Out of the eight provinces in Kenya, the two most disadvantaged, using a range of about 50 indicators, are North Eastern and Coast. The two most advantaged are Central and Nairobi. When you compare HIV prevalence, the two provinces with the highest rates are Nyanza and Nairobi and the two with the lowest are North Eastern and Central.
A broad range of advantages does not necessarily mean low HIV prevalence and a broad range of disadvantages does not necessarily mean high HIV prevalence. This is why it is important to look at development as a whole, rather than obsessing about HIV; it's just one disease and for many people, it is not even the worst thing that can happen.
If you look more closely at some districts you get even clearer insights into serious instances of underdevelopment. If you compare urban populations, they appear to have a lot of advantages over rural populations. But if you look at slums, and there are many in Kenya, you get a completely different picture. An estimated 71% of urban dwellers in Kenya live in slums (probably around 2.8 million people in Nairobi alone).
Some of the social indicators (health, education, infrastructure, etc) for slum areas are even poorer than they are in rural areas. Slums are growing, especially now as many IDPs are moving to urban areas. Others are moving from rural areas to find work, so there is particular pressure on urban areas right now.
A report published last year on the burden of disease in two of Nairobi's slums, Korogocho and Viwandani, list many features of these areas that differ from Nairobi as a whole. Although the report does not have the scope to measure HIV prevalence, it suggests that it, too, is higher there than in other parts of the country. Prevalence fell slightly in Nairobi between 2003 and 2008 but this is unlikely to reflect the situation in slums.
The report measures mortality in years of life lost to premature mortality (YLL). It found that under fives had four times the mortality rate of the rest of the population (standing at 692 years per 1,000 person years). The chief causes of death are pneumonia (22.8%) and diarrhoeal diseases (19.5%). It is notable that these two causes can be addressed, in part, by introducing intermediate technologies such as solar cookers and other techniques for sterilising water.
Infant mortality was 96.0, 82.6 and 81.8 per 1,000 live births for the years 2003, 2004 and 2005 respectively (compared to 79 per 1,000 nationally in 2005 and 96 per 1,000 in 1970). Under five mortality is 139.1, 119.1 and 121.4 per 1,000 live births (compared to 120 per 1,000 nationally in 2005 and 156 per 1,000 in 1970). Malnutrition is known to be an underlying cause for more than half of childhood deaths but may be underestimated by this survey methodology. Malnutrition and anaemia account for 8.4% of YLL.
In Nairobi province 20.3% of children are stunted, 6.3% of under fives are underweight and 2.1% suffer from wasting. Poor health and nutrition in children can be related to low maternal education, poverty, lack of food security, etc. Only 69.2% of children have full childhood immunisation. This suggests weak and inaccessible health systems and poor attendance at ante-natal clinics.
It is clear that nearly forty years of development has had little impact on infant and child mortality in Kenya. In fact these figures have mainly been disimproving nationally since the 1970s in Kenya. The HIV epidemic may have had some part in this but the trend started before HIV would have had much impact.
Among those over five years of age, around 50% of mortality is caused by HIV/AIDS and TB. TB has been counted with HIV because deaths caused by either are difficult to distinguish. Mortality in the population as a whole is 205 YLL per 1,000 person years.
Other findings are equally appalling: population density in this area is estimated to be 60,000 per square kilometre. Homicide is the second most common contributor to mortality (12.1%) in those over 5 years old. Road traffic accidents are the third most common (5.8%). These figures are higher than for Sub Saharan Africa as a whole
The ratio of males to females in these areas is similar to much of Nairobi and a large part of the population consists of those from productive age groups. Between the ages of 20 and 35, males outnumber females considerably. Where there are a lot of men relative to women, this can result in high levels of commercial/transactional sex. Nairobi had a particularly high ratio of males to females in the 1980s, a time when HIV was known to have spread very rapidly.
Health systems, clearly, are poor in these slum areas. Most people die outside the formal health care system. Verbal autopsy was used for the report in question but this has its limitations. Official death certificates are not common. For Nairobi as a whole, life expectancy is 57; 54.1 for men and 59.8 for women. 40% of people are not expected to survive to over 40, the worst figure for this indicator in the country. 54% of people have poor access to a qualified doctor.
The Human Development Index, a composite index widely used and recognised by the development community, is currently the highest in the country for Nairobi province. But this hides many problems faced by a huge number of the city’s population. The fact that many of the richest people in the country have a residence in Nairobi must distort many of the figures.
Slums are sometimes politely referred to as informal urban settlements or by some similar construction. They are barely alluded to by politicians and few official statistics exist to allow proper evaluation. But they are a reality for an increasing number of Kenyans, a reality that needs to be addressed now.
Friday, January 30, 2009
Monday, January 26, 2009
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'.
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'.
Saturday, January 24, 2009
Intellectual Oppression
If you were a subsistence farmer in Kenya and you were in desperate need of money, would you consider mortgaging your future? After all, if you don't risk your future, you may not even have one.
Here's what you can do:
The Rockerfeller Foundation and the Bill and Melinda Gates Foundation think that the 'Green Revolution' in other developing countries was so good, they want to see another one and this time they want it to include Kenya and other African countries. Never mind that countries who experienced the first green revolution now realise what a terrible mistake it was.
These philanthropic parties are spending millions of dollars to ensure that poor farmers can purchase genetically modified (GB) seeds so that they can plant a green revolution in their own fields.
Don't get caught up in the argument about how GM crops could damage your health. People who oppose those arguments only want to catch you out by asking what evidence there is for health risks. Of course, there may be health risks, GM organisms have not been shown to be safe for human consumption. But that is not even the most important concern about GM.
If you buy GM seeds, you must buy the appropriate herbicides, pesticides and fertilizers to ensure the 'benefits' promised by the manufacturers. Yes, they manufacture the seeds, the pesticides, the fertilizers and the stories about how GM is good for your health, the environment and just about everything else.
In fact Agra (Alliance for a Green Revolution in Africa) also claim to be aiming specifically at small farmers. GM crops and 'improved' agricultural methods are primarily aimed at big farmers, but hey, what's a little white lie here and there?
The only people that stand to benefit from GM are the manufacturers of GM products. Oh, and those who have a financial interest in GM companies. Maybe these esteemed philanthropic parties have such a financial interest, maybe they don't. But it's big, powerful, rich people and companies that make a lot of money; you, I and small farmers only stand to lose. By the time said parties have made themselves even richer, most land will be depleted and contaminated, it will lack diversity, it will be as far from organic as it can possibly be and we will find it very difficult to reverse what they have got us into.
Farms surrounding those growing GM crops will also be contaminated. This contamination will come from cross pollination and run-off that carries toxic substances to other farms and into the water supply. Farmers who buy into GM are not just mortgaging their own future, they also mortgage the futures of their neighbours.
Does it sound dramatic to say 'mortgage your future'? Well, if you are a farmer, you are probably used to the process of growing crops and taking advantage of the way you can keep some seed each year. This can be used to grow the next years crops and you can even be selective, to preserve the best qualities in your crops.
Sorry, but you are not permitted to collect seed and grow more GM crops next year. Some GM crops are not even appropriate for this process. You will owe the GM manufacturer money because the seeds are a piece of intellectual property, you must pay for it. Even your neighbours could be found guilty of infringing GM companies’ copyright, even though they didn't take the king's ransom!
Ok, you can, slowly, get rid of some of the GM contamination. You can start afresh, growing wholesome non-GM crops. Well, maybe you can. You will already have played a part in reducing the biodiversity on your land and on surrounding lands. In fact, herbicides and pesticides used on GM crops kill everything, plant and animal, but that GM crop. This is one of the things that GM producers like to boast about.
But if you replace the GM soya with non-GM soya because you find it is not as productive as it says on the packet, you may be in for a nasty surprise. If the 'non-GM' crop is found to contain some of the GM manufacturer's intellectual property you are still liable to pay for it. Which is fantastic…if you’re a GM company.
The Rockerfeller and Gates Foundations may well do some great work, they may well fund many laudable projects but that shouldn't stop people from scrutinising what they fund. GM crops are not in any sense laudable and the fact that so much money is being spent on trying to get people to grow them should sound alarm bells.
As a rule of thumb, where intellectual property is involved, the interests of the rich are being served. If someone tries to tell you that poor people will benefit, check their credentials very carefully.
This is another example of Development by Omission, where developing countries would be a lot better off if they didn't receive this 'donation' from the rich and powerful. It's a lot more subtle, but also far more damaging than stealing maize intended for starving Kenyans. And it's not even considered to be a crime. Not yet, anyhow.
Here's what you can do:
The Rockerfeller Foundation and the Bill and Melinda Gates Foundation think that the 'Green Revolution' in other developing countries was so good, they want to see another one and this time they want it to include Kenya and other African countries. Never mind that countries who experienced the first green revolution now realise what a terrible mistake it was.
These philanthropic parties are spending millions of dollars to ensure that poor farmers can purchase genetically modified (GB) seeds so that they can plant a green revolution in their own fields.
Don't get caught up in the argument about how GM crops could damage your health. People who oppose those arguments only want to catch you out by asking what evidence there is for health risks. Of course, there may be health risks, GM organisms have not been shown to be safe for human consumption. But that is not even the most important concern about GM.
If you buy GM seeds, you must buy the appropriate herbicides, pesticides and fertilizers to ensure the 'benefits' promised by the manufacturers. Yes, they manufacture the seeds, the pesticides, the fertilizers and the stories about how GM is good for your health, the environment and just about everything else.
In fact Agra (Alliance for a Green Revolution in Africa) also claim to be aiming specifically at small farmers. GM crops and 'improved' agricultural methods are primarily aimed at big farmers, but hey, what's a little white lie here and there?
The only people that stand to benefit from GM are the manufacturers of GM products. Oh, and those who have a financial interest in GM companies. Maybe these esteemed philanthropic parties have such a financial interest, maybe they don't. But it's big, powerful, rich people and companies that make a lot of money; you, I and small farmers only stand to lose. By the time said parties have made themselves even richer, most land will be depleted and contaminated, it will lack diversity, it will be as far from organic as it can possibly be and we will find it very difficult to reverse what they have got us into.
Farms surrounding those growing GM crops will also be contaminated. This contamination will come from cross pollination and run-off that carries toxic substances to other farms and into the water supply. Farmers who buy into GM are not just mortgaging their own future, they also mortgage the futures of their neighbours.
Does it sound dramatic to say 'mortgage your future'? Well, if you are a farmer, you are probably used to the process of growing crops and taking advantage of the way you can keep some seed each year. This can be used to grow the next years crops and you can even be selective, to preserve the best qualities in your crops.
Sorry, but you are not permitted to collect seed and grow more GM crops next year. Some GM crops are not even appropriate for this process. You will owe the GM manufacturer money because the seeds are a piece of intellectual property, you must pay for it. Even your neighbours could be found guilty of infringing GM companies’ copyright, even though they didn't take the king's ransom!
Ok, you can, slowly, get rid of some of the GM contamination. You can start afresh, growing wholesome non-GM crops. Well, maybe you can. You will already have played a part in reducing the biodiversity on your land and on surrounding lands. In fact, herbicides and pesticides used on GM crops kill everything, plant and animal, but that GM crop. This is one of the things that GM producers like to boast about.
But if you replace the GM soya with non-GM soya because you find it is not as productive as it says on the packet, you may be in for a nasty surprise. If the 'non-GM' crop is found to contain some of the GM manufacturer's intellectual property you are still liable to pay for it. Which is fantastic…if you’re a GM company.
The Rockerfeller and Gates Foundations may well do some great work, they may well fund many laudable projects but that shouldn't stop people from scrutinising what they fund. GM crops are not in any sense laudable and the fact that so much money is being spent on trying to get people to grow them should sound alarm bells.
As a rule of thumb, where intellectual property is involved, the interests of the rich are being served. If someone tries to tell you that poor people will benefit, check their credentials very carefully.
This is another example of Development by Omission, where developing countries would be a lot better off if they didn't receive this 'donation' from the rich and powerful. It's a lot more subtle, but also far more damaging than stealing maize intended for starving Kenyans. And it's not even considered to be a crime. Not yet, anyhow.
Friday, January 23, 2009
Kenyan Politicians Hold Key to HIV Prevention
After the civil unrest in Kenya early last year, many Kenyans ended up in camps for internally displaced people (IDP). They went to these camps for immediate security but many have stayed because their security is still not guaranteed and, in many cases, they have nothing to go back to. There are hundreds of thousands of Kenyans in IDP camps, although not all of them are there as a result of last year's post election violence.
Whatever about the conditions in IDP camps, people leaving these camps face acute hardships. They need to find a safe place to live and a way of making money, for a start. For some, cities are considered the best place to find work. If work cannot be found or if the pay is not adequate, some resort to various forms of transactional sex for survival, at least for a while.
Unemployment is very high in Kenya, people are facing high prices for basic goods such as water, food, fuel and accommodation. Therefore, finding work is not always enough. When employers know they can get cheaper, they pay less. The same applies to the clients of those depending on sex for survival. For some time, it has been a buyers' market. Certain bars in Nairobi have noticeably more females than males. The men can find what they want and negotiate a low price and even refuse to pay. There is no one to protect those engaging in survival sex.
This scenario can increase the pressure to have more clients per night and to take more risks, such as agreeing not to use a condom, agreeing to anal sex, group sex, anything that will attract more money. This increases the probability of contracting and transmitting HIV and other sexually transmitted infections (STI). It also increases other dangers that sex workers face because of their increased vulnerability, the increased amount of time spent on the street and numerous other considerations.
To make matters worse, there are extreme food shortages in many parts of the country right now. More and more people are moving to urban areas, especially Nairobi and Mombasa, but also other towns and cities. They are looking for work and access to basic goods. This is adding to the existing flow of people and creating a very dangerous situation.
Something curious happened in the mid 1980s in Nairobi. At this time, there were far more men than women in the city (and there probably still are). But in 1986, rates of HIV (and gonorrhoea) peaked among commercial sex workers (CSW). HIV peaked at 81%, one of the highest rates experienced anywhere. But the reasons why HIV peaked at this time, nearly a decade before HIV incidence (the rate of new infections) peaked in Nairobi, are not clear.
I have yet to hear a plausible explanation of why HIV peaked among CSWs, especially as the figures are for those who were new to sex work. There was very little prevention work being carried out at the time and what work had been done would hardly have had much time to produce results. Is it possible that there was a reduction in the number of CSWs, possibly because of an improving economic climate, and a consequent sellers’ market?
Well, rather than speculate further on that phenomenon, after all, I could just research it, I would like to speculate on what is happening right now in Nairobi and other parts of the country, especially urban areas.
If an increasing number of people are currently depending on survival sex, this could give rise to a huge increase in transmission of HIV and other STIs. Current crises, such as the water, food, fuel and economic crises, all increase vulnerability. An estimated 10 million people face starvation. A huge percentage of the population is extremely vulnerable.
HIV can take ten or eleven years to kill you. But you can die of thirst in a few days. Starvation is pretty quick too. Add to this the fact that you may have children and other dependents and survival sex doesn't seem nearly as dangerous.
Whatever politicians may say and whatever newspapers may publish about biofuels, world economic crises, global food shortages, global warming or any other reasons for current food shortages, around 70% of recently acquired maize has disappeared. Those to whom the maize was entrusted are known to those distributing it, but no one has yet been held accountable. Somewhere in the country, there is either a large amount of maize or a large amount of money.
Kenyan politicians are asking international donors for help, yet help may be closer at hand than they think. Their colleagues may have the maize or the money or they may know where it went to. Politicians raise a lot of questions but they should be closer to the answers than anyone. Ultimately, large stocks of food are under their care. If anyone can answer the questions, it is politicians or their friends and associates, people close to the top.
A survey in 2007 found that HIV prevalence in Nairobi had fallen slightly since 2003 (although it has been increasing in most provinces). In years to come, if HIV transmission is rising right now, it will probably be said that there was a food crisis, a fuel crisis, an economic crisis or any other crisis that has yet to come. But poor people in Kenya have been poor and vulnerable for a long time.
True, these crises make things a lot worse, but HIV is increasing because vulnerabilities are still not being addressed, more than 25 years after HIV was identified. Many social indicators have been disimproving since the 1980s but these issues continue to be ignored. Perhaps politicians can continue to hide behind multiple crises but when has there been a time that there wasn't some crisis, ostensibly beyond their control, that they could blame?
We may have the opportunity, right now, to intervene and prevent a significant number of new HIV infections that are about to occur under our noses. The technology to prevent these infections is well known and widely available. It's called food.
Will the Kenyan government do what it can to reduce the vulnerabilities faced by so many Kenyan people? Or will they just allow them to die and later attribute their deaths to circumstances beyond their control? Not all circumstances are beyond their control.
Whatever about the conditions in IDP camps, people leaving these camps face acute hardships. They need to find a safe place to live and a way of making money, for a start. For some, cities are considered the best place to find work. If work cannot be found or if the pay is not adequate, some resort to various forms of transactional sex for survival, at least for a while.
Unemployment is very high in Kenya, people are facing high prices for basic goods such as water, food, fuel and accommodation. Therefore, finding work is not always enough. When employers know they can get cheaper, they pay less. The same applies to the clients of those depending on sex for survival. For some time, it has been a buyers' market. Certain bars in Nairobi have noticeably more females than males. The men can find what they want and negotiate a low price and even refuse to pay. There is no one to protect those engaging in survival sex.
This scenario can increase the pressure to have more clients per night and to take more risks, such as agreeing not to use a condom, agreeing to anal sex, group sex, anything that will attract more money. This increases the probability of contracting and transmitting HIV and other sexually transmitted infections (STI). It also increases other dangers that sex workers face because of their increased vulnerability, the increased amount of time spent on the street and numerous other considerations.
To make matters worse, there are extreme food shortages in many parts of the country right now. More and more people are moving to urban areas, especially Nairobi and Mombasa, but also other towns and cities. They are looking for work and access to basic goods. This is adding to the existing flow of people and creating a very dangerous situation.
Something curious happened in the mid 1980s in Nairobi. At this time, there were far more men than women in the city (and there probably still are). But in 1986, rates of HIV (and gonorrhoea) peaked among commercial sex workers (CSW). HIV peaked at 81%, one of the highest rates experienced anywhere. But the reasons why HIV peaked at this time, nearly a decade before HIV incidence (the rate of new infections) peaked in Nairobi, are not clear.
I have yet to hear a plausible explanation of why HIV peaked among CSWs, especially as the figures are for those who were new to sex work. There was very little prevention work being carried out at the time and what work had been done would hardly have had much time to produce results. Is it possible that there was a reduction in the number of CSWs, possibly because of an improving economic climate, and a consequent sellers’ market?
Well, rather than speculate further on that phenomenon, after all, I could just research it, I would like to speculate on what is happening right now in Nairobi and other parts of the country, especially urban areas.
If an increasing number of people are currently depending on survival sex, this could give rise to a huge increase in transmission of HIV and other STIs. Current crises, such as the water, food, fuel and economic crises, all increase vulnerability. An estimated 10 million people face starvation. A huge percentage of the population is extremely vulnerable.
HIV can take ten or eleven years to kill you. But you can die of thirst in a few days. Starvation is pretty quick too. Add to this the fact that you may have children and other dependents and survival sex doesn't seem nearly as dangerous.
Whatever politicians may say and whatever newspapers may publish about biofuels, world economic crises, global food shortages, global warming or any other reasons for current food shortages, around 70% of recently acquired maize has disappeared. Those to whom the maize was entrusted are known to those distributing it, but no one has yet been held accountable. Somewhere in the country, there is either a large amount of maize or a large amount of money.
Kenyan politicians are asking international donors for help, yet help may be closer at hand than they think. Their colleagues may have the maize or the money or they may know where it went to. Politicians raise a lot of questions but they should be closer to the answers than anyone. Ultimately, large stocks of food are under their care. If anyone can answer the questions, it is politicians or their friends and associates, people close to the top.
A survey in 2007 found that HIV prevalence in Nairobi had fallen slightly since 2003 (although it has been increasing in most provinces). In years to come, if HIV transmission is rising right now, it will probably be said that there was a food crisis, a fuel crisis, an economic crisis or any other crisis that has yet to come. But poor people in Kenya have been poor and vulnerable for a long time.
True, these crises make things a lot worse, but HIV is increasing because vulnerabilities are still not being addressed, more than 25 years after HIV was identified. Many social indicators have been disimproving since the 1980s but these issues continue to be ignored. Perhaps politicians can continue to hide behind multiple crises but when has there been a time that there wasn't some crisis, ostensibly beyond their control, that they could blame?
We may have the opportunity, right now, to intervene and prevent a significant number of new HIV infections that are about to occur under our noses. The technology to prevent these infections is well known and widely available. It's called food.
Will the Kenyan government do what it can to reduce the vulnerabilities faced by so many Kenyan people? Or will they just allow them to die and later attribute their deaths to circumstances beyond their control? Not all circumstances are beyond their control.
Saturday, January 17, 2009
The Right to Trivia
On Friday the 9th of January, newspapers announced that the government was warning that up to 3 million people faced starvation because of growing food shortages. That's more than 10% of the population. By the following monday, the number had risen to 10 million, in excess of 25% of the population. There was no analysis of why the figures had changed so profoundly.
Yesterday, Friday the 16th, famine was not to be found, unless you count passing references in articles on unrelated matters. There is mention of millions facing starvation on page 6 of The Nation in an article on senior politicians spending large amounts of public money on a trip to the inauguration of the president of a foreign country. These politicians were not invited so taxpayers (which doesn't include politicians, because they don't pay tax) are going to pay for an expensive trip to watch the event on TV.
Perhaps they don't trust their own media to cover the event adequately. Their own media is far more interested in signs of disagreement in the coalition government. That's front page news today. After all, these signs of disagreement are so hard to discern, right? There is a a small amount of interest in various scandals that involve various politicians and other senior public figures but interest in these is currently waning.
But there is little interest in the matters that affect individual people, especially poor people. For example, why do water supplies only reach wealthier neighbourhoods and where does the water sold to poorer people at such high prices come from? Where did all the recently imported maize, intended to avert famine, go to? What has been happening to fuel that has been distributed to outlets, allegedly, but doesn't seem to have reached them?
One quarter of the country's population facing starvation didn't make the front page today. Nor did the fact that child death rates are up, again. Child death rates have been rising almost constantly since the 1980s, so this is not a recent trend. It's a trend that cannot be blamed on the HIV epidemic, the water, fuel or food crisis, global warming or any other issue. There is a long running crisis in health, education and other social services.
Of course, it's difficult to assess figures like those from the UN 2009 State of the World's Children report, showing that 121 out of every 1000 live births recorded result in death, mostly in the first year of a child's life. Difficult to assess because an estimated 40% of births are not recorded. The figure could higher or lower but it's difficult to know how many births have not been recorded!
It's not that political wranglings are not important or that the coalition shouldn't be urged to settle their differences and start running the country, these are important. But it's because of their failure to run the country that child mortality and maternal mortality figures, to name but a few, are so high. It's because of the government's failures that people are starving, have no water, are dying of preventable diseases.
Behind the shortage of maize, in addition to the cartels that may or may not exist, there are government plans to sell and/or lease land so that foreign countries can grow sugar for biofuels and food crops for their own people. This is land that is currently farmed by Kenyans or, at least, owned by Kenyans. It could be used to grow food.
The government says it is building a port in Lamu with the money they make from the land. This port will take many years to build, as Raila Odinga reminded us when he gave a figure of five years for enhancements to Mombasa Port.
So what's wrong with using the land to grow food that should be available after one season? In five years time, if the port is really built, will Kenya have any money left to import anything through a new port in Lamu?
More importantly, how many people will have died, unnecessarily, by the time this 'vital' port is built? Water and food cannot wait till political wranglings are sorted out. These wranglings, in many cases, date back to the earliest days of the Kenyan Republic. Death from lack of water and food is very fast. Some will already have died by the time the politicians who went, uninvited to party in the US, have returned.
It's not politicians who die in civil unrest, famine or epidemics; politicians children don't die of preventable diseases and their wives don't usually die in childbirth. They are completely divorced from the pain, although they may see it all on TV. That's if the media bothers to cover it. And if they are not watching US TV, in the US.
The press who appealed so recently to the electorate to protect them from government excesses is now little moved by the plight of ordinary Kenyans. Millions of people facing starvation and children dying in large numbers should be front page news, so should reportage covering what the government intends to do about it. And when the government says what they intend to do, their actions need to be followed until they show some result. Why is the press so obsessed with triviality?
Of course, government wranglings can turn to riots and many lives can be lost. But far more people die from malnutrition, starvation, water shortage, preventable disease and various other things than from civil distrubances. When these issues have been resolved there will be time enough to cover the many political farces but meantime, perhaps the press will reconsider its priorities.
Yesterday, Friday the 16th, famine was not to be found, unless you count passing references in articles on unrelated matters. There is mention of millions facing starvation on page 6 of The Nation in an article on senior politicians spending large amounts of public money on a trip to the inauguration of the president of a foreign country. These politicians were not invited so taxpayers (which doesn't include politicians, because they don't pay tax) are going to pay for an expensive trip to watch the event on TV.
Perhaps they don't trust their own media to cover the event adequately. Their own media is far more interested in signs of disagreement in the coalition government. That's front page news today. After all, these signs of disagreement are so hard to discern, right? There is a a small amount of interest in various scandals that involve various politicians and other senior public figures but interest in these is currently waning.
But there is little interest in the matters that affect individual people, especially poor people. For example, why do water supplies only reach wealthier neighbourhoods and where does the water sold to poorer people at such high prices come from? Where did all the recently imported maize, intended to avert famine, go to? What has been happening to fuel that has been distributed to outlets, allegedly, but doesn't seem to have reached them?
One quarter of the country's population facing starvation didn't make the front page today. Nor did the fact that child death rates are up, again. Child death rates have been rising almost constantly since the 1980s, so this is not a recent trend. It's a trend that cannot be blamed on the HIV epidemic, the water, fuel or food crisis, global warming or any other issue. There is a long running crisis in health, education and other social services.
Of course, it's difficult to assess figures like those from the UN 2009 State of the World's Children report, showing that 121 out of every 1000 live births recorded result in death, mostly in the first year of a child's life. Difficult to assess because an estimated 40% of births are not recorded. The figure could higher or lower but it's difficult to know how many births have not been recorded!
It's not that political wranglings are not important or that the coalition shouldn't be urged to settle their differences and start running the country, these are important. But it's because of their failure to run the country that child mortality and maternal mortality figures, to name but a few, are so high. It's because of the government's failures that people are starving, have no water, are dying of preventable diseases.
Behind the shortage of maize, in addition to the cartels that may or may not exist, there are government plans to sell and/or lease land so that foreign countries can grow sugar for biofuels and food crops for their own people. This is land that is currently farmed by Kenyans or, at least, owned by Kenyans. It could be used to grow food.
The government says it is building a port in Lamu with the money they make from the land. This port will take many years to build, as Raila Odinga reminded us when he gave a figure of five years for enhancements to Mombasa Port.
So what's wrong with using the land to grow food that should be available after one season? In five years time, if the port is really built, will Kenya have any money left to import anything through a new port in Lamu?
More importantly, how many people will have died, unnecessarily, by the time this 'vital' port is built? Water and food cannot wait till political wranglings are sorted out. These wranglings, in many cases, date back to the earliest days of the Kenyan Republic. Death from lack of water and food is very fast. Some will already have died by the time the politicians who went, uninvited to party in the US, have returned.
It's not politicians who die in civil unrest, famine or epidemics; politicians children don't die of preventable diseases and their wives don't usually die in childbirth. They are completely divorced from the pain, although they may see it all on TV. That's if the media bothers to cover it. And if they are not watching US TV, in the US.
The press who appealed so recently to the electorate to protect them from government excesses is now little moved by the plight of ordinary Kenyans. Millions of people facing starvation and children dying in large numbers should be front page news, so should reportage covering what the government intends to do about it. And when the government says what they intend to do, their actions need to be followed until they show some result. Why is the press so obsessed with triviality?
Of course, government wranglings can turn to riots and many lives can be lost. But far more people die from malnutrition, starvation, water shortage, preventable disease and various other things than from civil distrubances. When these issues have been resolved there will be time enough to cover the many political farces but meantime, perhaps the press will reconsider its priorities.
Sunday, January 11, 2009
Water: the hi-tech and the low-tech
For many years before coming here I was employed as a consultant, working on IT projects. I'm not a computer expert but the work related to the information and data rather than the technology. The work was often interesting but many of the projects seemed to be rather pointless or to miss the point.
For example, there were too few social workers in a local authority and they had too much work to do. Therefore, a lot of mistakes were made and the people who were supposed to benefit from social work either didn't benefit or suffered adverse consequences.
Another example, people didn't have enough money to pay certain bills or they had the money but they hadn't received the services. The result was that the authority didn't get the revenue they expected, but they also didn't know that their constituents were not getting the services and that that is why they were not getting the revenue.
You might think that more social workers and better investigation services would help with both of these problems. But a number of years ago, someone must have told the UK government that all their problems would end if they were to 'e-enable' everything. All they needed was ‘e-delivery’, 'e-government', 'e-payments' and anything else that you put 'e-' before would be miraculously transformed and would never cause problems again.
Well, I accept that you can do a lot with technology but only with certain sorts of problem. And it’s just one tool, depending, like any tool, on how it is used. Now, water services in some parts of the UK are terrible, not because people can't report faults in their area using their palm top. The people who live in the worst affected areas were unlikely to have palmtops. The problem was with the infrastructure.
If technology is a solution to administration and communication problems, why is it not a solution to infrastructure problems? Some of the water infrastructure in the UK dates back more than a century and the technology goes back a lot further than that. Apparently the water companies like spending money on certain sorts of technology, it makes for great publicity. But they are not so keen on other sorts of technology. So pipes continue to leak, bills continue to go up and more and more people have problems with their water supply.
Well, there is little comparison between London and Nairobi. Indeed, there are far worse places than Nairobi, but as a densely populated city where more than half of the inhabitants live on less than 2 dollars a day, the problems here are extreme enough. The water infrastructure is not as old as that in London but it was built for a much smaller population and doesn't even extend to many of the most densely populated areas. Most of these places have no running water, no electricity and no proper roads.
Other infrastructures are similarly dilapidated and oversubscribed. There are some fortunate (and relatively posh) areas where there is always water at the turn of a tap. But there are other areas where water is an expensive commodity that requires either a lot of work, a lot of money or both. Of course, if you have the money, you can avoid the work. But if you don’t have the money, and many people don’t, then you are in big trouble.
So, I didn't know whether to laugh or be angry when I heard the Prime Minister, Raila Odinga, announcing his plans for 'e-government'. This is the PM suspected of trying to rig the last elections. Perhaps he and the President, Mwai Kibaki, who was 'e-lected' under highly suspect circumstances think that 'e-government' is one where there can be no rigging or gerrymandering? Odinga went on to talk about the many possibilities of ‘e-enabling’ and the benefits people could expect.
I don't know whether the election chaos was caused by politicians, the police, the army, civil servants (and the Electoral Commission of Kenya is certainly getting a lot of the flack), business people or other interested parties. But 'e-enabling' the election process, or any other aspect of the administration of the country, will not cut corruption, inefficiency, lack of resources, accessibility or anything else that matters.
And if people don't have water, there is no abstruse technological process that will give them access to it. The technology required is so simple that it is not even called technology. I'm not saying there are no complications, just that Nairobi is not waiting for some spoddy geek to come along and sort it all out. There is a water authority here already, with engineers and other experts. They need to be enabled, whatever that involves, not 'e-enabled'.
When people have adequate access to water, food, education and other social services, then it will be time enough for the 'benefits' of high technology. That high technology, also, can wait until the country is able to afford it. If there is not enough money to improve the water supply, nor is there enough money for technological frippery.
I'm quite sure there are Western companies falling over themselves to supply technical equipment and services, there always are. No doubt they were behind Odinga’s speech. Well, they are finding it increasingly hard to palm their innovations off on Western countries, who are just beginning to realise that they have long been hoodwinked by glossy brochures. I hope the leaders of Kenya are not swayed by promises of modernisation and technological enhancements when there are far more basic and more important things to worry about.
Finally, I hope that these leaders will not be hoodwinked into believing that privatisation will solve all their problems with public utilities and services. They only need to ask some of their neighbours about their experiences of privatisation. The word Biwater springs to mind when anyone mentions water privatisation in developing countries, but other words spring to mind too.
PS: I got completely distracted from what I wanted to talk about! There is a cheap and simple method of purifying water in areas where there is plenty of sun. It’s called the Sodis technique (Solar Water Disinfection). It costs little or nothing, it’s accessible to most people, no matter how poor, it’s sustainable and it provides many benefits. Just check out the manual!
Exposing water in clear plastic water bottles to the sun for up to six hours reduces or eliminates micro organisms because of the effects of ultraviolet radiation and the rise in temperature. In strong sunlight, where high temperatures are reached, the water can be purified in as little as one hour.
Of course, you need to be careful about certain things. Small bottles need to be used, no bigger than about two litres, the bottles need to be kept clean and when they get too scratched they need to be replaced. Also, you cannot remove chemical contamination by this method.
But it is a true empty pocket scheme in a place like Kenya, where many areas are strewn with used plastic bottles. Now that they have a value when kept clean and usable, perhaps there won’t be so many of them thrown out along with other household rubbish.
I was pleased to see an item about the Sodis technique on national television yesterday, just after I returned from a meeting about water and sanitation in Kibera. There isn’t much space in Kibera, (unless you include the well watered golf course next door) but there is enough scope to put bottles out in the sun to provide drinking water for the family. The only problem is that it is so simple, people are not very impressed with it!
For example, there were too few social workers in a local authority and they had too much work to do. Therefore, a lot of mistakes were made and the people who were supposed to benefit from social work either didn't benefit or suffered adverse consequences.
Another example, people didn't have enough money to pay certain bills or they had the money but they hadn't received the services. The result was that the authority didn't get the revenue they expected, but they also didn't know that their constituents were not getting the services and that that is why they were not getting the revenue.
You might think that more social workers and better investigation services would help with both of these problems. But a number of years ago, someone must have told the UK government that all their problems would end if they were to 'e-enable' everything. All they needed was ‘e-delivery’, 'e-government', 'e-payments' and anything else that you put 'e-' before would be miraculously transformed and would never cause problems again.
Well, I accept that you can do a lot with technology but only with certain sorts of problem. And it’s just one tool, depending, like any tool, on how it is used. Now, water services in some parts of the UK are terrible, not because people can't report faults in their area using their palm top. The people who live in the worst affected areas were unlikely to have palmtops. The problem was with the infrastructure.
If technology is a solution to administration and communication problems, why is it not a solution to infrastructure problems? Some of the water infrastructure in the UK dates back more than a century and the technology goes back a lot further than that. Apparently the water companies like spending money on certain sorts of technology, it makes for great publicity. But they are not so keen on other sorts of technology. So pipes continue to leak, bills continue to go up and more and more people have problems with their water supply.
Well, there is little comparison between London and Nairobi. Indeed, there are far worse places than Nairobi, but as a densely populated city where more than half of the inhabitants live on less than 2 dollars a day, the problems here are extreme enough. The water infrastructure is not as old as that in London but it was built for a much smaller population and doesn't even extend to many of the most densely populated areas. Most of these places have no running water, no electricity and no proper roads.
Other infrastructures are similarly dilapidated and oversubscribed. There are some fortunate (and relatively posh) areas where there is always water at the turn of a tap. But there are other areas where water is an expensive commodity that requires either a lot of work, a lot of money or both. Of course, if you have the money, you can avoid the work. But if you don’t have the money, and many people don’t, then you are in big trouble.
So, I didn't know whether to laugh or be angry when I heard the Prime Minister, Raila Odinga, announcing his plans for 'e-government'. This is the PM suspected of trying to rig the last elections. Perhaps he and the President, Mwai Kibaki, who was 'e-lected' under highly suspect circumstances think that 'e-government' is one where there can be no rigging or gerrymandering? Odinga went on to talk about the many possibilities of ‘e-enabling’ and the benefits people could expect.
I don't know whether the election chaos was caused by politicians, the police, the army, civil servants (and the Electoral Commission of Kenya is certainly getting a lot of the flack), business people or other interested parties. But 'e-enabling' the election process, or any other aspect of the administration of the country, will not cut corruption, inefficiency, lack of resources, accessibility or anything else that matters.
And if people don't have water, there is no abstruse technological process that will give them access to it. The technology required is so simple that it is not even called technology. I'm not saying there are no complications, just that Nairobi is not waiting for some spoddy geek to come along and sort it all out. There is a water authority here already, with engineers and other experts. They need to be enabled, whatever that involves, not 'e-enabled'.
When people have adequate access to water, food, education and other social services, then it will be time enough for the 'benefits' of high technology. That high technology, also, can wait until the country is able to afford it. If there is not enough money to improve the water supply, nor is there enough money for technological frippery.
I'm quite sure there are Western companies falling over themselves to supply technical equipment and services, there always are. No doubt they were behind Odinga’s speech. Well, they are finding it increasingly hard to palm their innovations off on Western countries, who are just beginning to realise that they have long been hoodwinked by glossy brochures. I hope the leaders of Kenya are not swayed by promises of modernisation and technological enhancements when there are far more basic and more important things to worry about.
Finally, I hope that these leaders will not be hoodwinked into believing that privatisation will solve all their problems with public utilities and services. They only need to ask some of their neighbours about their experiences of privatisation. The word Biwater springs to mind when anyone mentions water privatisation in developing countries, but other words spring to mind too.
PS: I got completely distracted from what I wanted to talk about! There is a cheap and simple method of purifying water in areas where there is plenty of sun. It’s called the Sodis technique (Solar Water Disinfection). It costs little or nothing, it’s accessible to most people, no matter how poor, it’s sustainable and it provides many benefits. Just check out the manual!
Exposing water in clear plastic water bottles to the sun for up to six hours reduces or eliminates micro organisms because of the effects of ultraviolet radiation and the rise in temperature. In strong sunlight, where high temperatures are reached, the water can be purified in as little as one hour.
Of course, you need to be careful about certain things. Small bottles need to be used, no bigger than about two litres, the bottles need to be kept clean and when they get too scratched they need to be replaced. Also, you cannot remove chemical contamination by this method.
But it is a true empty pocket scheme in a place like Kenya, where many areas are strewn with used plastic bottles. Now that they have a value when kept clean and usable, perhaps there won’t be so many of them thrown out along with other household rubbish.
I was pleased to see an item about the Sodis technique on national television yesterday, just after I returned from a meeting about water and sanitation in Kibera. There isn’t much space in Kibera, (unless you include the well watered golf course next door) but there is enough scope to put bottles out in the sun to provide drinking water for the family. The only problem is that it is so simple, people are not very impressed with it!
Wednesday, January 7, 2009
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.
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.
Subscribe to:
Posts (Atom)
