Hepatitis, TB, HIV and Ebola: Healthcare Associated Epidemics?

It is sometimes claimed (by UNAIDS and others) that if HIV was frequently transmitted through unsafe healthcare in sub-Saharan countries, then hepatitis C (HCV) would also be common in the same countries, because HCV is usually transmitted through unsafe healthcare (dental procedures, surgery, stitches, etc). Indeed, HIV prevalence is often higher in countries that have low prevalence of HCV; and the high HCV countries tend to have low HIV prevalence.

However, given that it is well established that both viruses can be transmitted through unsafe healthcare, and that unsafe healthcare practices are probably very common in most (all?) African countries, the non-correlation between HIV and HCV prevalence seems like a very weak and unappealing argument. Because we don't know the relative contribution of HIV transmission through unsafe healthcare, neither do we know how much transmission is a result of heterosexual risk.

Blaming high rates of HIV transmission almost exclusively on 'unsafe' heterosexual behavior has a number of dangerous consequences. For a start, it stigmatizes those who are already infected. It also results in people who don't engage in 'unsafe' sexual practices failing to recognize their risk of being infected. More serious still, it means that public health programs aiming to influence sexual behavior will be relatively ineffective.

HCV prevalence in Egypt is the highest in the world and HIV prevalence is low. But a recent survey concludes that "Invasive medical procedures are still a major risk for acquiring new HCV infections in Egypt". It sounds like measures to reduce transmission have not yet been completely successful. More worryingly, another paper finds that "there could be opportunities for localized HIV outbreaks and transmission of other blood-borne infections in some settings such as healthcare facilities".

What about countries where HIV prevalence is extremely high, such as South Africa? HCV prevalence is very low, so the UNAIDS argument above would suggest that unsafe healthcare does not play a significant role in HIV transmission. But does that mean unsafe healthcare is unimportant? After all, resistant strains of TB have been transmitted in hospitals in South Africa and this has even spread beyond South Africa, to surrounding countries, and even to another continent.

In reality, we don't know that much about HCV in the Africa region. A review of research on the subject concludes that "Africa has the highest WHO estimated regional HCV prevalence (5.3%)" in the world. That's a striking figure, because HIV prevalence across the whole sub-Saharan African region is also around 5%. There are two serious viral pandemics on the continent that may both be driven to a large extent by unsafe healthcare.

HCV concentrates in certain countries and in parts of certain countries. But so does HIV. Prevalence is relatively low in most of Kenya, for example, only a few percent. It's high in the two large cities, Nairobi and Mombasa, and highest in three (out of 47) counties around Lake Victoria. The situation in Tanzania is similar, with three high prevalence areas. In Burundi and Rwanda prevalence is also low, except in the capital cities.

So the fact that most high HIV prevalence areas do not overlap much with high HCV prevalence rates is not a very convincing argument that the two viruses are transmitted in completely different ways, the former being mainly transmitted through heterosexual sex and the latter through unsafe healthcare. Comparing HCV and HIV patterns only makes the heterosexual sexually transmitted HIV contention look all the more infantile.

The good news, then, is that improving healthcare safety would reduce transmission of both HCV and HIV, and even a range of other diseases that don't get anywhere near as much attention as HIV. Good healthcare is also safe healthcare, whereas indifferent healthcare, with low standards of infection control, results in alarmingly high rates of transmission of serious diseases.

Journalists have recently had their attention drawn to the potential drawbacks of neglecting healthcare; ebola is difficult to control in a healthcare environment (as opposed to a rural village, where it appears to die out quite quickly). But it has been shown that it is difficult to control in healthcare facilities because of unsafe practices, such as reuse of skin-piercing instruments, gloves and other disposable supplies, lack of infection control procedures, a shortage of skilled personnel, etc.

One newspaper article even made a connection between ebola and HIV, suggesting that because many West African countries had relatively low HIV epidemics, investment in healthcare was lower, hence the weakness of the response to ebola.

Their analysis is not very perceptive. HIV-related investment in Sierra Leone and Liberia has been high enough to ensure that more than 80% of HIV positive people are provided with antiretroviral treatment. Guinea is way behind them in this respect, with less than 50% of people receiving treatment. But spending money on preventing supposedly sexually transmitted HIV, and on treatment, does nothing to address unsafe healthcare.

HCV, HIV, ebola, TB and various other diseases can be transmitted through unsafe healthcare, so this is an argument for strengthening all health facilities in all developing countries. A human right to health does not make any sense if healthcare is so unsafe that patients risk being infected with a deadly disease when they visit a health facility. So 'strengthening' healthcare must include making health facilities safer.

It is hardly surprising that people in Guinea, Sierra Leone and Liberia run from health authorities and hide family members who are sick. The prospect of having your house searched by people in hazmat suits, sometimes backed up by people with guns, is frightening enough. But if your property is dragged outside in broad daylight and burned in public, and your sick relatives are hauled off to a ramshackle, understaffed, undersupplied health facility, these must extremely traumatic experiences.

If health facilities are unsafe, healthcare associated transmission of serious diseases will only increase as more people are admitted to them. Transmission rates will not go down until safety is made a priority; this applies as much to HIV as it does to HCV, ebola, TB and other diseases. The additional assurance that people will not be exposed to life-threatening diseases through unsafe healthcare should also increase demand for healthcare.

UNAIDS' 3 Ones: One Disease, One Theory, One Solution

[Cross posted from the Don't Get Stuck With HIV site.]

According to Avert.com "more than $400 million [of donor funding] was committed to HIV and AIDS in 2007/2008". However, less than a quarter of that funding, probably around 20%, was spent on 'prevention', with the usual assumption that almost all HIV is transmitted through heterosexual behavior. Around 60% is estimated to have been spent on treatment and care, say around $240 million.

It's tremendous that a lot of money is being spent on treating and caring for people who have been infected with HIV. Not all HIV positive people are currently eligible for treatment. Perhaps UNAIDS' claim that 60% of those who are eligible were on treatment at some time, although the figure, however many hundreds of thousands it may be, does not discount those who have died or who have been otherwise lost to follow up.

Around 95% of Tanzanian people are HIV negative. Out of the 1,470,000 people who are living with HIV, between one and two thirds may be on treatment. That's 1-2% of Tanzanian people, at the most. So how do those who control the money decide how to spend the approximately $80 million in order to reduce transmission of HIV; what kind of prevention activities should be prioritized among those 46,300,000 Tanzanians who are still uninfected?

UNAIDS has a slogan (aside from their 'three ones' slogan alluded to in the title above) that goes 'know your epidemic - know your response'. This makes it sound like UNAIDS believes that there are different epidemics in each country, and perhaps even different subepidemics within each country. But their response is always to treat HIV epidemics in Africa as if they are all virtually the same, although they may vary in intensity: but they are all assumed to be 'driven' by heterosexual behavior.

It's not very clear how far $1.70 per head can go towards 'changing people's sexual behavior', but that hasn't stopped UNAIDS and other big players in the HIV industry (and some of them are very big players indeed) from trying. Billions have been spent on wagging fingers at rooms full of adults and children over the almost 20 years of UNAIDS' existence.

Luckily there are a few things that can be done to help establish that HIV is probably not entirely heterosexually transmitted and that most finger-wagging exercises are a complete waste of money (their inherent paternalism is probably not considered to be a disadvantage; perhaps neither is their clearly demonstrated ineffectiveness).

For example, in Tanzania (and most other countries) there are only a few places where HIV prevalence is really high. Here's a list of prevalence by region (the five with the lowest prevalence are the Zanzibar archipelago):

Njombe 14.8
Iringa 9.1
Mbeya 9
Shinyanga 7.4
Ruvuma 7
Dar es Salaam 6.9
Rukwa 6.2
Katavi 5.9
Pwani 5.9
Tabora 5.1
Kagera 4.8
Geita 4.7
Mara 4.5
Mwanza 4.2
Mtwara 4.1
Kilimanjaro 3.8
Morogoro 3.8
Simiyu 3.6
Kigoma 3.4
Singida 3.3
Arusha 3.2
Dodoma 2.9
Lindi 2.9
Tanga 2.4
Manyara 1.5
Mjini Magharibi 1.4
Kusini Unguja 0.5
Kusini Pemba 0.4
Kaskazini Pemba 0.3
Kaskazini Unguja 0.1

And there are further generalizations that can be made about HIV in Tanzania. Prevalence tends to be higher among females, urban dwellers, wealthier people, people with higher levels of education and employed people. It tends to be lower among men, rural dwellers, poorer people, people with lower levels of education and unemployed people.

UNAIDS tends to 'analyze' these features, which are shared by all high HIV prevalence countries, and conclude that wealthier, urban dwellers with jobs have bigger 'sexual networks' (etc) as if every person with HIV must have a 'sexual network' (etc). But there are other figures they could avail of when they are in an analytical frame of mind.

For example, while women are said to be more susceptible to HIV infection for various biological reasons, wealthier, urban dwelling, better edcated women with a job are also much more likely to attend ante natal clinics (ANC) and seek the assistance of some kind of trained health professional when they are giving birth.

Now, you might expect women who attend ANCs and have assisted deliveries to be less likely to be infected with HIV, but you'd be wrong. In many instances they are more likely to be infected, sometimes a lot more likely. Indeed, some countries with the highest HIV prevalence figures also have the highest ANC and attended birth figures, Swaziland, Lesotho, Namibia and Zimbabwe, for example. The contrary tends to be true of low prevalence countries in sub-Saharan Africa.

This is not to say that HIV is never transmitted through heterosexual sex, or that it is always transmitted through unsafe healthcare (even among women). It's just a clear indication that we need to know exactly what contribution heterosexual behavior makes to epidemics, and what contribution may be made by non-sexual routes, such as unsafe healthcare, cosmetic care and perhaps other practices.

The whole concept of a UN agency set up to 'fight' one disease is bad enough. But it's a whole lot worse if they and the rest of the industry continue to squander precious resources on poorly targeted and ineffective interventions. Resources need to be spent on health, defined as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (there's no irony intended in citing WHO here).

Apparently one third of all aid in Tanzania is being spent on HIV, which leaves the other two thirds to be spent on other development areas. So perhaps some of that will eventually be used to address the many poorer, less well educated, jobless people living in rural areas with virtually no infrastructure or social services, but who are HIV negative. They will likely remain negative if even a fraction of available donor funding is spent on working out the relative contribution of unsafe healthcare to the worst HIV epidemics in the world and addressing this issue, however belatedly.

The Media in Africa: Beware of Natives

BuzzFeed has photos of 10 signs photographed in South Africa during the apartheid era and it is truly shocking to think that, as the article points out, these signs only became illegal in 1994. But that's why it should be even more shocking that instances of extreme racism and apartheid style thinking should still be so common in the international media today. I have listed a number of examples below, with links to some of the most offensive articles I've read in the past few years.

These are just the tip of the iceberg and a full study would take years. But, in no particular order, let's start with the stories about condom 'recycling' in Kenya and condom 'rental' in Tanzania. Whether the journalists who wrote these stories were bored or desperate is just one question; but what about the media outlet that published them and the public who read them?

One that goes back a few years is the 'story' about starving HIV positive people on antiretroviral drugs eating cow dung in Swaziland. Numerous media outlets echoed that one and it cropped up several times. There was even a story about a woman in Namibia who  claimed to have eaten cow dung but then admitted that she had made it up. She didn't attract anywhere near as much publicity, though.

The ever-popular notion of 'African' sexuality is a trusty tool in the journalist's store of prejudices. Although it has been debunked many times, the media picture of Africans has remained faithful to their apartheid agenda. Africans are truly 'other', that's why there are such massive HIV epidemics in some African countries, isn't it?

The UNAIDS Modes of Transmission analysis, which produces the 'science' behind the media's HIV related racism has also been criticized, but why attack the source of so many stories that everyone seems to enjoy and find so completely inoffensive? UNAIDS even recognizes the true HIV danger in African countries, unsafe healthcare. But they keep that to themselves, publishing advice about avoiding non-UN approved health facilities in a booklet for UN employees, courtesy of the sweetly named 'UN Cares' (about its own employees).

Occasionally a journalist may allude to the use of African participants as research fodder, but people are too used to hearing about the oversexed and feckless African to care very much about such abuse, especially when it can always be dressed up as 'helping'.

It's coming up to about six years since the international media 'discovered' the Tanzanian albino attacks and killings, even though they had been reported in local media for some time. The sloppy and offensive coverage that followed this great 'scoop' for the BBC continues, as do the attacks on persons with albinism. Why revise a story that has won praise and awards? Of what importance are accuracy and insight when opportunities for self-adulation are at stake?

The disgusting US Christian right story of the use of adult pampers as a result of anal sex among men who have sex with men has even done the rounds in some of the local media. We see articles about African countries claiming that homosexuality is 'brought in' by foreigners. But where did the homophobia come from?

There are sometimes instances of the kind of media friendly racism that is 'roundly' condemned, trivial matters that keep readers entertained, much easier to write about than anything that matters. But what the media writes is clearly not yet a source of offence to most people. Perhaps in years to come sites will be able to list some of the shockingly abusive things the mainstream media published about African people, who knows?

Open Letter to the United Nations Office of the High Commission for Human Rights

[Crossposted from Blogtivist; the link provided to the UN report was to a different report and the correct link has now been provided, apologies for any confusion this may have caused]

Dear High Commissioner Navanethem Pillay

This open letter to you is about one of your recent reports, entitled 'Persons with albinism' (A/HRC/24/57), dated 12 September 2013. Your summary gets to the point: "In some communities, erroneous beliefs and myths influenced by superstition put the security and life of persons with albinism at risk." You also refer to 'ritual' killings and attacks to which many persons with albinism have been subjected over the last six or seven years, particularly in Tanzania. You remark that "[t]he information on the various cases collected by OHCHR came from multiple sources, but the level of verification varies in each case.

It is this level of verification that especially interests me. Earlier in the report you stated that "[t]he collection and verification of cases of ritual attacks is a challenge due to the secret nature of witchcraft rituals, the inability and/or fear of victims’ relatives to report such incidents...[etc]." I would suggest that, from the earliest killing reported in the international media, widely believed to emanate from the BBC, all witchdoctors and other people reputed to be engaged in witchcraft, or related activities (very different sorts of activity among which the BBC makes no useful distinction), have been thus implicated in the attacks.

I hardly need to remind you what that means. Many people, in Tanzania and other countries, have been persecuted by mobs, even lynched, because of the belief that they were engaged in witchcraft or something similar. Indeed, what may have been the first 'ritual' killing of a person with albinism, reported in the Legal and Human Rights Center in their 2006 report, is a brief mention of two men who were lynched by a mob; the brief mention is, essentially, about the killers themselves, not their victim. Your report does not mention the Tanzanian Witchcraft Ordinance of 1928, which proscribes public accusations of witchcraft without providing evidence that the accused actually practiced witchcraft or claimed to possess witchcraft powers, etc, but I’m sure you are acutely aware of the risks that those merely suspected of witchcraft, and even those investigating attacks on persons with albinism, face.

I needn't labor the point; witchdoctors have very good reason to be secretive, especially when everyone points the finger at them following the (rether frequent) occasions on which the media sees fit to implicate them. I'm sure you haven't forgotten earlier stories about the 'skin trade' in Tanzania, 'devil worship' in Kenya and various other phenomena more notable for the vast number of column inches dedicated to them that to the substantive content of the various reports that came to be written about them.

Your report notes that victims, their relatives and fellow community members are afraid to report killings. But it's only natural to fear those who are thought to have magical powers, and worse, to be so ruthless that they would attack people with machetes to maim and/or kill them, or even to instigate such a killing. However, could people actually be more afraid of the absolute demons they read about in the press than anything they have ever experienced? Could they be afraid of something they have never seen, but which they are assured by everyone who has read these reports, exists among them and wields a terrible power over them?

As you say, levels of verification are important. The vast quantity of media coverage may one day yield up something that constitutes evidence of such devotion to superstitions that it leads to maimings and killings; the small handful of sources of information on which the media depends, and on which your preliminary report now depends, may have some checkable, some verifiable source of information that lies, however hidden, behind it. Perhaps this could be used to carry out an investigation into some of the killings, at least the ones for which there is even a minimum level of documentation.

But I would suggest that the media itself has often been secretive, a bit ritualistic, even a bit fetishistic, at times. They constantly refer to things as if they have evidence, words like 'official' are used (although few journalists, if any, seem to view the police, or any other commonly used informants in such cases, as a possible source of anything except further unsubstantiated information, ridicule, stories about corruption, predictable stuff), they write as if the very dogs on the streets know that all these attacks were carried out by witchdoctors who paid 'middlemen' to 'obtain' body parts of people with albinism, for which 'rich and powerful' people pay large amounts of money to ensure that they become more rich and powerful.

It's a very credible story, in a sense, given the many other incredible stories we are told about Africans or, in this case, Tanzanians; a story of superstition, poverty, bullying by rich people, incompetence by 'officials'. But it's a story for which the media provide little or no evidence. Tanzanian people may well have been convinced that witchdoctors are rich and powerful, and that they themselves could become rich and powerful by working for them, or for their rich and powerful clients. But, aside from the plentiful supply of gossip, where is the evidence? Or should I ask what constitutes evidence in these cases? If the sheer number of media reports constituted evidence, all Tanzanian witchdoctors (and those thought to be witchdoctors) would be locked up, perhaps even condemned to death. But none, as far as I know, have been executed (unless some have been killed by mobs). Few have even been through the courts.

I truly hope any evidence that exists that sheds light on these attacks on people with albinism is going to be handed over to you by those who have generated so many media reports based on what seems to them to be so certain. Your preliminary report suggests that little new evidence, with a reasonable level of verification, has yet been made available to you. It is to be hoped that all will be revealed in the final report, after a thorough investigation, one that looks critically at the assumptions we have been making for around seven years without putting a stop to the attacks, apprehending the attackers, or protecting the victims and those around them.

As things stand right now, perhaps there is something wrong with our assumptions? The practice of 'witchcraft' was banned without that preventing further attacks. Over 170 people were allegedly arrested, and let go (at least, I hope they were let go). Apparently over 70 of them said they had been told by witchdoctors to bring them albino body parts. Could this be an important lead? Or could it suggest that everyone reads what has been written in all the papers for months, or talks to someone who does? None of these people were convicted. That could be because there was no evidence, aside from the fact that they were witchdoctors, suspected of being witchdoctors, associated with witchdoctors, etc.

Or maybe they were not involved, or not even completely aware of what was going on, aside from what they read in newspapers or heard from people who read them, or claimed to? The media calculated and recalculated the figures for victims and deaths: there were 4 in December 2007 but 20 by January 2008, without any media report that I could find accounting for any of these new attacks by providing basic details; who were all these victims? Generally we don’t even know their names, sometimes not even their gender. Was their body discovered somewhere, or was there even a body? You may think these are silly questions, because the media eventually agreed by some time around 2012 that there were over 70 deaths. But how starkly all this contrasts with reporting on murders in Western countries, where some of them become household names; at least we get the basic details.

At first, it was claimed there were 71 deaths if you included 17 from Burundi, seven from Kenya and three from Swaziland, but it is asserted that there were 71 deaths in Tanzania by the end of 2012, without that qualification, and by 2013 the BBC raised that to 72 deaths in Tanzania. I suggest that the running tally of deaths has become a bit confused and that various reports are mixing up important details. Perhaps all I am lacking is access to ‘official’ sources, to which some refer, but if there are official sources I believe they should be named, or at least described. Otherwise we don’t know if this is an instance of secrecy, sloppiness or exaggeration.

According to the media accounts that I have looked at there were well over 30 deaths that attracted enough media interest for something about the incident to be recorded, the age, location or some circumstance, such as 'skinning' of the victim. There were well over 70 documented attacks. Not over 70 killings, as the media eventually agreed, but as I said, they could be keeping their cards close to their chest. But attacks continue. Media coverage has waned considerably since 2008 and 2009, but I have tried to account for documented victims in the linked table and I would welcome additions to it.

You will, no doubt, have read a lot already, possibly coming across odd recurrences and even more odd contradictions, even convenient, but unsubstantiated juxtapositions. You will probably even notice that predictions, such as the fear that lots of persons with albinism would be maimed and killed before the 2010 Tanzanian elections turned out to be unfounded? It doesn't say that in the mainstream media, as far as I know, but nor could I find any articles about a noticeable uptick in attacks. Documented victims peaked in 2008, but again in 2011. There was a big dip in 2009 (without a corresponding dip in media coverage), with a further dip in 2010, by which time media coverage began an exponential decline that has continued for several years. I quite accept, of course, that my data is limited to what is available, free of charge, online; the media may have access to other information to which I am not privy, but to which, I hope, you are privy.

To conclude: you mention 'erroneous beliefs and myths, heavily influenced by superstition' in your analysis of attacks on persons with albinism. I would add to that a set of erroneous beliefs and myths that are heavily influenced, even promoted, by the media. If people believe in the great power of witchdoctors, and believe that they can get paid a lot of money to carry out a maiming or a murder, they are quite wrong, and it behooves the media to make that completely clear, now. But why would ordinary Tanzanians even believe such a thing? Perhaps they deserve to be condemned for being stupid enough to commit a terrible crime on the stuff of rumor and gossip. But ordinary Tanzanians themselves are not the source of all rumor and gossip, nor are they the sole spreaders of rumor and gossip.

If it is the case that not all witchdoctors are so powerful and so ruthless, that not all 'middlemen' (and what ordinary Tanzanian could not, going by media descriptions, fill that role?) are so greedy or so gullible, even that most ordinary Tanzanians living in rural communities (and we are frequently told about levels of superstition in rural areas) are not so cowardly or so despicable as to turn a blind eye, or to conspire with other parties, as to maim and kill members of their own community or their own family 'because of their superstition', or worse, because of lust for money, then the entire investigation of the attacks needs to begin again.

Why? Because the received view of these attacks needs to be called into question. We simply don’t know much for sure about witchcraft, a ‘trade’ in body parts, or a ‘rich elite’ that is willing to pay large sums of money for goods and services provided by witchdoctors; we don't know who we are looking for, what they are like, how many they are, aside from the suggestions provided by the media.

I believe  it is vital for us to understand the root causes of attacks and discrimination, and your report refers  to these among your recommendations. However, the distinction between the causes of the attacks and the causes of the discrimination is just as vital. The attacks are a relatively new phenomenon, even various media cited sources agree on that. But the discrimination goes back decades, perhaps centuries, and affects the millions of disabled people living just in Tanzania alone (an estimated 2% of the population), to this day, not just the tens of thousands of persons with albinism (or hundreds of thousands, depending on which article you read).

Media reports, and other reports depending on media reports, do not constitute a solid foundation on which to base further investigations. I am sure you are aware of that, but what I have read so far, in the media and in other reports, is highly questionable. Yet I see virtually the same material in your preliminary report. It is not my intention to advise you, only to urge you that the current body of data on attacks on people with albinism may not yet be very reliable.

I look forward to a report that results in the protection of persons with albinism, brings perpetrators of violence to justice and ensures that these attacks never happen again. Following the publication of the report, persons with albinism, those associated with them, those associated with attacks on them, and all other innocent people, will enjoy those human rights that have, up to now, been denied them.

In addition to compiling a web page of documented attacks, to which I have provided a link, I have various other data that I have collected. If I can be of any assistance to you or your officers, please do not hesitate to get in touch with me.

Respectfully

Simon Collery

Huge Birth Control Programs Don't Work: Time to Give Education a Chance

I recently moved from a job as grant proposal writer for an NGO working in several different development areas to a similar job in a secondary boarding school for girls, which is being built in a country where many girls don't even finish primary school. So I was comforted to find an article entitled 'Women's Education Slows Population Growth'. That women's education can have such profound and positive consequences is not the issue, that has been recognized for a long time, at least by those working in education. But the priority is so often given to population growth, rather than to education or any other development area.

A shocking proportion of 'development' money and a disturbing number of development related insitutions concentrate almost exclusively on population control, in some form or other. They bang on about an unmet need for contraception as if many women will have depleted health or lives as a result of lacking birth control methods, when they are likely to be in far greater need of better nutrition, healthcare, security, governance, equality, infrastructure and, indeed, education. Shovelling contraceptives into rural communities may be a lot easier than providing people with what they need, but without the education and other development areas being addressed, the only gain will accure to the pharmaceutical companies who produce contraceptives.

Similar remarks apply to a lot of other 'health' programs, which target whatever health issue is currently fashionable and well funded; many of them are also necessary, but they would work a lot better if people had the level of education to capitalize on them. Otherwise, they can just go through the motions of attending numerous courses, often for the per diem they may be paid or the free lunch or other minor benefits on offer. I have met people who have been to various 'training courses' only to attend the same course several more times, sometimes provided by the same NGO as before. Training courses are a great way to spend money and it's easy enough to gather data that allows the donor to pronounce the intervention successful. Some health drives pick out some particular disease, perhaps a water borne disease, without addressing water and sanitation in the area. The current drive to 'eliminate' polio is a cases in point; those who attend immunization drives go home to drink contaminated water and contract something else.

Education itself, as we found in my own country, Ireland, is not enough when there are no jobs to go to. And here in Tanzania, women are not considered to be able to do many jobs that they would in fact be well able to do, if they had the education. Sadly, they are considered to be able to do many jobs that are not particularly appropriate for them when they are too young, too old, pregnant, childraising or breastfeeding, but that's another matter. I always feel a bit dishonest when I tell people about how important education is when there is little guarantee many of them will ever get to use it, especially girls and women.

As if there are not enough obstacles, also, school-going girls who become pregnant are excluded from school. In the rare instances where they are allowed to return to school, most do not. This is to 'set an example', we are told. And it does. It shows that girls who get pregnant will be treated very harshly, whereas the boys or men who make them pregnant, generally, will not. The fact that underage girls being made pregnant by older men is a serious crime doesn't get the girls off the hook. Men don't appear to be prosecuted, boys are generally not excluded from school and the strong prejudice against females appears to be practiced by the very institutions that might be in a position to change things.

According to the article, the average birth rate is less than half in regions where education is valued; as I'm working in one of those regions, I'm hoping that birth rates are lower because education is valued. However, even expensive schools with nice, well-funded buildings and facilities, don't always have especially high educational standards. As a fundraiser, sometimes I can see funds for all sorts of things, but not so many that clearly improve education. There is not so much available for good teachers or other provisions that would make a difference. And many fundraisers are tasked with raising money for the buildings, which is important, but often distracts from the ultimate purpose of these buildings.

So, as the article suggests, it's not the correlation between higher standards of education and lower birth rates that is important; it is the priority that is given to education. Proponents of the population control theory of development, so beloved throughout the last fifty years (and still loved by the Rockefeller Foundation, the Gutmacher Institute, the Gates Foundation, Population Services International, Family health Internationa and many more), never appeared to realize what needed to come first, that with development of education, health, infrastructure and the rest, lower birth rates would follow. Similarly, poverty is pervasive in Tanzania, but lower birth rates does not have much direct effect on poverty; rather, lower poverty rates result in improved health, education and the like.

For education to be of benefit, many other things need to be in place as well. But one thing is for sure; reducing birth rates and hoping that other development areas will benefit accordingly has not worked. The funding these charlatans have received urgently needs to be directed towards people's true needs, which are still education, health, a decent standard of living, security, food security and the rest, just as these are the true needs of all people.

Next Year's Famine Victims Currently Being Groomed by Western Powers

If you look at the top 30 donors to the East African Famine, number one is the US. It is one of the richest countries in the world, although donations as a percentage of per capita income are nowhere near the highest.

But the US is also pretty good when it comes to land grabbing. This time it's Tanzania, where a substantial deal is being questioned by opposition MPs. But recently, it came to light that big, wealthy US educational institutions were snapping up land in various African countries that are, or have had, shortages of affordable food.

An estimated 162,000 Tanzanian smallholders stand to lose their land if the deal goes through. This means that more than half a million people would be impoverished as a result. And all so that some US energy company can produce what they refer to as food crops, but are much more likely to be used for biofuels.

'Affordable' food is the key term. There isn't a shortage of food in Tanzania as a whole (nor in Kenya or several other countries where people are starving). Indeed, some of Ethiopia's most productive land is also being grabbed, as millions there face starvation. Famines typically involve lack of access to affordable food, not lack of food.

One of the culprits mentioned in relation to Ethiopia is Italy, which also appears in the top 30 donor list, albeit at number 19. (The EC, number 2 in the list, is busy trying to ensure that India will no longer produce affordable drugs for HIV positive people by pressing them to sign an 'Economic Partnership Agreement'.)

The most generous also stand to reap far more than they sow. The UK is number 5 on the list and their history of land grabbing, which is still a huge contributor to the country's wealth, is legendary. They are one of the biggest grabbers in Africa, though they are more likely to boast about how much they 'contribute' in aid. Another big and long running land grabbing incident in Tanzania involves a British company called Sudeco.

It's interesting how a lot of the land being grabbed is being used for sugar cane. This can conveniently be referred to as a food crop but is far more likely to be used these days for biofuels. Western powers spend decades driving African sugar producers out of business by subsidizing their own producers and dumping their surplus on African markets. But now they seem to want African sugar again.

Canada is number 6 on the list. Much of Tanzania's gold, much of Africa's gold, is extracted by a Canadian company, which pays little or nothing in taxes or royalties. The US, UK and even South Africa, number 28 on the list, also extract gold at massive cost to ordinary Africans. Gold extraction puts huge tracts of land out of use, though direct contamination, water contamination and through forcibly excluding indigenous people, often people who once made a living from the gold.

Make no mistake, famines like the one currently developing in East Africa, are generally not 'natural' disasters. They occur and last because they are a consequence of large scale theft, government sponsored, multinational sponsored, philanthropic institution sponsored, even international institution sponsored, theft.

I don't wish to suggest that contributing money to the current famine is wrong, I would encourage people to contribute. But, bearing in mind what we are 'contributing' to next year's famine, giving money is not the only thing we can do. We can also ask public representatives tough questions about things that are often presented as 'business' or 'aid' or 'partnership', especially when they involve land and water use.

The majority of people in all East African countries depend very directly on land for their food and income. If that land is taken from them, or even if its use is dictated by those whose sole aim is profit, their lives and livelihoods are threatened. A famine is not an 'act of God', it's a consequence of human activities.

Pregnant African Women Face Both Sexual and Non-Sexual HIV Risks

Researchers in South Africa aiming to estimate how many pregnant women were in the 'acute' phase of HIV infection, where their status would be undetectable using ordinary HIV tests, found that an astonishing 38% of women were HIV positive. They estimate the yearly rate of infection at over 11%.

It doesn't take a genius to work out that at these rates, the majority of women will be infected or dead from AIDS by the time they are in their thirties. These rates may have been found elsewhere, but they are still shocking. And yet, these researchers seem to think that they will achieve something by testing more and more people with better and better testing methods.

How are they being infected? The article assumes that most transmission is through heterosexual sex but this is just not credible. Some of the women were very young, they would hardly have had enough time to have enough sexual experience to become infected with a virus that is difficult to transmit through penile-vaginal sex.

If they are being infected by HIV positive men, who are these men? Incidence among men of similar age is often ten or more times lower. While it is argued that young women have sex with older men, who are more likely to be infected, are there even enough older HIV positive men to explain incidence figures among women? And are these women having sex with them? These have never been demonstrated.

Earlier research in South Africa has suggested that the probability of transmission is often 1, that a woman can become infected despite having only one partner and possibly even only having unprotected sex once. Would the researchers like to claim that there is a different strain of HIV in South Africa? Has the possibility of such transmission rates through heterosexual intercourse ever been demonstrated?

I don't believe so. I believe a lot of things are assumed, despite evidence to the contrary. And the authors of this paper go on making those assumptions. But HIV transmission will not be prevented if we don't even know how it is occurring. Rather than establishing how they may have become infected, it is assumed that most African women were infected sexually and conveniently forgotten that the chances of this happening to a few women, let alone to many, are extremely low.

Non-sexual HIV transmission must be considered. Most women, African and non-African, even young women, do not take stupid risks when they are pregnant. Most women don't take stupid risks even when they are not pregnant. Many HIV infections among pregnant women occur once they are already pregnant, often long into their pregnancy.

Transmission rates may well be higher among pregnant women, but so is the number of risks they face from being infected through unsafe injections or other medical procedures. And interestingly, the percentage of women in South Africa who visit an ante-natal clinic several times during their pregnancy is in the 90s. Compare that to a country like Tanzania, where some may visit once but the majority never visit at all, and where rates of transmission are many times lower than in South Africa.

Is it just a coincidence that HIV rates are often lower in areas where people don't have access to health services? Perhaps it is. But it is vital to find out if it is a coincidence. If it isn't a coincidence, then health services could be busy spreading the very virus they are supposed to be preventing.

Facts that do not Speak for Themselves

It's very tempting to blame the spread of a sexually transmitted infection (STI) such as HIV on promiscuity. It would be useful to have a criterion for 'promiscuity' as opposed to reasonably normal levels of sexual activity, of course. But the fact is that there is no evidence that Africans, as opposed to people from other continents, are more promiscuous. The evidence suggests that in Africa, as in other continents, some people have a lot of sex and some don't.

It would be very easy to dismiss the last paragraph on the grounds that so many articles state or imply that Africans are more promiscuous than the rest of the world. However, I have yet to come across any evidence for the belief, unless the constant reassertion of something counts as evidence. We don't need an explicit definition of promiscuity, we understand what it means. It's just that the term is being applied indiscriminately.

An interesting study of sexual behaviour was carried out in four African countries with very different rates of HIV; Benin and Cameroon, which both have low HIV prevalence and Kenya and Zambia, which both have high prevalence. The highest rates of partner change were found in Cameroon, especially among men. Even among women, partner change was higher in Cameroon.

In Kenya and Zambia, the age of sexual initiation was slightly lower. There were also lower rates of circumcision and higher rates of other STIs, such as herpes simplex virus (HSV). But there was simply no correlation between HIV prevalence and indicators of sexual behaviour, such as concurrent sexual partners.

Another study found that there were more people in African countries than in countries in other continents who reported having had no sex in the month preceding the survey. And most men in all countries surveyed had no extramarital sex or no sex outside of a long term relationship. Overall, the views of Africans surveyed were more enlightened than the views of those from other continents.

Yet another survey found that age of sexual initiation for females was increasing in most countries surveyed in Africa between the 1960s and the 1990s. But it's interesting to compare age of sexual initiation in developed and developing countries. The country with the highest percentage of 15-19 year olds who are not married and have already had sexual intercourse is the UK, and this stands for both males and females. Also high on the list are Brazil, the US and the Dominican Republic. All these countries have low HIV prevalence, less than 1% in the UK, the US and Brazil.

When it comes to lack of knowledge about sex, contraception and safe sex, levels of unwanted and teenage pregnancies and other matters, the US and the UK are usually very high on the list. It is interesting that these two countries have so many worrying indicators, yet they both have relatively low HIV prevalence.

And so on. Eileen Stillwaggon in AIDS and the Ecology of Poverty lists a number of studies that show that the evidence does not bear out the assumptions about HIV transmission being explained wholly by sexual behaviour. In every country, people have sex. In every country some people have more sex than others. But there is no country where HIV rates can be correlated with high levels of unsafe sexual behaviour, partner change, concurrent relationships and the rest.

This is not to say that there is not a lot of evidence of unsafe sex in developing countries. There is a lot of unsafe sex taking place all over the world. But not all countries have high HIV prevalence. That is the question that researchers have been trying to find the answer to for so many years. It hasn't escaped their notice that STIs are spread by people having sex. They are asking why there are extremely high levels of HIV transmission in some countries and low levels in other countries.

Some have suggested that poverty is a key factor in the spread of HIV. Indeed, people probably don't engage in commercial sex work when they have money coming in from other activities. So poverty must play a part. Others have gone on to show that poverty alone doesn't explain HIV prevalence rates because some poor countries don't have high rates of HIV. One response to this is that economic inequality may be a better way of looking at wealth and poverty, some people are dependent and others have the opportunity to buy sex as and when they want it, they can afford concurrent partnerships.

There are many counter examples to poverty and even inequality driving HIV epidemics and it has been clear for a long time that HIV has many drivers. It is futile to expect to find one factor that drives all epidemics and pointless to argue that poverty or inequality or whatever have no part to play. Epidemics involve many different people with different lives and circumstances interacting with each other.

This blog already covered Senegal, where education, health and other social indicators are probably not that different from those in Kenya, certainly not different enough to explain the low levels of HIV in Senegal. The histories of HIV transmission are many and various, between and within different countries.

A recent literature review listed the top factors contributing to HIV transmission as: "poverty, famine, low status of women in society, corruption, naive risk taking perception, resistance to sexual behaviour change, high prevalence of sexually transmitted infections (STI), internal conflicts and refugee status, antiquated beliefs, lack of recreational facilities, ignorance of individual's HIV status, child and adult prostitution, uncertainty of safety of blood intended for transfusion, widow inheritance, circumcision, illiteracy and female genital cutting and polygamy."

The article also finds these factors to be "interrelated and complementary". There is no one factor that is the most significant. Even poverty, which is by far the most significant, is closely related to many of the other factors. For example, people who are poor are also more likely to have lower levels of heath and therefore be more susceptible to HIV. They have worse living conditions, they have fewer opportunities, less education, they are more vulnerable to the effects of corruption, crime, global financial crises, food prices and global environmental degradation, and the list goes on.

The issue of connections between poverty and HIV transmission keeps coming up, as if examples of HIV transmission that are not related to poverty suggest that poverty is not a problem. Even if HIV were to disappear tomorrow, poverty is a problem. Poverty needs to be eradicated because it denies people many of their human rights. But also, in countries where wealthy people are more likely to be HIV positive, poverty is not in any way less relevant.

If there are some people who can afford to pay to have wide sexual networks and there are some people who need to be part of a sexual network because they are poor, then 'poverty' doesn't describe the problem. The level of economic inequality more accurately describes it. And before anyone starts throwing counterexamples at me, this is not to say that there are not many other factors involved. The very point is that there are many factors in the transmission of HIV. Poverty and inequality are important but they relate to numerous areas of underdevelopment that are also important factors.

It has been recognised for some time that in Kenya and Tanzania, for example, HIV prevalence is higher in wealthier quintiles. Clearly, there are different circumstances surrounding each instance of HIV transmission. But the problem is to explain what circumstances give rise to, say, the fact that women in the wealthiest quintile in Tanzania have four times the level of HIV positive people than the poorest quintile.

If your causal story is that rich men pay to have sex with poor women, would you add to this that rich women are even more likely to pay to have sex with poor men? I'm not saying that this never happens but I have seen no evidence that this is common. I don't know where all these transactions could take place because I haven't seen young men in bars looking for rich women. There are many young men in bars looking for women to have sex with but they tend to target foreigners, so this doesn't explain the level of HIV among wealthy Tanzanian women.

There is clearly a lot about HIV transmission that we don't yet know. I took a quick look at the occupations of women who are in the wealthiest quintile and was surprised to find that 10% say they do subsistence work and 25% say they do stall and market work. The highest percentage say they have no occupation. Those in the wealthiest quintile may well be dependent on their husbands, but this does not explain why the correlation between wealth and HIV prevalence is stronger for women than for men.

There is more to wealth than occupation and those surveyed are also asked about property, household income as a whole, amenities, etc. But it is remarkable that more than 75% of women in the bottom three quintiles give their occupation as subsistence work. Even in the second wealthiest quintile, more than 50% list their occupation as subsistence work. The bottom three quintiles have a lot in common on the basis of occupation type, the top quintile is quite different. No doubt, these differences in occupation type are related to many other differences in factors that relate to HIV transmission.

But this is only speculation, there is too little data available and it is not finely grained enough to work out or evaluate all the important drivers of HIV epidemics. There are many factors and therefore there are many facts. But the ‘facts’ often appear counterintuitive and there are probably many that we, as yet, know nothing about. What is clear is that a lot of interpretation and clarification is needed and that the facts do not in any sense speak for themselves.

Sex, Christians and Abstinence

Christians are unique in the animal kingdom in that they only experience the desire and even gain the ability to have sex once they are in a relationship of a sort that is approved by their church. If you don't believe me, just read a copy of a Christian bible. Ok, you have to interpret it a bit, but you'll find it there if you want to, and many people want to.

Or perhaps you would not take advice about sex from people who claim to only indulge in sexual intercourse for purposes of procreation? They are the last people I would ask for such advice. It is not supposed to be enjoyable and it is not even supposed to occur at all until approved by the church through marriage vows. Oh, and if you do 'transgress' you must feel terribly guilty and confess to someone who is probably exactly the same as you.

It's been a long time since (my last confession?) I have blogged as I have been travelling a relatively short distance very slowly. That's public transport in East Africa. And since I have reached my destination, Kigoma, Western Tanzania, there has been no electricity. The internet cafe I am writing from is supplied by a diesel generator that shudders and threatens to cut out at regular intervals. So I'll have to keep this posting short.

Several papers I have read on HIV transmission mention lack of diversion or entertainment and boredom as one of the factors in transmission. The man I am staying with mentioned the boring evenings several times and we killed some time by working late, by candle light, taking a long walk, stopping in a pub for a soda and chatting. But we would both have preferred to do something more entertaining or even just read with real electric lights.

Reading is not a big thing in Tanzania. It's very hard to get books and many people have difficulty with reading large amounts of text. So I don't even expect a big demand for books to develop any time soon. TV is popular but those who can afford TV may not be able to afford a generator to run it. Radio is a possibility, but evening with so few things to do and so little money to spend inevitably leads people to pursue cheaper and more readily available activities.

But there doesn't need to be a power cut or lack of things to do for sex to be an option, it's not just a way of filling in time. People don't need to list sex as a hobby no more than they need to list eating. They won't die if they don't have sex but nor will sexual desire go away. In fact, the desire for sex will not go away even if a load of Christians shout very often and very loudly about how you will die if you have sex of a sort they don't approve of.

One of the most extraordinary consequences of the HIV pandemic is the reaction of the Christian churches. They have been preaching abstinence, restraint, poverty and whatever else while practicing the opposite for two thousand years. They manage to attract the poorest people to give away a large chunk of their pittance to a church that lives in splendour. And they are supposed to abstain from their natural desires because of the dogma of people who, very often, know little about abstinence.

Even ostensibly secular states, such as the US, have spent millions of dollars at home and in developing countries on 'abstinence only' sex education. The word 'abstinence' is not just the absence of sex, a run of bad luck, perhaps. It refers to a decision to not have sex until marriage. The word has inherent religious and moral connotations. The policy has been a failure in the sense that most pledgers have sex as much as non-pledgers. In fact, many pledgers soon deny that they took a pledge. Worse still, the pledgers are less likely to use condoms or any form of birth control.

Here in East Africa, I have come across many interpretations of 'sex education', 'abstinence', moral issues, etc. There are those who teach 'abstinence' without even telling people what sex is. Of course, they know, vaguely, what sex is. But they are supposed to be teaching sex education. The word 'abstinence' is not clearly understood by people but even if plain English was used (without the religious and moral baggage), it seems difficult to comprehend the imperative to avoid doing something when you don't know what that something is.

Sex education programmes need to be mindful of what sex is, especially for those who claim not to indulge in sex. HIV is spread, to a large extent, by sex between heterosexuals. But people can be taught what sex is, what sexually transmitted infections are, how to ensure that you don't take risks that might result in unwanted pregnancy or sexually transmitted infection, etc. And the conditions of people's lives, the conditions that determine when, where and how sexual intercourse takes place, these have little to do with sex.

So if people are too squeamish or moral or religious or whatever to talk about sex, and I really think they should avoid the subject, they could better spend their time and money on infrastructure, poverty, gender inequality, poor health and education and many other areas of people's lives. It could be claimed, by the way, that many orphanages, schools and hospitals are run by religious institutions. But the money they spend represents a fraction of the money extracted from church followers. In areas like Kigoma, perhaps some of the churches could consider 'tax exemptions' or monetary rebates from the very poor.

Kenya's Neighbours, Uganda and Tanzania

How does Kenya’s HIV epidemic compare to those of neighbouring Uganda and Tanzania?

Well, HIV probably arrived first in Uganda, next in Tanzania and then in Kenya. After that, it took very different courses in each country. It spread quickly and rose to a peak prevalence of 14% in Uganda. It spread less quickly in Tanzania and peaked at below 8%. And, having started later in Kenya, it spread quickly and prevalence peaked at just over 10%.

As the graph below shows, there has been a gradual decline in prevalence in Uganda and in Tanzania. However, the decline in prevalence in Kenya reversed around 2004 and now stands at 7.8%, higher than it was back in 2002.



The next graph shows that death rates also have very different patterns in each country. Aids deaths started later in Kenya, as you would expect if HIV arrived later. But the number of deaths rose very rapidly and peaked at perhaps over 140000. This is far higher than Uganda and Tanzania, whose rates peaked at 120000.



Death rates in all three countries are now declining. One would expect this trend to be enhanced as anti-retroviral therapy (ART) is rolled out because this keeps more people living with HIV alive for longer.

The graph below plots the estimated numbers of people living with HIV and Aids. The rising number in Kenya is probably due to a combination of new infections and people living longer because of ART. The fact that the number in Tanzania is stable could be for similar reasons, except that there, the death rate is still pretty high. This is, of course, just one analysis and a quick and dirty analysis, for that matter. It’s possible that Uganda has a low rate of new infections at present; I don’t have access to recent figures.



Personally, I think the above figures alone can tell us very little about how the HIV epidemics stand in these three countries at the moment. I think the way HIV affects a country, how the epidemic spreads, waxes and wanes, depends on many things. Of particular importance are health and health services, education and literacy, various economic factors, social services, infrastructure and much else.

The annual Human Development Report collects national figures and uses them to calculate indices of various aspects of development. Thus, the gender development index shows inequalities between men and women in health, education and economic welfare; the life expectancy index shows the relative achievement of a country in life expectancy at birth; the education index brings together adult literacy and school enrolment; and the human development index (HDI) brings together health, education and economic welfare, being a composite of the education index, the life expectancy index and the GDP index. The GDP Index shows the gross domestic product per capita for a country.



There is a large amount of overlap among these figures, but they are all reproduced here to show how the three countries stand in relation to each other. From this chart, they would all seem pretty close together. In most cases, Kenya is a little better off than Uganda and Uganda is a little better off than Tanzania. If these factors also have an influence on the course a HIV epidemic takes in a country, each country’s epidemic may become more and more alike, despite their initial differences.

However, if you look at trends in the HDI (the only one for which historical trends are supplied), Kenya is not only out of step with Uganda and Tanzania, after being ahead of them for many years; Kenya’s HDI has also been declining for a long time. Over the same period, Uganda and Tanzania’s HDI has been improving.



Well, putting all these figures together doesn’t really put one in a position to analyse each country in sufficient detail to make predictions about what will happen next. Out of the three countries, only Kenya is seeing prevalence increase, after an initial improvement. It’s possible that Uganda and Tanzania’s prevalence are levelling off and will rise, but it’s hard to say.

However, a recent paper shows that prevalence is still increasing in Tanzania in more rural areas, though it is declining in less rural areas. Bear in mind, over 80% of people in Tanzania live in rural areas. Another paper suggests that the behaviour change that was said to have reduced HIV prevalence in Uganda substantially in the nineties and early 2000s is now reversing, that condom use is declining and unsafe sex is increasing.

Rural areas in Tanzania are less likely to benefit from HIV education, perhaps any education, from health services and other social services. And those in Uganda who are deciding to ignore the safe sex message, if the message is still being broadcasted, may need to be approached in a different way. What worked during a time of high prevalence followed by a time of high death rates, may not work now that the word ‘Uganda’ is usually accompanied by mentions of the country’s success in reducing HIV prevalence.

Among all the indicators relating to sexual behaviour that are collected by Demographic and Health Surveys, none show that one of the three countries is significantly ‘better’ or ‘worse’ than the other. These figures, even taken all together, don’t suggest why Tanzania’s prevalence never reached as high as Kenya’s or why Kenya’s never reached as high as Uganda’s.

Some health indicators show Tanzania to be in a far better position than the other two countries, despite public expenditure on health being lower. However, some of Tanzania’s health indicators are far poorer than the others. Other figures are very similar to those found in Uganda and Kenya. Education indicators are similarly mixed, though Kenya again has the highest level of public expenditure in education.

Some gender related figures do differ greatly. Kenya has very few female MPs, just over 7% them being women. For Uganda and Tanzania, the figures are 29.8% and 30.4%, respectively. More births are attended by skilled health personnel in Tanzania. And the rates of female genital mutilation are much higher in Kenya (32.2%) than in Uganda (0.6%) or Tanzania (14.6%).

Figures for communications, access to communications and media, water and sanitation vary somewhat here and there but there is still a surprising amount of similarity in these areas. All three countries have seen high population growth in the last thirty years and are predicted to continue growing. Demographic figures are also reasonably similar.

A notable exception is the urban population as a % of the total population, which stood at 20.7% in Kenya in 2005, 24.2% in Tanzania but only 12.6% in Uganda. Uganda also had a low urban population in 1975 and this is expected to continue. Urban population is thought to be a highly significant factor in the spread of HIV by some analysts. However, it is also argued that the HIV epidemic was unusual in Uganda, having started in rural areas and spread from there. In Kenya and Tanzania it was said to have started in urban areas.

In a nutshell, I think HIV spread readily in these countries because of poor health, education, social services, water and sanitation, governance, social cohesion and many other things. Many measures have been taken to reduce the spread of HIV, in the fields of health, education and other areas. However, unless the original development conditions that allowed HIV to spread are improved vastly, HIV will continue to spread.

The people of Kenya, Uganda and Tanzania may well need HIV education, but they are in far greater need of teachers and affordable, accessible schools. HIV health programmes are great, but only where there is an affordable, accessible health service. There is little point in educating people about sexual health and behaviour while ignoring reproductive health, sanitation, nutrition and other aspects of health.

As long as HIV is seen as a short term (or even medium term) crisis that will be resolved by crisis measures, it will continue to spread. Small gains may be made here and there, but without ensuring a healthy, well educated, secure population, HIV will never be conquered.

The conditions that allowed HIV to take hold and reach high levels in so many countries have been around for a long time and the HIV community seems to have allowed itself to be distracted by crises and crisis measures. It is the long term issues that need to be resolved, the same problems of poverty, exploitation and underdevelopment that have been around for as long as anyone can remember.

Centres and Peripheries

The trip back from Mumias to Nairobi was long, hot and often bumpy. But there were no incidents, flat tyres, etc. Only the usual poorly surfaced roads and traffic jams in Nairobi. It’s only about 350km so nine hours is slow, but not the worst.

Infrastructure is a big problem in Kenya and East Africa in general. So many projects assume a certain level of telephone, mobile, rail and internet connections and quickly run into difficulties.

For example, there are hundreds of internet cafes in Nairobi but try to find one where you can do everything you need to do online and you may have difficulties. I tried today for three and a half hours and just as I was about to compromise and try to achieve only some of my objectives, there was a power failure throughout the city. How long it will last is anyone’s guess.

There is a tantalising possibility that the poor roads in Kenya, Tanzania and other countries played a part in protecting many people from becoming infected with HIV early on in the epidemic. People in more isolated areas were not infected in large numbers in the early years.

However, that is not the case any more. As mentioned in the last few days, people in rural areas and more isolated areas in both Kenya and Tanzania are being infected now in greater numbers than before. They are not receiving the prevention education that is sometimes found in towns and cities and testing facilities are scarce or non-existent.

Countries with relatively good infrastructures sometimes have much higher HIV prevalence than Kenya or Tanzania. Examples of this phenomenon are Zimbabwe, Malawi, South Africa and Botswana. Of course, there are probably other reasons why HIV prevalence is so much worse there, but demographic balance, mobility and circular migration play an important part in the transmission of HIV.

One of the reasons why urbanization may be so strongly associated with high and fast transmission rates of HIV is the high number of males in urban populations. Botswana, one of the richest countries in Africa, with one of the highest rates of HIV in the world, has also experienced rapid urbanization, economic growth, population growth, high levels of income inequality, a history of mobility and high levels of commerce with surrounding countries.

Botswana's economy depends to a large extent on extractive industries and they, typically, employ large numbers of men who live in all-male accommodation. This results in high levels of commercial sex and a consequently increased risk of contracting and spreading HIV and other STIs.

Employees are not just from Botswana, so when they return home, they can transmit HIV and other conditions to their home countries, which are often poor, with high unemployment rates.

Ok, Kenya doesn’t have a lot of mining, certainly not on the same scale as Botswana. But there are industries that give rise to circular migration and the resulting demographic imbalances and consequent spread of HIV and other diseases.

Kenya’s number one product is tea. As mentioned, Mumias is dominated by the sugar industry. Some coastal areas grow little but sisal. And there are natural resources here, such as soda and uranium. Other examples are the massive cut flower businesses around Lake Naivasha and the fruit and vegetable growing farms.

All these industries depend on large supplies of casual labour, very often for only part of the year. People arrive and stay for as long as the work lasts and then go back to their homes. Many of these economic migrants are male and they live away from their families for much of the year.

This kind of circular migration, often driven by rural poverty, is common in developing countries and is associated with many health hazards, for example, TB. Labour practices in South African diamond and gold mines result in similar conditions and again, the HIV related effects were transmitted to surrounding countries that suffered worse HIV prevalence than that of South Africa.

Eileen Stillwaggon, in AIDS and the Ecology of Poverty, talks of the “circular migrant streams” that are fuelled by mines, factories and plantations and the consequent slums and shanty towns with their poor sanitation and high rates of disease and malnutrition. It must also be noted that circular migration transmitted HIV from urban to rural regions in earlier years but later the transmission was in both directions.

John Iliffe, in A History of the African AIDS Epidemic, cites the “male predominance in urban populations” in East Africa as one of the reasons why levels of infection were higher there than in western equatorial Africa. In the early 1990s, “Kigali had 50 per cent more men than women aged 20-39” (page 21). In Nairobi in 1979 there were 138 males for every 100 females, the imbalance was even higher among adults and many of the males were unmarried.

A high male to female ratio in the population does not just affect urban dwellers. Fishing communities in rural areas around Lake Victoria were predominantly male and HIV rates there are very high. Nyanza province has the worst HIV rates in Kenya. Rural dwellers are also affected by these imbalances because the migration is temporary and people come and go, perhaps for much of their working life.

There are also certain occupations that involve high levels of mobility. Iliffe mentions urban immigrants, truck drivers, alluvial miners, their female partners and labour migration as examples of particularly mobile groups. Towns along trade routes often have higher rates of HIV than other towns.

This problem is especially prominent at borders. Border controls are very slow moving and truckers often have to spend several days in border towns because of slow administrative procedures. It can be cheaper for them to stay with a casual partner there than to put up in a hotel, so it’s an ideal place for commercial sex workers to look for business.

These are all major factors in the history of the transmission of HIV in Kenya and East Africa in general. They crop up constantly in the literature and mobile people were among the first ‘vulnerable groups’ to be studied, along with commercial sex workers.

It was Zimbabwe's “excellent transport system” and circular internal migration between urban and rural areas that transmitted HIV out into rural areas, according to Iliffe (page 39). In the case of Malawi, Iliffe makes a further connection between higher education and greater mobility, perhaps elucidating the phenomenon of higher HIV prevalence sometimes being associated with higher levels of education.

Iliffe tracks the transmission of HIV from Western Equatorial Africa to East Africa, Southern Africa and West Africa. He makes it clear that mobility is the chief driver of the epidemic at the regional level.

Indeed, obstacles to mobility from east to west is one of the possible reasons Iliffe suggests as to why West Africa's epidemic was less severe than that of some other African regions. Where HIV rates were high in West Africa, one of the principle drivers was mobility, especially among commercial sex workers.

Tantalising as it is to suggest that poor infrastructure reduces the spread of HIV, it is not really true. It is true, but trivially so, that complete isolation is a protection against HIV and any other transmissible disease. In reality, people are not completely isolated, even in the most remote parts of Kenya.

Isolation explains why HIV spread slowly to rural areas and more quickly and earlier in cities and densely populated areas. It also demonstrates the critical situation that many towns, villages and rural areas are in, right now.

The situation is critical because we really don’t know what HIV prevalence is in more remote areas. People there are less exposed to HIV prevention publicity, they have less access to health and other social services and especially, to voluntary counselling and testing centres.

The further people are from urban centres, the more isolated they are, the less we know about HIV rates in those areas. The difference in prevalence between urban and rural areas may be merely apparent.