ aid money was not used to increase sustainability or self-reliance.
So neither country has developed much in the last couple of decades, despite their great mineral wealth. How much aid money has gone towards developing their ability to produce something other than raw materials? And I’m not talking about money and technology to achieve greater yields from marginal mining outlets. I mean, to what extent has ‘development’ ever meant reducing the extent to which developing countries are completely dependent on developed countries to reach a position that really only constitutes just getting by?
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