Saturday, April 11, 2009

Prediction Versus Observation

Nobody could have predicted the development and spread of HIV/AIDS in the decades leading up to the 1980s, when the disease was identified. Why would I (or anyone) say something that seems so mind-numbingly obvious? Well, predictions relate to the future, they don't relate to the present or the past. Ok, that's pretty obvious as well.

But try this: in Kenya and other African countries, it was mind-numbingly obvious in the 1980s that, if any epidemic, natural disaster, economic crisis or other highly threatening event were to occur, many people would be adversely affected. Despite post independence improvements and optimism, the majority of people were poor and vulnerable, they had limited access to health, education and other social services. Things were improving, but not fast enough.

There were economic crises, there were oil crises, there were crop failures and famines, there were high rates of disease of various kinds and, inevitably, many people suffered and died prematurely. In the 1980s, it was obvious that most people in Kenya were highly vulnerable as a result of earlier events and also because of rising poverty and disease and decreasing levels of coverage of services that would reduce exposure and mitigate the effects of exposure to disease and other processes.

In the 1980s, there was a clear need for development to reduce the spread of disease, to reduce rising levels of malnutrition and food insecurity, to increase levels of education, to develop infrastructure, especially water and sanitation. Countries like Kenya had a lot of developing to do. The country lacked resilience and would continue to suffer badly every time disaster struck.

The economic fundamentalism of wealthy countries in the 1980s, which continued into the 90s and beyond, dictated that what developing countries needed was, exclusively, economic development. Maybe at the time it seemed like a good bet, that if the economy was ok, everything else would be ok. Perhaps it wasn't clear that most people would remain poor and vulnerable, even when the economy was doing well (whatever 'doing well' happens to mean). If it wasn't immediately clear, it became clear; economies, even in poor countries, waxed and waned. But disasters, diseases, poverty, starvation, etc, and their devastating effects, continued.

But in what way were economies improving? An article I came across recently points out that African economies grew by 1.8% in the 80s and 2% in the 90s and never kept up with population growth. The goal to halve absolute poverty by 2015 is predicated on the achievement of 7% economic growth. At the same time, the percentage of people living below the poverty line increased from 42.6% in the 80s to 44.1% in the 90s and 45.7% in 2003.

Over the decades following the identification of HIV/AIDS, researchers continue to make clear that HIV is transmitted as a result of many factors. These factors relate to the economy, the environment, infrastructure, labour, legal issues, equality, especially gender equality, human behaviour, especially, sexual behaviour and many others. Additional factors and their respective significances are being discovered all the time. Those involved in work to reduce the transmission of HIV and to mitigate its effects cannot be faulted for not knowing about things that have yet to be discovered.

But rather than approach HIV as the multifaceted threat that it is, most approaches to HIV ignore the broader picture of extreme underdevelopment in which HIV transmission needs to be viewed. Most approaches treat HIV as a disease that is spread by sexual intercourse and a disease that can be fought by influencing people's sexual behaviour. There are exceptions, of course, but most of the big HIV money goes into these approaches.

It’s true, HIV is mostly spread by sexual intercourse in developing countries like Kenya and it is vital to understand sexual behaviour and to influence it to the extent that people's levels of exposure and vulnerability can be reduced. But levels of exposure and vulnerability increase during times of economic and social stress. There is an increasing number of poor and unemployed people in Kenya right now. There have been high levels of civil disturbance for some time and there may be more to come. The poor working practices found in Export Processing Zones (EPZ, a polite term for sweat shops), mines, sugar, tea and flower plantations, continue. These, and other conditions, need to be addressed as a matter of urgency.

It has proved very hard to influence people's sexual behaviour and that will probably always be the case, the dangers of sexually transmitted infections (STI) notwithstanding. But services to screen and treat people for common STIs should already be an integral part of Kenya's health services. Children and adults can receive sex education and can be given access to family planning advice and services. These benefits already relate to human rights to which people were entitled long before HIV became an issue. HIV wasn't predictable but high levels of poor health and low levels of education have long been obvious. The fact that people were vulnerable to anything that struck has long been obvious.

In addition, the success of HIV interventions, whether they relate to health, education or anything else, depends on the levels of health, education and other social services in a country. It has never been a secret that, without these services, interventions would have little impact and mitigation of the effects of disease (or any other threat) would be difficult.

The virus may be an 'act of god' but levels of vulnerability are due to decades of underdevelopment and decades of impoverishment of developing countries by developed countries. There were good times in wealthy countries but most people in developing countries never experienced any good times. Now that times are bad again in wealthy countries, no doubt, developing countries will suffer even more.

It's not as if developing countries could never have done anything to help. Oxfam have estimated that the financial bailout package currently in operation represents $1250 for every person on the planet. The same amount of money could lift 1.4 billion of the world's poorest people out of poverty for fifty years. This package is unprecedented, but large financial packages have been made available in the past for wars, following wars and for really important things like the race to the moon.

But I don’t see the global financial industry sacrificing a handful of failed financial institutions for the benefit of a few billion people. As for whether it will work, the bailout package is probably as effective as eating beetroot to protect against HIV.

There is little point in approaching HIV as it were the first infectious disease in the history of medicine to be entirely independent of people’s living conditions. The areas of underdevelopment that were involved in the spread of HIV have been more or less ignored since HIV has been identified. Yet, any measure to reduce transmission of HIV requires those areas of underdevelopment, all of them, to be addressed. Once they have been addressed, HIV transmission will reduce and efforts to reduce transmission further and mitigate the impacts of HIV have a greater probability of success.

There are serious HIV epidemics in many developing countries because they are underdeveloped; the people are vulnerable. As long as they stay underdeveloped, people will continue to be vulnerable and the HIV epidemics will remain. Future predictions are tenuous and difficult but we should all be perfectly capable of making observations about the present and the past.


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