Tanzania: No Albino People Were Harmed in the Making of This Story?

[Crossposted from Blogtivist]

Early in April 2008, President Jakaya Kikwete is quoted as saying "I am told that people kill albinos and chop their body parts, including fingers, believing they can get rich." This kind of statement, which has appeared many times over the seven years of reporting on attacks on albino people, always needs to be read with care. Other accounts, vague as they tend to be, suggest that there are people who do the killing and maiming, people who buy the body parts and people who pay for those parts or 'potions' made from those parts.

Those are three very different ways of 'getting rich'. The first represents a serious crime, with the expectation of substantial reward. The first does not require that there be any 'superstition' involved, though it doesn't preclude it. The second is also a crime, but the expectation is that there are enough superstitious people to buy potions and other services using parts of albino people. The person providing these services doesn't need to be superstitious either, though they may very well be. The third crime very likely requires the 'client', the person paying for the service, to be superstitious.

It's very important to distinguish between these different crimes in order to understand how such attacks could begin and continue for years. Each type of participant takes different kinds of risk, risks of being apprehended, financial risks, etc. Some attackers have, apparently, said they were sent by a witchdoctor to find a victim and promised money in return. The witchdoctor needs some degree of certainty that their clients will pay large sums of money. The client is the only one who must be superstitious, or somehow deluded, about the power of witchdoctors and the services they provide.

Media accounts emphasize the issue of superstition and often remark how widespread superstition is in some areas or, especially, among certain groups of people: "Superstitious miners and fishermen in the [Lake Zone] region hoping to get rich quick have been accused of fuelling the demand for the potions." This statement has been frequently paraphrased, and even copied and pasted, as if superstition gives some kind of insight into these killings. Sure, superstitious people can be found, everywhere. But most superstitious people do not generally carry out brutal attacks, maimings and killings. (Nor do most witchdoctors, fishermen, miners or 'businesspeople'.)

Not only are media accounts incomplete, vague and often rather unconvincing, but they have tended to repeat the same sorts of gossip and rumor for seven years, with few noticeable insights that one might expect from investigation, research or analysis. If we want to understand how these attacks began, how can we do that? What kind of data and analysis can we use? Remarks about witchdoctors, miners and fishermen are nothing new, and long predate attacks on albino people. More importantly, none of these groups are noticeably rich, not that anyone has demonstrated, anyhow. Commentators like to imply some kind of organized crime, but how organized is it? How 'lucrative' is it?

Looking for as much information as I could find online about attacks on and killings of albino people in Tanzania between 2006 and 2013, I came across a fairly small quantity of empirical data and a somewhat larger quantity of speculation. While there was a fair amount of disagreement about much of the empirical data, there was a fair amount of agreement about the speculation. This could be the opposite to what one might expect, unless the entire media became contaminated by some of the more 'pornographic' among the early reports.

After all, it should be possible to say with a fair amount of certainty how many albino people there are in Tanzania, how many were attacked and how many were killed, where and when these events occurred, and the like. Those are examples of empirical data. Who may have been involved in these events and what their motives were would seem, I think, more a matter of speculation, at least until some investigation and research has been carried out.

Yet almost all sources agreed, right from the very start, that witchcraft (or something similar, or thought to be similar) was behind the attacks; and witches, people perceived to be witches (and similar sorts of people, and those thought to be similar enough) were demanding albino bodies and parts of albinos; their 'clients' were demanding potions (and similar, you get the picture) that would make them rich (yes, almost all the articles said that wealth was what the clients wanted). Therefore, there were also these 'middlemen', sometimes referred to as 'businessmen' (both terms being suitably vague), who were carrying out the brutal maimings, murders and other crimes.

I have searched numerous articles and documents to create a table of all the attacks where victims were named, and/or enough detail was given to show that there probably was an attack or violent or threatening event, matters that could be further investigated, so that a more accurate picture of these dreadful murders and attacks can be built up. I have also tabulated some data about numbers of attacks, numbers of named victims, numbers of articles, numbers of victims claimed by the media, etc.

Whereas sources are in reasonable agreement that at least one hundred of these incidents took place (some say there were many hundreds, and that most are undocumented), that about 70 albino people were killed and about 30 were maimed (or otherwise injured), I have only been able to find accounts of 71 victims, some of them fairly scanty. Only 46 of these victims (65%) have been named, although some have only been partially named (only first or second name). 24 out of those 71 victims identified, or partially identified, were killed. Only ten of those who died have been named (or partially named).

The cumulative number of deaths estimated by the media, which seems to be almost entirely speculative, especially in the first few years, waxes and wanes. Some of the earlier articles say there were 4 murders in the three months to December of 2007, but the Tanzania Human Rights Report for 2007, published some time later, claims there were 20 during this period (prior to this, there was only one documented, in April 2006). The numbers estimated for 2008 range from 19-30, which may or may not suggest a halving in killings during 2008. By the end of 2009 numbers have jumped to 35, and then to 53 early in the year, this being the highest mentioned for 2009. In 2010, the figures rose to 71, without rising above 72 by 2013.

The number of incidents reported by the media in those years makes a very different pattern. From 1 in 2006, reported in the LHRC report published about a year later, there were 3 in 2007 (all reported in Under the Same Sun's document listing 34 victims, mostly survivors). The highest number of identifiable incidents was reported in 2008, 17 in all. Numbers fell to 11 in 2009 and 8 in 2010, only to rise to 15 in 2011 and drop to 7 in 2012 and 8 in 2013. So there were two peak years for incidents described in the media. The number of articles describing these events took a third pattern, rising from 1 in 2007 to a peak of 20 in 2008 and 22 in 2009, then falling to 4 in 2013.

If, as much of the online media claims, there were about 70 murders of albino people in the last 7 years, an average of 10 a year, why has the media feeding frenzy failed to document the majority of them? Western murder victims usually have a name; but only one in 7 Tanzanian albinos said to have been murdered has been named (or partially named). About one fifth of those maimed or suffering some other kind of injury have no name either, despite being victims of crimes such as attempted murder, abduction, rape and false imprisonment.

Media coverage of attacks on and murders of albino people in Tanzania has been appallingly sloppy. So I am prepared to believe that there may have been additional, undocumented attacks and murders. But it is also hard to avoid concluding that the conviction that albino body parts can bring great wealth, whether to criminals, witchdoctors or their clients, is partly based, perhaps largely based, on media reports. The involvement of 'witchdoctors' and the promise of wealth are two of the most enduring concepts in the media, appearing in almost every one of the eighty or so articles I have used for this study.

Attacks, maimings, murders, rapes and other crimes are carried out by criminals, and they deserve to be prosecuted and punished for their crimes. But the media should become more cautious when certain kinds of crime appear to display a pattern. Given the constant mention of 'great wealth', it would have been more responsible to play down this aspect of the crimes; not by failing to mention the oft cited amounts that could be made, but by emphasizing that no clear instances of large sums of money changing hands have been documented; no rich witchdoctors were identified; the evidence, at best, points to rumor and gossip about money, nothing more.

Apparently there were four attacks in a period of 16 days earlier this year, resulting in two murders, two maimings and attacks on two other people. It's not too late to look back on the last seven years of reporting and set the record straight, and doing so may help to ensure these these attacks eventually cease to occur. So far, media coverage has been insulting to albino people, their families and friends, and to Tanzanian people.

Call for Inquiry into Media's Coverage of 'Tanzanian Albino Murders'

[Cross-posted from Blogtivist]

Instead of merely using the word 'witchcraft' in one of the earliest mainstream media articles on a series of murders of albino people in Tanzania, the author could as well have issued an edict that henceforth, all articles on the subject use a term with 'witch' in it, or some other, equally obscure term. Because every single subsequent mainstream media article on the subject did use such a term.

Other terms that crept in include: witchdoctor, foreign witchdoctor, herbal medicine, herbalist, ancient tradition, black arts, black magic, satanism (satanic inspired), traditional healer, magic potion, ritual medicine, ritual killing/murder, muti, muti medicine, sorcery, cannibals, magic potion, child sacrifice, superstition, taboo, fetish, voodoo, devil worship, occult, etc [There's a partial list of articles consulted on this page.]

'Here be Dragons...', began the BBC, and the rest of the 'free' press joined in unison. In the years following 2007, which marked the beginning of the media frenzy concerning attacks on and murders of albino people in Tanzania, no convincing explanation was ever given for why people should be attacked and killed just because, apparently, they are albinos.

Indeed, no light was shed on how that first article found online (there are likely to be many articles that have not been found by this study) had already 'established' that the 'four deaths (of albino people) in the past three months' (later reports suggest as many as 20 deaths in 2007) were a result of the work of 'witch-doctors'; but there was already a call for arrests.

Not that any subsequent research has shown that witches/witchdoctors/traditional healers, etc, were not behind the attacks and murders. In fact, one of the biggest single barriers to understanding these attacks and murders is that none of the articles examined have bothered to make clear exactly what they mean by 'witch', or whatever other term they used. For years, old people suspected of 'witchcraft' have been persecuted and lynched; such lynchings still occur, but they are surely not the target of these articles?

The World Health Organization estimates that in "some Asian and African countries, 80% of the population depend on traditional medicine for primary health care". Not only are conditions in most public health facilities in Tanzania appalling and dangerous, but many people are not able to afford them, neither the fees (official or otherwise), nor any of the other costs involved, such as transport and drugs. There is little left for poorer people other than some kind of local healer. Are these the targets of all the media articles about attacks on and murders of albino people in Tanzania?

Difficult as it is to believe, the government soon declared a 'ban' on all kinds of 'witchcraft'. The undefined set of activities that this poorly defined 'group' engage in becomes a target of intense media interest. But not for the first time. Poor and vulnerable old women and men in rural areas, who are probably becoming isolated from their communities, are not the only targets of savage persecution, beatings and lynchings. Virtually anyone said to be involved in any area of 'witchcraft', whether they hand out traditional cures for illnesses or potions said to make their clients wealthy, has gone through all manner of threats to their livelihood over the years.

In the mid 1990s, the Kenyan government was somehow persuaded that various elements of another poorly defined set of activities, devil worship, were 'rife' in rural areas, in schools, in (recently established) churches, in public places, everywhere. A government commission, headed by senior representatives of better established churches, was set up to investigate and several years later they, apparently, presented a report to parliament. The report was never made public, but the media was able to salivate over its possible contents for years, and the issue of devil worship is alive in the minds of many people who lived through those years.

What has witchcraft got to do with devil worship? Well, they were all lumped together by the Kenyan commission, just like all the terms listed above. "President Moi appointed the Commission in 1994 in response to public concern about a perceived resurgence of witchcraft, ritual murders, and other ostensibly "Satanic" practices associated with aspects of traditional indigenous religions." That one sentence damns a whole host of groups.

The document continues: "The Commission's report included numerous reports of ritual murder, human sacrifice, cannibalism, and feats of magic allegedly done by using powers acquired through such acts." Attacks on and murders of albino people in Tanzaina, from very early on, were seen as 'ritual' murders. Even descriptions of those murders became more lurid, listing the various parts of bodies, including their skin, and what they would be used for, bleeding and drinking of blood, hacking limbs off live victims, etc. Who wouldn't immediately see 'witchcraft' in these bloody attacks and murders in Tanzania?

Given the sheer weight of media footballs to choose from, few may remember Tanzania's (human) 'skin trade'. But it was a big enough story to attract attention for several years in the late 90s and early 2000s.  An article in 1999 refers to "a series of [at least three] brutal murders in which the skins and organs of the victims are apparently being sold for use in witchcraft". The article even claims that a "human skin can fetch a price of up to $9,000", just as the media later reveled in claims about how much money could be made from the parts and entire bodies of albino people.

Two years later it is reported that a gang, a ringleader called Adamu and twelve members, had been arrested in connection with similar murders, these also taking place in the Southern region of Mbeya (the majority of attacks on and murders of albino people took place in Mwanza, in the North West). The price range is now said to be "$2400 and $9600, apparently depending on the age of the victim". It is stressed that the ultimate market for these skins is West Africa and those involved are described as having become 'expert' at mutilating the bodies.

After another two years the issue is back on the BBC site; again it is stressed that the market is "outside Tanzania", and there is a "huge demand". Again, the murders are said to have taken place in the South of the country and there is mention of 'ritual' and 'witchcraft'. The total number of deaths is said to have been six. In common with the later attacks on and murders of albino people, it is implied that the skin is used by practitioners of witchcraft to bring wealth to the client: "This is also to educate people that they do not have to to use human skin to become rich".

None of the above tells us why albino people in Tanzania were subsequently mutilated and murdered, why the bodies of albino people were dug up and parts hacked off, why several people attempted to 'sell' an albino person for use by 'witchdoctors'. But it gives some idea of what the use of the term 'witch' and various other terms adds to an article about these horrific events: absolutely nothing. It simply labels the issue as a media football, to be kicked around along with other, similarly labelled bumf, a hotch-potch of rubbish that goes together to make up what counts as 'African' reportage.

It is estimated that over 100 albino people in Tanzania were attacked and over 70 killed since (probably) some time in 2006. Those who carried out the attacks, for whatever motive, deserve to be punished for what they did. But, despite hundreds of arrests claimed, hardly anyone has been punished. Reports are vague and unreliable, perhaps three or four people were convicted. One of those convicted was Kenyan, for human trafficking, as the victim was neither mutilated nor murdered.

So what's the problem? Witchdoctors are not that hard to find. If their work becomes a big secret they don't get many clients. The media loves to refer to how secretive they are, but given the sort of things that they have been implicated in over the years by the same media, who could blame them? Some may have become so secretive that they no longer get any clients at all; they may have found something safer to do. Just about anything would be safer, really.

More importantly 'witchdoctors' do not, according to evidence available, tend to charge a lot for their work; how could they, most of their clients are poor? So if 'witchdoctors' are not that hard to find, rich witchdoctors must really stand out. If there is any truth in the various rumors about how much they charge for 'potions' containing parts of mutilated and murdered albinos, some of them, probably a mere handful, must be noticeably well off. But no article found has produced evidence of a wealthy 'witchdoctor', only rumors, the media's stock in trade when writing about 'Africa'.

No article has produced evidence of a wealthy client, either. Artisanal miners and fishermen, mining and fishing being among the few sources of income in Mwanza, are frequently mentioned. But they, along with the hapless 'witchdoctors', have been blamed for many other things. Some sources mentioned politicians as possible clients of witchdoctors and predicted many further maimings and killings of albino people in the run up to the 2010 elections. Either there was no surge in violence against albino people, or the media merely failed to report it. So do politicians give large sums of money to 'witchdoctors' in return for success? Perhaps they now settle for potions that don't contain human remains.

Where is all the money involved in the often referred to 'lucrative' trade in albino body parts? Most articles stress the rural character of places where maimings and murders of albino people take place; they stress the poverty of the victims and the people around them; they stress the high levels of superstition and sometimes the low levels of education and the lack of opportunity in the area. How many rogue 'witchdoctors' were there, ever? And how many wealthy clients? Can the media, after all their 'investigations', over a period of so many years, tell us anything that is certain?

Or should we suspect that much of the talk of a 'lucrative' trade in albino body parts, talk that may have have contributed to so many maimings and deaths, was to a large extent the result of a media frenzy, that there are few wealthy 'witchdoctors' or clients, if any, that most, if not all of the perpetrators of these horrendous acts are still free, and that if anything could have been done to prevent such attacks it has not yet been done?

There were several further attacks and deaths this year. Late though it is, there needs to be a full inquiry into this phenomenon, one that takes into account the possible role of the media, the police and other officials, political, church and traditional leaders, everyone who may have something to add to finding out what went on, and what is still going on. We owe this, at least, to all the people who have already suffered and to those who may be protected by the results of a thorough investigation.

[I will be putting together data and sending it to the media outlets involved, calling for an inquiry into the shoddy coverage of the many attacks on and murders of Tanzanian albino people over the past seven years, and the failure of all those involved to identify the perpetrators and to protect other albino people from subsequent attacks and murders.]

Farewell to the HIV in Kenya Blog

After just over four years of blogging about HIV and other development issues in East Africa and beyond, I need to move on. It has become too much for me to keep up with the reading and other things necessary to write such a blog. It has been an interesting experience, but I have become poor, not having had a paid job for five years. Volunteering can be great, but it has to stop eventually. And criticizing the HIV industry has probably not made me any more likely to get paid work in the field! Besides, I am no longer in East Africa.

I was offered a job as a grant proposal writer for an NGO in Cambodia called SISHA. So I arrived in Phnom Penh a week ago and started working on Tuesday. Writing grant proposals can be intense because there's a lot of work involved without any guarantee of getting the grant. There are more and more NGOs chasing after fewer and fewer funds. Also, huge grants tend to go to huge NGOs, small grants to small ones and none at all to ones that have never had grants before!

OK, that's an exaggeration, but it's hard to get going and hard to move up. And it's the easiest thing in the world to move down or stay resolutely in the same place, indefinitely. So I don't fancy trying to do that and then chase after the latest HIV research in my free time. I need to spend time working, getting fit, learning Khmer (or trying) and maybe some other things. More importantly, I am now a married man with my first child on the way in June or July. I hope to blog on Blogtivist from now on, where all my other blogs will be available. I'm sure I'll return to HIV in Kenya from time to time if I can. But I doubt if I'll ever again have the time needed to do as much writing and research as I did over the past four years.

Everything will remain available as long as Blogspot (owned by Google) keeps it available. I am grateful to all the people who have read and comment on posts, some of whom I have met face to face. I hope we all keep in touch. To those also blogging, I hope to hear from you and to continue to visit and comment on your posts from time to time. Maybe I'll see you on Blogtivist, you'll be welcome. THANK YOU!

Maternal Health Care a Significant HIV Risk in Ethiopia

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

A young doctor who had been working for 26-28 hours was taking blood from a baby born to a HIV positive mother and accidentally pricked himself with the needle. He reported the incident and got some kind of treatment in the same hospital, but he had to drive himself to another hospital 45 minutes away to get the drugs he needed after being awake for 29 hours. There are several issues here but I'd like to concentrate on the fact that a hospital that had a HIV positive female patient did not have the drugs required to administer post-exposure prophylaxis. Thankfully the doctor in question was OK, but he had to wait six months to have that confirmed.

An accident like this could occur in any country in the world. In this instance it happened in Ireland, where HIV prevalence is very low, around 0.2%. The mother was known to be HIV positive, whereas the HIV status of a significant proportion of people in many countries, perhaps the majority of people in high prevalence countries, would not be known. Needlestick injuries are more common in places where there are fewer staff, less well trained staff and where access to supplies and equipment are poor. But even in countries where conditions for infection control are probably good there can be slips, such as the one described above.

Of course, the fact that conditions for infection control are not good in developing countries does not mean HIV is frequently transmitted through unsafe medical procedures. UNAIDS, WHO and the rest may be right in their claim that only 2-2.5% of HIV transmission is accounted for by unsafe injections, contaminated blood transfusions and other health care risks. But it would be comforting to hear that unexplained HIV outbreaks are investigated. It's not as if there are no such unexplained outbreaks; many infants are found to be HIV positive even though their mother is negative; many adults are infected even though they have no identifiable sexual risk, etc.

One of the oldest high prevalence HIV epidemics in Africa, that in Uganda, should have taught us a lot. It is now obvious that at least some of the rapid drop in prevalence after its peak in the late 80s must have been a result of high death rates. Some of the drop in incidence, the rate of new infections, must have been a result of improvements in infection control practices in health facilities. Very little of the drop in infections can clearly be associated with various 'initiatives' aiming to address sexual behavior, which (much) later became known as ABC (Abstain, Be faithful and use Condoms). So why is there now so much emphasis on sexual behavior when we know that many of those approaches have had very little impact, in Uganda or anywhere else?

According to an article from IRIN news, Uganda is targeting 'cheaters'. This is an extremely inept piece of campaigning (and reporting). Knowing that someone is HIV positive is not the same as knowing how they became infected. The data itself even suggests that most of the people considered to be 'cheaters' could not have been infected through sexual behavior because their behavior is classified as low risk. Some of them may have been infected sexually, but it is unlikely that they all were. Yet this group, people who are in long-term relationships, often married, makes up the biggest group of HIV positive people, 43% of all new infections. To establish how they became infected it is first necessary to do some investigating.

Another group of unexplained infections can be found among women of child-bearing age. Some may well be infected sexually, but some may not. It's certainly not a foregone conclusion that all of them must have been infected sexually just because they have had sex. The group that is especially in need of investigation is those who have given birth with the assistance of a health care professional. The 2005 Demographic and Health Survey for Ethiopia shows that HIV prevalence is eight times higher for this group (prevalence is 9.9% for those who received assistance from a health professional and 1.2% for those who gave birth without assistance from a health professional). In addition, HIV prevalence is a lot lower among men. HIV in Ethiopia is very low in rural areas and appears to be higher among employed, better educated, wealthier people who live in urban areas. A more recent Demographic and Health Survey for Ethiopia was published in 2011, but there is no figure cited for this group.

There are so many ways HIV can be transmitted, especially in countries where HIV prevalence is high and most people don't know they are infected. It must also be remembered that most people don't realize that there are significant non-sexual risks; if they don't know about the risks they will not know anything about protecting themselves and their families. There are health care risks, such as operations, vaccinations and dental care, traditional practices, such as circumcision, scarification and traditional medicine and cosmetic risks, such as manicures, pedicures, tattoos and piercing.

Rather than continuing to waste money on sexual behavior interventions, many of which have been largely unsuccessful and all of which fuel the stigma that attaches to HIV infection in African countries, it is time to investigate non-sexual transmission in all its forms. If there is any shortage of evidence that non-sexual HIV transmission makes a significant and underestimated contribution to serious HIV epidemics, that can only be because of a lack of research and a lack of investigation where levels of HIV transmission are unexplained by sexual behavior alone.

Donor countries, including Ireland, are keen to get women in developing countries to use ante-natal care clinics and other health facilities. Far more important than providing people with health care is providing people with safe health care; otherwise we could be increasing risk of transmission of HIV and other infectious diseases rather than reducing risk. Needlestick incidents are probably the least of people's worries in countries like Ethiopia, but only because many people don't attend health facilities most of the time. If our aim is to increase access to health care we had better ensure that health facilities are also safe.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

PrePex at Loggerheads with Main Recipients of Circumcision Funding?

Only a few weeks ago, the owners of the company that makes PrePex 'bloodless' circumcision devices (effectively, a plastic ring and a rubber band) were happily plugging their ware, a difficult process of persuading journalists to regurgitate an entire press release without any research or criticism. This time, the press release was set in Uganda and a researcher, presumably one not versed in the skills of PR, claimed that "We have so far tested it on about 50 clients but we need 250 more to confirm its acceptability but so far it has worked properly with those who used it". No need for any Ugandans to worry, then.

But alas, some of the main proponents of circumcision, who are also some of the main recipients of the copious millions of dollars available for the mass male circumcision programs in Africa, have announced that "The PrePex Device Is Unlikely to Achieve Cost-Savings Compared to the Forceps-Guided Method in Male Circumcision Programs in Sub-Saharan Africa". They were even generous enough to make the findings available in a free peer-reviewed source. This is all the more remarkable when you consider how most research relating to mass male circumcision is made available: selectively, at the convenience of those who collected the data, rather than that of anyone who may wish to scrutinize it.

Of course, this may be just a bit of a spat between those who prefer to know that scalpels are used (who currently receive the lion's share of funding) and those who don't give a toss how the operation is carried out as long as they make lots of money out of it. The paper by Walter Obiero, Marisa Young and Robert Bailey claims that at $45-50, the PrePex method is "unlikely to result in significant cost-savings". The authors declare no competing interest, unless the fact that at least one of them is a founder of the Nyanza Reproductive Health Society, which provided some of the funding for the research, represents some kind of competing interest.

The $45-50 figure is interesting. According to an article from the UK's National Secular Society, hospitals in Sheffield are going to start charging for non-medical circumcision. They carry out fewer than 200 per year, which is surprising enough, but they expect to save nearly $1,600 per operation. Could it really cost 32 times more to carry out a circumcision in an English hospital? I can imagine costs are lower in African countries, for lots of reasons, but I wonder what, exactly, will be excluded from the mass circumcision campaigns to keep the costs so low. I wonder also if Sheffield could be induced to reconsider their decision if they could offer the operation so cheaply, and how many people would then take them up on it.

One person commenting on Sheffield's decision feels that this may give rise to 'backstreet operations'. But in African countries where circumcision is already carried out for tribal reasons, almost all circumcisions are 'backstreet operations', carried out by someone with no medical training, often without sterile instruments. The several billion dollars on offer for mass male circumcision programs in African countries are mainly available in areas where circumcision is not routinely carried out already.

A spokesperson for the National Health Service said: "Non-therapeutic circumcisions are not clinical interventions and as a group, we would not want anybody to undergo a medical procedure if there was no specific clinical need." A spokesperson for the National Secular Society said "We believe that non-therapeutic circumcision should not be permitted until the boy is old enough to give informed consent." These guys have evidently never heard about the US government's plans for African males.

Most articles promoting mass male circumcision for high HIV prevalence African countries claim that "results from three trials in sub-Saharan Africa, including one from Rakai, Uganda, showed that circumcision could reduce HIV transmission from positive women to negative male partners by up to 60 percent". This is not what the trials showed. HIV transmission was lower in the group that was circumcised than in the group that was not. But the trial did not show that all transmission was a result of sexual contact. Some may have been through unsterile healthcare, reused medical equipment, etc. Perhaps more importantly, at least one of the trials suggests that HIV transmission increased in the control group, rather than decreasing in the intervention group.

It seems hard to believe that current interest in promoting mass male circumcision to reduce HIV transmission from females to males could be based entirely on the evidence for the effectiveness of such a strategy, because the evidence is extremely mixed so far. It seems equally hard to believe that the whole thing is just a money earner for those competing for funding. But there is a lot of money involved. You might expect the Nyanza Reproductive Health Society to be unworried about whether PrePex is used, or some other method. But the difference in cost could be about 10%, some $100,000,000. So how much does something have to be worth to be a 'competing interest'?

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

Water and Sanitation: Probably the Greatest Possible Benefit to Health that Exists

Great to read an article in the New England Journal of Medicine (NEJM) making it quite clear, if it wasn't clear enough already, that the cure for cholera is improving access to safe water and sanitation. The recent massive cholera epidemic in Haiti means that several years and billions of dollars of aid money have not resulted in the provision of safe water and sanitation. The epidemic in Zimbabwe means that provision of water and sanitation, which may have been adequate at one time, collapsed. (It is estimated that about half a million people were infected with some kind of diarrhea in Zimbabwe alone in 2012.)

The good news is that lots of diseases can be wrapped up along with cholera and eradicated; most water-borne diseases. The bad news is that no country has ever eradicated cholera or any other water-borne disease without providing clean water and sanitation. The mere development of a vaccine for cholera or any other single disease misses the point and misses a wonderful opportunity. Half a million cholera infections and thousands of deaths are reported every year, all for want of clean water and sanitation. But the true number of infections is likely to be several million and the number of deaths likely to be 100-200,000.

Institutions such as the Gates Foundation like to boast about how many billions they are putting into vaccines for individual diseases, such as rotavirus. That's admirable in its own way, but why line up a few diseases to be addressed and ignore the conditions that ensure these diseases will remain endemic for the foreseeable future? Especially considering how long lack of access to clean water and sanitation has been one of the most serious issues facing developing countries. If, as the NEJM article claims, the problem is related to rapid urbanization, we're a long time getting around to it; urbanization in many African countries began decades ago.

Access to clean water and sanitation for all may seem like a very long term goal. However, in conjunction with improved health services and education, better water and sanitation will also lead to better health and educational attainment indicators. Even maternal and child health, which are often said to be priorities, would be greatly improved. Rather than targeting various diseases and sectors of developing country populations, improved water and sanitation for all would result in benefits for all sectors. Indeed, progress in health and education provision will be a lot slower without improvements in water and sanitation provision.

In relation to the challenges of such an intervention, NEJM mentions expanded access to antiretroviral treatment to poor people in developing countries. But improved water and sanitation is not at all like antiretroviral treatment; everyone needs access to water and sanitation, not just pockets of people in certain parts of certain countries. Improved antiretroviral treatment does not aim to prevent HIV transmission, though big claims are now made about preventive benefits. Antiretroviral treatment is not like provision of water and sanitation because the former targets one disease, almost entirely ignoring other diseases, and even health, education and other development areas.

Indeed, the parallel is even weaker than that. Lack of access to water and sanitation affects all poor people, especially those living in rural areas and, arguably, affects women and children more, perhaps more directly, than adults and men. HIV is often more common among wealthier people with better education, and certainly among those who live in more urbanized areas. The article concludes that "the current state of development leaves more than a billion of the poorest and most marginalized people at risk of ingesting feces with their food and water". So let's not approach lack of water and sanitation as we did HIV and access to antiretroviral drugs. Access to clean water and sanitation is a basic human right, so why not approach it that way?

Lynas Spanks One Out for Genetic Engineering, Again

It's good to read a simple article by a Kenyan in a Kenyan newspaper about staple crops rather than cash crops for export being the key to tackling poverty. Many people probably suspect that it is true, but we are constantly blasted with articles about luxury fruits and vegetables for the European market and cash crops that make Kenyan farmers very little money but sell well in the West.

The article refers to a study brief by the International Food Policy Research Institute (IFPRI) called Strategies and Priorities for African Agriculture. The study concludes that "producing more staple crops such as maize, pulses, and roots and more livestock products tends to reduce poverty further than producing more export crops such as coffee or cut flowers". IFPRI is connected with some of the big bullies among the multinationals and some heavy handed Western governments, but they can still produce sensible research, it seems.

Unfortunately, all the mainstream media are taking an interest in Mark Lynas' supposed conversion from environmentalist to promoter of genetic engineering (GE). Lynas spanked one out in public for GE over 18 months ago. Perhaps the press weren't quite ready then for such a shocking conversion, or they had other things on their mind. But back in July 2011 Lynas claimed that Africa must embrace GM technology to abolish hunger and malnutrition.

Lynas would be well aware that his claims are utter rubbish, so one can only conclude that he is making them for reasons that don't relate to science or anything too academic. All the more surprising that he considers opposition to GE to be 'anti-scientific'. Even his own arguments are not primarily about the science of GE, but the economics; and his arguments are based on falsehoods.

Back then, Lynas said "One of the most pervasive myths about biotech crops is that they are part of a nefarious plot by multinational seed companies such as Monsanto to dominate the world food chain." But that's pretty much how Monsanto and other GE multinationals would describe themselves, albeit using a slightly different rhetoric. Any science involved is of little relevance, which means that even someone with as little grasp of science as Lynas has can still take part in the debate, as long as they come to realize what exactly the terms of the debate are.

The most astonishing thing about GE crops is that they are so unneeded. Conventional crops have developed at a pace that GE can not keep up with; costs are also far lower; the claimed advantages of GE crops, where they didn't turn out to be exaggerations and lies, turned out to be short lived. Lynas and the GE industry are well aware of this, hence the need to keep pumping out the party line. Conventionally bred staple crops are what poor people depend on for survival, not expensive high technologies that don't perform well, despite all the hype.