Born Obsolescent But Still Around, Unfortunately

Apparently a report has found that the IMFs (International Monetary Fund) fiscal and monetary policies have stifled Kenya's fight against HIV and TB. They concluded that restricting government spending on health resulted in poor health outcomes.

That's not just a conclusion, that's almost a tautology. Poor healthcare always, everywhere, gives rise to poor health outcomes. I applaud the report writers but I wonder what influence their findings and recommendations will have in the secretive and atavistic 'Bretton Woods' institutions. The report even found that HIV/Aids work is now almost totally dependent on donor funding.

Virtually anyone who has studied HIV, its spread and the almost total (but extremely expensive) failure to reduce its spread, would have, and probably have, come to the same conclusions. But what effect has research ever had on the way the IMF does its work?

The report also concludes that the IMF's policies are partly to blame for Kenya's poor economic performance. But this is true of the economic performance of every country that the IMF has interfered in. In the whole history of the IMF, they do not have one single success story. They beat on about reform, democracy and accountability. Yet they have never been reformed, they are not in the least bit democratic and they are not accountable to anyone.

It's odd that both the World Bank and the IMF can produce reports that, at the same time, boast of the great things that they have done and also admit the failures that, essentially, are the great things they have done. Anyhow, the full report is available, but keep a sick bag handy.

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.

Senegal: an Exception Among HIV Epidemics in Africa?

After spending a lot of time studying as much HIV literature as I could find, I decided to chart the history of HIV in one country, Kenya. This decision stemmed from the belief that the conditions in a country prior to the arrival of HIV are as important as what a country does subsequently to deal with the epidemic. In fact, those conditions may be far more important than the subsequent measures taken to reduce the spread of HIV and certainly would determine a country’s ability to reduce the spread of HIV.

Many of the HIV prevention interventions carried out to date, throughout Africa, have had limited success. In Kenya, very little was done until early in the 2000s, by which time HIV prevalence was declining quickly as a result of a high death rate. Now that HIV prevention programmes have been around for long enough to carry out significant evaluations, it seems that a lot are not performing very well.

Since a lot of HIV funding was motivated by political, religious, moral and commercial considerations, it is not very surprising that so many of the programmes have been a failure. Of course, not all have been so motivated and not all have been a failure, but much of the money has clearly been wasted. 

The politics, the religion and the moral posturing continues. The commercial considerations, on the other hand, have changed radically. HIV is a massive opportunity for pharmaceutical companies. It has also been a godsend for suppliers of other goods and services, consultancies, private health and large, prominent NGOs such as Family Health International, Population Services International and others.

Senegal is often cited as an exception among African countries. HIV prevalence there remained at a very low rate for the whole of the nineties and, though it has been steadily increasing since, has probably never gone far above 1%.

It must be made clear, West Africa is quite different from East Africa (and, indeed North, South and Western Equatorial Africa, which all have identifiable 'regional' pandemics). The majority of countries in West Africa never had prevalence of above 2%. This compares with a high of 14% in Uganda and 11% in Kenya. In fact, the majority of East African countries currently have HIV prevalence rates of over 4%.

This is a relatively quick and dirty comparison of Senegal and Kenya as I am not in a position at the moment to do more detailed work on Senegal; but here goes!

Kenya made some advances in health, education, the economy and other social areas in the 1970s, the decade following independence. Their success began to level off in the 1980s, in part as a result of conditionalities and structural adjustment policies emanating from the International Monetary Fund (IMF) and the World Bank. By the 1990s, Kenya was on a downward trend that continues today. This downward trend is sometimes blamed on the effects of HIV but it started before HIV would have had much influence.

Senegal seems to have had a steady upward trend in social indicators from 1975 to 2005 and is on target to exceed Kenya's position. Senegal is still behind Kenya in some areas, such as education, but this may yet change. And Senegal is ahead in life expectancy, a significant health indicator.

The Human Development Index (HDI), produced by the United Nations Development Programme, is a composite measure of the level of development in a country. It combines measures "of life expectancy at birth, adult literacy and combined gross enrolment in primary, secondary and tertiary level education, and gross domestic product (GDP) per capita in Purchasing Power Parity US dollars (PPP US$)".

The graph, below, shows how Kenya and Senegal compare in their Gender Development Index (GDI), Life Expectancy (LE) Index, Education Index, Human Development Index (HDI) and Gross Domestic Product (GDP) Index.

The second graph shows Kenya's rise and fall and Senegal's steady rise in the Human Development Index.

With regard to the HDI, it is to be hoped that developing countries are doing just that, developing. That is not the case in Kenya. It has experienced retrogressive development since the 1980s and this trend, presumably, has roots in the 1970s and earlier. Senegal seems to be going in the right direction.

But the difference between Senegal and Kenya going by these five social indicators does not explain, on its own, why Kenya has had a serious and generalised epidemic and Senegal has not.

Senegal is said to have a concentrated epidemic, meaning that most of the people infected belong to high risk groups, such as commercial sex workers (CSW), men who have sex with men, intravenous drug users, haemophiliacs and perhaps others. Kenya's epidemic is classified as generalised because the majority of those infected now are not members of identifiably high risk groups. Members of high risk groups are infected but they are increasingly outnumbered by people who are not members of such groups.

My suspicion is that there is something about the conditions that existed in Senegal when HIV arrived that resulted in the epidemic not spreading beyond high risk groups. I think it was inevitable that Senegal would only experience a concentrated epidemic and equally, it was inevitable that Kenya would experience a generalised epidemic.

I have already discussed on this blog why I think it was inevitable that HIV would become generalised in Kenya. But, although I haven't had the chance to study Senegal in detail, there are several telling factors that could shed light on the matter.

John Iliffe, in The African AIDS Epidemic: a History, notes that commercial sex workers are licensed and inspected, following a French model. This contrasts sharply with the situation in Kenya, where sex workers are not an easily identifiable group, with some people resorting to transactional sex as and when they need to. But also, sex workers, and even those suspected of being sex workers, are treated as barely human. They are victims of abuse from the public, their clients and the police. Few, if any, of their rights are recognised by the law and they are obliged to accept this.

In Kenya, unlike in Senegal, there are few health services, health is not particularly accessible and it is especially inaccessible for those known to be or thought to be involved in commercial sex work. Iliffe notes that Senegal already had a successful programme to reduce sexually transmitted diseases, started in 1978, and their health services were able to control the blood supply, something Kenya and other countries are still struggling with.

There were other factors in Senegal that worked to its favour; male circumcision is almost universal; many Senegalese are Muslims and, consequently, have very different lifestyles from the predominantly Christian Kenyans (although the positive and negative effects of any religion can be mixed); HIV-2, a less virulent form of HIV (more correctly called HIV-1) was already common when HIV-1 arrived; condom use during casual sex was already very common in urban areas; and the country was quick to mobilise leadership, education, NGOs and various social services in reaction to the epidemic.

Travelling around Kenya and talking to people, it is clear that the government has done very little and will probably continue to do very little. Educators often know as much about sex as anyone else (and that's not much); they often shy from talking about sex and especially about condoms because of their religious or moral beliefs or because of those of their peers and those of parents; male attitudes towards females seem to have changed little; a lot of NGOs are carrying out pointless HIV 'prevention' activities because their donors would remove funding if they did anything else; other NGOs are doing a good job but are hampered by lack of money and support.

From what I have seen and read in Kenya, it is hard to believe that billions of dollars have been pumped into the country to contribute to the fight against HIV. At least since the 1980s, health, education, infrastructure and other social services have been run down, despite all the talk about achieving millennium development goals (MDGs) and fighting HIV. Most development indicators have been declining for thirty years.

Conditions in Kenya, I think, made it inevitable that HIV would spread rapidly and become generalised, almost from the beginning. The positive feedback from the epidemic would also fuel the already declining social trends. If Iliffe is right, conditions in Senegal were never such that HIV would spread beyond high risk groups and the country was in a position, and continues to be in a position, to protect people from dangers like HIV.

Kenya is not in this position and this explains their continuing predicament. It also explains why I think universal male circumcision, universal testing and treatment (UTT) pre-exposure prophylaxis (PrEP) or any other technical solution will have limited success. The country is weak and vulnerable. Thirty years of retrogressive development need to be reversed. Money needs to be spent on basic needs such as primary health, education, infrastructure, water supply and food security.

(For further discussion of PrEP, see my other blog, pre-exposureprophylaxis.blogspot.com)

Can Kenya Treat Its Way Out of the HIV Epidemic?

There is a question that is frequently being asked these days: 'Is it possible for a country to treat its way out of the HIV epidemic?' That is to say, given the treatment options available now, is it possible to reduce the rate of new infections to a very low level? The hope is that, although HIV may not be eradicated, it could change from being a pandemic to being a chronic but manageable disease that affects relatively few people.

It has been claimed, for example, that universal HIV testing and subsequent treatment (UTT) for everyone found to be HIV positive could reduce HIV prevalence to less than 1% within 50 years (using data from South Africa as a test case).

So in Kenya, there were 1.4 million HIV positive people in 2007 in Kenya. 190,000 (14%) of them were on ART by mid 2008. Proponents of UTT want all 1.4 million to be on antiretroviral treatment (ART) as soon as possible.

One of the problems is that, after independence Kenya experienced many improvements in social conditions. But these were partly reversed as a result of internal and external crises in following decades. A combination of poor governance and structural adjustment policies resulted in a reduction in health, education and other social services.

I don't believe the issues surrounding UTT have yet become polarised, as so many other issues relating to HIV have become. There are persuasive arguments that much can be done to reduce rates of transmission and that UTT could play a big part in this. There are equally persuasive arguments that very little of the prevention work that has been carried out so far appears to have been unambiguously successful.

That's not to say nothing has been done or that what is being done should stop. People need sex education, they need to protect themselves from dangers such as physical and emotional injury, diseases such as HIV and other sexually transmitted infections, unwanted pregnancy, social stigma and even imprisonment. But such education and awareness pertain to basic human rights. It is not necessary that there be a serious pandemic before these basic rights are recognised.

Similarly, people need access to nutritious food and clean water, they need assured food security to avoid shortages and famine, they need the means to provide for themselves, access to health services, infrastructure, power, transport, commerce and many other things. These too pertain to basic human rights. People are entitled to these rights whether there is a HIV pandemic or any other kind of pandemic.

Yet it is such basic rights that are being denied to people in Kenya and other developing countries. They also need medicines for malaria, malnutrition, cholera, meningitis and intestinal parasites. In fact, countries could do more than treat their way out of the HIV epidemic. They could treat their way out of almost all endemic diseases.

The reason that people do not have access to medicines is more often because they are too expensive than because they have yet to be developed. And most don’t have access to health care in Kenya because there are very few health facilities and personnel.

The reason people don't have enough food is because they have been marginalised to the extent that they cannot access basic goods, not because there is not enough food.

But what if available medicines were to be provided to all those who need them? For a start, what level of health service provision would be required to provide all HIV positive people with ART? At present, after nearly three decades of HIV, countries like Kenya are struggling to provide HIV testing for everyone. Until people know their status, they continue to do as they have always done. Once they know their status, some, perhaps most, will seek medical care of some form. As to whether they will receive the care they need, that's another matter.

Far from increasing health structures in Kenya, health spending has not even improved to keep pace with population increases and increases in the need for health care. In general, spending has been and continues to be curtailed by loan conditions imposed by international financial institutions. The Kenyan government appears to have little interest in health and even less interest in HIV. People from outside Kenya are more interested in resources, land and cheap labour than in improving conditions in the country.

For many people willing to be tested for HIV, the services are not reaching them. There are HIV positive people who could be on ART, which would improve their health and reduce their risk of their transmitting HIV. But they are not always able to get the medication they need, for example, because they live in an isolated area. Or they are lacking some of the things they need for the drugs to be effective, such as clean water and a reasonable level of nutrition.

So is the answer to the question 'yes, it is possible for a country to treat its way out of the HIV epidemic'? I think this would be the answer if all the relevant conditions for such an undertaking were met. Then questions arise as to whether Kenya is on the right track to be in a position to roll out ART to all who need it, whether people will be fully supported in this treatment, whether they and those indirectly affected will be allowed to enjoy their rights to education, health and other benefits.

For me, the question really boils down to this: many developing countries are not much better off and some are worse off than previously, despite high levels of development aid over a long period of time. If 'treating their way out of the HIV epidemic' in Kenya means allowing the country to develop in the areas that allowed HIV to spread rapidly since the 1980s, then the project should have a lot of success. And not just with HIV but with most development issues.

But if the intention behind the question is to continue with various development programmes and tack on another one that involves mass testing and drug distribution, this will not be very successful.

It’s true that many people now on ART are doing very well, there is little evidence that they are responsible for transmitting HIV, more people are receiving sex education and HIV positive people are less stigmatised than they were in the past; many things are changing.

But despite this, HIV transmission is still high, too high for HIV prevalence to reach the very low levels envisaged by proponents of mass HIV treatment campaigns.

For UTT to be feasible, HIV needs to be seen as one of many symptoms of serious, long term underdevelopment. It is not merely a health crisis, a disease that needs to be eliminated. There are numerous factors in the transmission of HIV. They will not just go away. These factors include inequality, poverty, unemployment, poor health, education and infrastructure.

Only after all relevant factors have been dealt with will adequate HIV treatment and care succeed in reducing transmission to a level where it will be a chronic, treatable disease.

Expediters of Suffering

The International Monetary Fund (IMF) and the World Bank (WB) give loans to developing countries on condition that they introduce certain measures such as elimination of tariffs, subsidies, state intervention, regulation (that includes regulation to protect people against unscrupulous practices), public sector recruitment and many other things. Yet, many of the items that are advised against under WB and IMF Structural Adjustment Policies (SAPs) are widespread in Western countries. Not only did these countries depend on protecting their industries to become as rich as they are now, they still depend on protection today.

Take agricultural subsidies, for example. The European Community and the US insist on the need for everything being market driven, on the need to reduce protectionism. At the same time, they grow sugar that is uneconomical to grow, they produce more cereals and dairy products than they can use. The US is the biggest cotton producer in the world, not because labour is so cheap there or because they are so efficient but because cotton farmers receive such high subsidies. Then these rich countries dump their surplus produce on developing country markets, resulting in farmers in developing countries being unable to sell their products, often having to leave them in the field to rot.

Worse than that, much 'aid' money is spent on buying up surpluses in developed countries and distributing it in developing countries. This has the same effect as dumping surpluses but it has the advantage for developing countries that they can claim it is 'aid'. This trick is even seen as a way of palming off genetically modified (GM) food in the hope that people who are starving will not be in a position to refuse whatever they can get. And the chief beneficiaries of these subsidies in rich countries are big farmers. In developing countries, most agriculture is very small scale. Many small farmers who don't get some form of help go bankrupt and/or starve.

But some developing countries have challenged IMF and WB strictures on subsidies. Malawi, who introduced a subsidy programme in 2005, is a good example. They have realised that SAPs have made them poorer and more vulnerable, despite all the promises they were given by international agencies. Last year they trebled maize production by subsidising seed and fertilizer. Therefore, in the present season they will treble their agricultural subsidies because this policy has worked so well already. They are exporters of grain and have won praise for their success in reducing food insecurity. The IMF and the WB opposed an earlier version of these measures and advised the country to sell its national grain reserve, which it did!

This was followed by a famine that killed more than 1000 people. Donors, belatedly, supported the programme and subsequently, Zambia, Ghana, Senegal and Kenya announced plans for similar subsidies. How far they have got with the plans is still not clear. Mozambique has also decided to subsidise fertilizer for its farmers, a move opposed by the US. But Mozambique realises that, long term, they need to produce their own fertilizer. They also realise that they need to improve roads, something the IMF and the WB would, doubtless, disapprove of (unless foreign, private contractors were to be utilised).

This doesn't mean that Malawian agriculture is sustainable, of course. Malawi, like many other developing countries, is highly dependent on imported pesticides, fertilizers and other technologies. In the long run, it is to be hoped that they will be able to reduce their dependence and achieve better sustainability. More importantly, it is vital that they don't fall for the GM propaganda that claims it to be sustainable and productive. That will only increase their dependence and reverse whatever gains they have made.

But against all advice, especially international agency advice, Malawi went ahead with this programme. Will Kenya eventually do the same thing? They don't have the advantage of a president who is also a minister of agriculture. Worse than that, their president is an economist. So it seems unlikely that the present administration will go for subsidies. But even unlikely things sometimes happen. After all, the current president was re-elected against all odds, wasn't he?

Malawi has reduced their food budget by 120 million dollars and it has reduced their dependence on food aid. That must appeal to an economist, especially given the food insecurity and budgetary problems being faced by Kenya right now. But even if the government were willing to consider it, the IMF and WB would probably object. In fact, a cynic might suggest that these international financial institutions are not really interested in the good of ordinary people in developing countries. After all, in the 1970s Africa was a net food exporter, now it is highly dependent on imports and aid, at least in part as a result of their policies.

Before SAPs were concocted by IMF and WB economists some time in the late 70s or early 80s, Kenya was enjoying a period of relative prosperity. It wasn't to last long because those ruling the country were mainly interested in enriching themselves. (That makes them sound like the present rulers but, hey, most of this lot have been in senior positions since the early days of independence!) The international community went along with this because Kenya was being a good capitalist and opening up the country to foreign direct investment. In fact, the country was dominated by foreign capital, but this also suited the Kenyan elite very well.

Once Kenya accepted loans with SAPs, things changed. The foreign (and native) investors who were doing so well out of subsidised industry found that costs were getting high in Kenya and they left as quickly as they could. Unemployment increased as public sector employees were laid off and recruitment was cut. That's still going on, by the way, and if you think little of public sector employees, just think doctors, nurses, educators and other public service employees. There are good reasons why the roads are so bad in Kenya. There are good reasons why under five mortality, maternal mortality and many other health indicators have been slipping for most of the last three decades. (And from the point of view of this blog, there are good reasons why HIV was able to spread rapidly among people with so many increasing vulnerabilities, but I'll return to that another time.)

Many of the problems being reported in this week's newspapers stem from policies that were adopted nearly thirty years ago. These policies were honed and twisted to suit those who stood to gain most from them, the rich and powerful in Kenya and in other countries. The whole process couldn't have been carried out without much help from an array of international financial, political and other institutions. And while the policies may often be referred to as 'economic', or even 'ideological', they are more correctly political. They cannot be justified on economic grounds because they destroy economies. They cannot be justified on ideological grounds because they are applied inconsistently, where and when it suits.

These policies have long been backed up, and continue to be backed up by their advocates. This is so, regardless of any evidence that they are responsible for hunger, disease, suffering and death. And that's because they suit a particular political standpoint. They could be called 'pragmatic', but I prefer the term 'expedient'.

Development by Omission

In a previous posting on male circumcision, I suggested two possible ways of looking at this HIV prevention intervention. Of course, there are many other ways of looking at it! But first, it could be seen as a desperate attempt to throw huge amounts of money at an intervention that will only have limited benefits for a relatively small part of the population.

Or second, it could be seen as a good opportunity to strengthen the whole of Kenya's health sector in order to ensure maximum benefits and sustainability. If several million people are to be circumcised in clinical settings, over a lengthy period, a large number of health personnel will need to be trained, new clinics will have to be built, existing ones will have to be improved, the whole programme will need careful monitoring and evaluation.

Health capacity in Kenya is not very high at present. There are very few facilities per person and very few trained personnel. The figures are better for some provinces, such as Nairobi and Central, but still not encouraging. There have been small improvements in capacity but they don't usually keep pace with the growing population or increasing need.

A reflection of how poor health capacity is at the moment comes from Bungoma in Western province. There, circumcision is very widespread. Some of the operations take place in traditional settings, some in clinical settings. However, the rate of complications resulting from circumcision is very high in both settings, about 25%, overall. Unsurprisingly, the rate is higher in traditional settings, standing at 35%. But it is also worryingly high in clinical settings, standing at 18%.

The pro circumcision argument is generally, either tacitly or explicitly, for circumcision in clinical settings. A recent paper suggests that mass circumcision would involve high costs in the first five years but the savings and benefits would eventually outweigh the costs.

These findings apply to Nyanza province only, where male circumcision is the lowest in Kenya and HIV prevalence is highest. The model the authors use assumes circumcision rates are 10%, which is lower than other estimates I have seen. They also estimate HIV prevalence to be 24%, which is much higher than other estimates, especially for males, male rates being far lower than female rates in Kenya at present. But their results should still hold.

So if total health capacity in Kenya is going to be increased, this can only be a good thing. Of course, the improved capacity only directly applies to a minority of men in the country, though it should benefit health capacity as a whole as well, albeit indirectly. But in short, I find it hard to believe that the intention of those advocating mass circumcision includes strengthening health capacity. I think it is an intervention with very narrow aims (much like universal testing and mass rollout of antiretroviral therapy).

I believe circumcision is an important prevention intervention but it is not the only one and it is not going to have much effect on its own. It is expected to reduce the risk of HIV infection by 60%. That is not enough. Kenyans also need better sexual and reproductive health, better education about sex, health and other things, better social services, employment opportunities, etc. Even if you believe sexual behaviour is the only relevant factor in the transmission of HIV, circumcision on its own will not cut transmission very much.

If programmes to roll out mass circumcision, universal testing and antiretroviral therapy for all those who are found to be HIV positive were to include development of all health, education and social services in Kenya, that would be great. Because at present, public expenditure on health is very low (most expenditure comes from individuals or from donors). For example, immunisation rates are low and infant and child mortality rates are high, especially in the poorer quintiles. Many Kenyans don't live for long enough to become sexually active.

HIV is just one disease, just one of many sexually transmitted diseases. There are many other, more pressing health problems, such as poor nutrition and lack of access to clean water and sanitation. These affect people on a daily basis, causing more illness and death than HIV. HIV takes a long time to kill people, water borne diseases are very quick. On the other hand, nutritional deficiencies are treatable and most water borne diseases are curable!

Incidentally, there are many reasons why health capacity in Kenya is so low. Several decades of structural adjustment policies emanating from the International Monetary Fund (IMF) and the World Bank (WB) have reduced capacity, especially personnel, severely.

But brain drain has also had an enormous influence. Brain drain is not just the process of trained personnel looking for work in other countries because they can't find work in their own country. They often can't find work in their own country because of aforementioned IMF and WB policies. (A cynic may suggest that, however unintended, these policies often seem to benefit wealthy countries.) And they often end up going to other countries because those countries come looking for them.

The costs of educating professional personnel plus other losses that Kenya must bear are huge. The benefits to the wealthy countries who poach them are also huge. Hence the practice of aggressively poaching personnel whenever there is a shortage in these wealthy countries. Countries that have been heavily involved in poaching doctors in large numbers include the US and the UK. Countries that have poached significant numbers of nurses include Canada, Denmark, Finland, Ireland, Portugal, UK and USA.

The UK recently published a nauseatingly sanctimonious document detailing how they did not poach personnel from developing countries. They didn't say that this was only because they discovered they had an oversupply of doctors and nurses and they no longer needed to poach so aggressively, for the moment, anyway. It could be compared to their similarly sanctimonious claim to have reduced carbon emissions when all they had done is externalised them by exporting them to developing countries. But their change of policy is too late to be of much help to Kenyan health services, regardless of their motives.

Development is not, therefore, just about figuring out 'what we can do to help developing countries'. We also need to look at policies and practices that impoverish and exploit developing countries, such as structural adjustment policies, exporting carbon emissions and aggressive poaching of skilled personnel. But these are what the title of this blog refers to, a theme I shall return to frequently.