Friday, May 29, 2009

Predictions and Evaluations - HIV in Kenya Today

Sadly, I am now back in the UK. But I will continue to study and blog about HIV and development in Kenya and other places.

About two months ago I wrote a posting entitled A Short History of HIV in Kenya. At the time there was little response but in the last few days someone has responded, at some length. As the respondent raises important issues, I am replying to some of them via a new posting rather than continuing what is now an old thread.

The respondent points out that many people have questioned the HIV predictions of institutions such as UNAIDS, given that they have had to revise their figures downwards on several occasions.

I am not a big fan of UNAIDS but methods of measuring the extent of HIV epidemics and predicting future prevalence are evolving. It is hardly surprising that figures include a lot of somewhat vague modelling and informed guesswork. Over the years, measurements and predictions have become better informed, but they will continue to be rough.

However, estimating the overall severity of a HIV epidemic is not just a matter of surveying the number of people infected and affected and making predictions about future prevalence. It is also necessary to establish who is at risk, why they are at risk, if the level of risk in increasing, if the number of people at risk is rising, etc.

It is also necessary to judge a countrys capacity to prevent new transmissions and to support and care for those infected and affected by HIV. Mere numbers of people infected and affected will not, on their own, be of much help in preventing further infection or helping those who are infected. Nor will they shed light on why people continue to be infected in high numbers, despite large amounts of money supposedly being poured into HIV prevention.

The big worry in Kenya and other developing countries is not whether prevalence is high or low (whatever may count as high or low, whether it is increasing, decreasing or flatlining; the big worry is what countries have been doing so far and what they are able to do in the future.

Are there adequate health services that are accessible to everyone, are all children attending school, are adults well enough educated to raise healthy and well educated children, does the country have the infrastructure to implement health, education and other social programmes to reduce HIV transmission and to keep it low, etc?

The main concern is not whether the HIV pandemic is increasing or decreasing according to some vague figures and guesswork. The main concern is whether the original factors in the spread of HIV in the 80s, 90s and 2000s are still present in developing countries.

And there is a lot to be worried about; health services, education, infrastructure, social services, employment, legal conditions, levels of inequality and human rights suggest that very few improvements have been made in Kenya and other countries. Therefore, there is no reason to assume that HIV will just disappear.

It is true that, at one time, Kenyan HIV prevalence was estimated to be about 15%. Then it was realised that this was incorrect and the figure was revised down to about 10%. Over a period of several years, prevalence continued to fall, mainly because infected people died of Aids. But in the mid 2000s, rates started to increase again.

The respondent in question is right to be sceptical about HIV prevalence figures but wrong to come to any conclusions on the basis of these unreliable figures.

What is a low prevalence figure, anyway? A few years ago, North Eastern Province had an estimated prevalence of below 1%, perhaps well below 1%. But the risk factors there were significant, high unemployment, low education, poor health and health services, rapid urbanisation, increasing mobility, high levels of economic and gender inequality. More recently, prevalence was estimated to be well over 1%. The fact that figures may seem low in some areas now does not mean that they will stay low.

As for the claim that people outside of Sub Saharan Africa (or outside of certain developing countries) are not likely to contract HIV, this is also not borne out by the evidence. Eastern European countries are seeing high rates of HIV transmission, especially among high risk groups, such as intravenous drug users, commercial sex workers and men who have sex with men.

But even developed countries, such as the UK and the US, are also seeing substantial transmission rates and not just among high risk groups. The risk is nowhere near as high as it is in developing countries but it certainly raises questions about the effectiveness of their HIV prevention programmes. After all, these same programmes are being exported to developing countries, where they may have even less success.

Finally, it is still the case that everyone is at risk. It is just that they do not all have the same odds (and they never did). People in developing countries are more at risk, women are at more risk than men, men who have sex with men are at more risk than heterosexuals, etc.

If figures are unreliable, and they often are, take a look at the risk factors. Take a look at the conditions people live in. Cholera, for example, is not a problem in Zimbabwe because 100,000 people have been infected and thousands died. It is a problem because water and sewage services are not adequate and any water borne disease could flare up and become an epidemic in a short period of time. And if this happens, the country will not have the capacity to prevent it from spreading, perhaps to surrounding countries.

Right now, many Kenyans are poor, unemployed, undereducated, malnourished, unhealthy and desperate. There is a good chance that things will get worse before they get better. People are vulnerable to HIV and many other diseases. These are the kinds of things you need to know to judge whether the HIV epidemic is getting worse or not.


Friday, May 22, 2009

How to Save a Failing Church

A Nigerian bishop, the Archbishop of Ibadan, recently became one of the many defenders of the pope’s infamously garbled pronouncement on condoms. The fact that the pope’s statement was garbled makes it easy for people to either reinterpret it in a favourable light or in an unfavourable light, whatever suits their purposes. But the problem is that the statement did not give the sort of clarity that many people seek.

Previously, the pope has opposed the use of condoms under any circumstances and advocated abstinence and fidelity as a response to the HIV pandemic. Christians sought clarification because they felt that abstinence and fidelity were great in theory but were not feasible for many people. And even if they were achievable for some, they were not necessarily achievable for their partners, for sex workers, for victims of sexual assault, etc.

Some Catholics and Christians went even further and preached that condoms had holes that allowed HIV virus through or that condoms are very unreliable or that they often burst.

So the guidance that people received from the church ranged from unfeasible to vague to untrue. It’s little wonder that Catholics and Christians were left to do what most of them have been doing for generations: using their own interpretation and doing the best they could.

But there are people who take what they hear from church leaders rather more literally, either because they feel that’s what it is to be a Catholic or Christian or because that particular course of action suits them. So there are people who waited till they were married before having sex only to be infected by their partner. Others ended up with more children than they could provide for. Others didn’t have any choice about whether to have sex, when or with whom.

The Nigerian bishop claims that the pope’s statement is about people’s sexual behaviour and that people’s sexual behaviour is behind the HIV pandemic. But if the bishop (and the pope) were to think about it a little more carefully, they would see that sexual behaviour does not occur in a vacuum. People’s behaviour and sexual behaviour are determined by other circumstances. Just as TB is airborne, you don’t prevent transmission of TB by telling people to stop breathing, so you won’t reduce HIV transmission by merely trying to legislate over people’s sexual behaviour.

For example (and it is only one example), there are many women who have no option but to have sex in exchange for money or other benefits, because they have no job or because they have too low an income; they are desperate and need the money immediately; they don’t want to have sex with strange men and expose themselves to all sorts of dangers, they have no option. Do the church leaders understand any of this?

Some women find that if they apply for jobs they have to pay a substantial amount of money to secure a position. Others find that they are expected to sleep with their boss in order to be selected for a job, to keep a job or to improve their income, sometimes very slightly. Is this even a viable alternative to commercial sex work? I don’t think so.

So if church leaders are concerned about people’s behaviour, sexual or otherwise, they should take a look at people’s circumstances, the way people live. No matter how devout people are, they need to provide for their family, for their dependents and for themselves. To criticize the pope and other church leaders for failing to see this is not polemic. Preachings that are manufactured in one of the richest states in the world have little relevance to the lives of people in the poorest states in the world.

Church leaders, firstly, take a look at the realities of people’s lives, engage with the real problems, not the ones you wish to prognosticate over; secondly, make your prognostications clear and unambiguous; thirdly, engage with debates honestly, don’t resort to the lies and fabrication which you have relied on for so long.

If you want the respect and obedience of your followers you have to earn it.

The Nigerian bishop also makes a comment about Africa being used as “a guinea pig of foreign business ventures”. This is a valid point but Africa is just as much a ‘market’ and a ‘business venture’ for the churches, too. The churches also come up with slogans and marketing campaigns because they are also businesses who stand to gain or lose large amounts of money. They compete with other business, though they may see themselves as being above business and commerce.

Finally, the bishop makes the often made remark about distributing condoms increasing the “sexual waywardness of the continents’ [sic] youth who have access to it” and promoting “sexual recklessness”. Despite the claims of various churches, distributing condoms, teaching children about sex and safe sex and various other measures, does not give rise to higher levels of unsafe sexual behaviour. On the contrary, children who know about sex and safe sex delay having sex for the first time and are more likely to take precautions when they do have sex.

If the churches really have compassion, if they really care about the welfare of their followers, they need to look at how people live, how their behaviour and sexual behaviour are determined. Human dignity is not about doctrine and dogma, it is about basic human rights. People are being denied their rights and the church would do well to address this issue, rather than shoring up their dubious philosophies with pseudo scientific claptrap.

Of course, church leaders could lead by example, observing vows of poverty, chastity and obedience, for instance. But many seem to have chosen to live in wealth. Their chastity has often been open to question. And their obedience often appears to be to political interests, commercial interests and even human desires for power, sexual gratification, etc, rather than to any spiritual authority.

Church leaders, come and live like the majority of human beings and you’ll find yourselves rewriting your vast tomes in a language that most people will readily understand.


Thursday, May 21, 2009

Last Night, Condoms Saved Many Lives

IRIN (Integrated Regional Information Networks) had an article recently about Tanzanian bars and nightclubs getting condom vending machines soon. These machines would be placed in toilets as part of the national HIV prevention programme.

From reading HIV literature over the years, you would have thought there would already be dispensers in all bars, clubs, restaurants, hotels and anywhere else possible. But that is not the case. I have stayed in over 50 low budget hotels, eaten in over 100 restaurants, drunk in nearly as many bars and been to plenty of nightclubs and other places where people gather. And very few of them had an obvious supply of condoms.

Occasionally, when you are leaving a nightclub or late opening venue, you will find an enterprising stallholder outside, selling condoms. A little more frequently, you will see a box of condoms or even a selection of brands behind bars. I have little doubt that if you asked in some places you would get condoms.

Recently I stayed in a hotel and happened to open a drawer to find over 100 unbranded (donor supplied) condoms in an unmarked bag. Wonderful, except that they were manufactured in 2004 and will all expire in August.

But the problem is that people often don’t ask for condoms, for various reasons. And I’ve tried asking in some places, without success. As a result, people can be without condoms when it is too late to turn back. Or they are stuck with a vendor who only has expensive brands, so they don’t bother.

Condoms are too important to leave to chance. It’s true that they are an individual’s responsibility. But not everyone thinks of them at the right time; you can be taken by surprise and not everyone is as responsible as they should be. The Tanzanian programme is starting in Dar es Salaam, the commercial capital. But this is one place where you are much more likely to be able to find condoms, especially late at night. Let's hope the programme moves away from the capital to where the need for condoms and condom related education is far more urgent.

A young man who works for a HIV/Aids related community based organization recently told me that he thinks the only thing standing between Kenya and a far more serious HIV epidemic is condoms. He is a Muslim, a faith opposed to the use of condoms. But he works with people who are poor and marginalized. He knows a lot about why HIV spreads and he knows a lot about preventing it from spreading further.

It's not enough for people to be able to see the numerous signs and billboards about HIV and condoms, they need to be able to see the condoms, they need to know where to get them. And the times and places people are most likely to need condoms are no secret. People go to bars, clubs and other places to meet up with other people and have fun. Sometimes having fun involves having sex. Denying that this happens or arguing that it shouldn't happen is not going to prevent transmission of HIV, other sexually transmitted infections or unplanned pregnancies.

A reliable and accessible supply of condoms should become part of the country's national infrastructure. Yet, you still come across people who say they don't see them as much any more or you don't hear about them as much or they subscribe to one of the many myths about condoms not working or having holes in them that let viruses through. They do not have holes in them and they do work.

Of course they are not 100% safe. People say the only thing that is 100% safe is abstinence. The problem is that abstinence does not always work. People can have the best intentions but find themselves in a position where they are unable or unwilling to keep to them. The decision to abstain does not remove the possibility of circumstances and temptations.

I hope Tanzania and other African countries with a HIV epidemic, 'serious' or otherwise, make condoms more obviously available. This is one of the most important steps towards reducing transmission of HIV, sexually transmitted infections and unplanned pregnancies. To those who think that to promote condoms is to promote promiscuity I would say this: some people are promiscuous and until there is a feasible means of reducing promiscuity, condoms are one of the few things they have got to protect themselves from becoming infected and from infecting others with sexually transmitted infections.


Tuesday, May 19, 2009

Appeal For Help

Dear readers and followers of the HIV in Kenya blog:

I have been studying and travelling around East Africa for the last 14 months. During that time I have been looking for work, preferably HIV related work. However, I have not yet found an organisation that can support me to work here.

I don't need a salary or large expenses, just help with day to day living. But the most important thing is getting a working visa. This is difficult and expensive and only some organisations are able to obtain these visas, even for voluntary workers.

I don't have a background in public health but I have been studying HIV for some time and would very much like to continue in the field. I am particularly interested in HIV prevention but I would consider any work in development.

The working environment is not an issue, whether urban, rural, slum, refugee camp, etc.

If anyone knows of any organisations that have an immediate need for volunteers to work in HIV related work I would love to hear from them.

Thank you in anticipation.


Monday, May 18, 2009

Isiolo Youth Against Aids and Poverty

I have just had the pleasure of visiting Isiolo, a few hundred kilometres North East of Nairobi in the Eastern Province. From the time I got on the bus to Isiolo, it felt like being in a different country. The bus was filled with people who look different, sound different, play different music and chew miraa all the time. As you leave the more fertile central areas of Kenya, which consist of green fields of intensively farmed crops and rather less green horticultural polytunnels, everything becomes a bit more dusty. Eventually, there are a lot of dry plains, dotted with steep volcanic hills and thorny, low level trees and bushes.

And when you arrive in Isiolo, you really are in a different country. You have left the people who mostly think of their 'tribes' around election time and meet people whose lives are affected by tribal disagreements on a more regular basis. There are still abandoned houses and farms from the last serious land, property and livestock disputes. Many owners have left the area, often for the cities, especially Nairobi. The area is a tough environment for people to live in and to gain a living from. It is mainly pastoralist, although some people are now trying to diversify and depend less on herding animals.

I went to Isiolo to visit a group of people I met, by accident, in Dar es Salaam. They run a voluntary counselling and testing (VCT) centre in the town. We exchanged notes about Kenya, HIV and various other matters. The people invited me to visit and I did. I was met off the bus and taken to the home of some of the IYAP (Isiolo Youth Against Aids and Poverty) members, where I was to stay for my time in the town. I have been to the houses of various other members and been fed and watered thoroughly. If I hadn't already developed an ugali (and beer) belly this would have been a good opportunity (although I drank no beer there).

IYAP's VCT is located in a region where, for cultural reasons, sex is not talked about. Not that that is so unusual in East Africa, but people are even less likely to talk about sex in more Northern regions than in other areas. Clothing, behaviour, manners and lifestyles are less influenced by Western values than they are in the cities and even other rural areas. So the VCT often has to go out into the community to mobilise people, raise awareness about HIV and about the availability of counselling, testing, support and treatment for those infected.

There have been limited mobile VCT facilities available in Kenya for some time but they don't seem to penetrate the most isolated areas. In fact, I have only seen specialised mobile units in urban areas where there are already fixed facilities. But IYAP organises what are called 'moonlight' clinics as well. They go to isolated areas at night and people can turn up in the cover of darkness. It sounds like a desperate measure. But in isolated areas, most people know all of their neighbours. There is little opportunity to visit a VCT clinic without many other people knowing that you have been there.

In fact, all over the world there are people who are naturally shy about the possibility that everyone in the neighbourhood could end up knowing what they are doing. I don't tell everyone I know when I've been for a HIV test and I don't think my friends and acquaintances do, either. But in many parts of East Africa, the very admission that you may be at risk of being infected with HIV can have serious social consequences. People from the area do not openly associate with sex workers. Sex workers themselves are neither talked to nor talked about by many. They are outcast, regardless of the fact that they may have become sex workers because of circumstances beyond their control. As for their clients, they always seem to be above reproach.

But not all things are so different in Isiolo than in many other parts of East Africa and probably many other countries. Sex is a difficult subject in Ireland, where I come from and the UK, where I have lived for many years. Few people talk frankly about their sexual experiences to anyone and everyone. Few would expose their private lives to the censure of all those around them, friends, family, employers, peers, neighbours, etc. And why should they? People are entitled to privacy, even if they live in closely knit communities.

Isiolo, and Eastern Province in general, are home to some of Kenya's poorest people. Together, Eastern and North Eastern Provinces have long been marginalised while Nairobi and Central Provinces have seen most of the benefits of economic growth, and even the large amounts of donor money that comes into the country. This is not to say that there are no poor people in the well off provinces. On the contrary, the majority of people are poor, even in Central and Nairobi. But people in Eastern Province feel they have been overlooked and forgotten. And I think they are right to.

IYAP is one of several organisations in the area that concerns itself with poverty, poor health and inequality, some of the very things that drive the HIV epidemic. As well as providing VCT, sex information, support for those with HIV and those who are in danger of being infected, IYAP work with other local groups, such as women’s' groups, giving them advice and support, helping them raise funds and advocating for their interests.

It is difficult to please everyone when doing this kind of work. Some religious leaders see the sexual behaviour of their people as a religious matter. Politicians see community based organisations and NGOs as either for or against their interests. Older people see young people as in need of education and experience; they don't think they have anything to learn from the young. So a youth based organisation is viewed with suspicion by some. But that is what makes the work organisations like IYAP do so special. It is not easy to go against the current, especially in small and traditional community. But over time they have gained some of the respect they deserve.

The work that IYAP and other similar organisations do is vitally important for the future of Kenya and other developing countries. Let’s hope they are allow and enabled to continue working to reduce poverty, inequality, injustice, prejudice and bad health.


Sunday, May 17, 2009

The Money Follows the Hype

I was reading a social and economic profile of the area I’m currently visiting, Isiolo, in Eastern Province, Kenya. Close to the end of the profile, it was stated that donor funding is usually followed by government development funding. Therefore, the development priorities of donors strongly influence the priorities of the Kenyan government. Anything not considered a priority receives very little funding from donors, but also from the government.

This leads to the ridiculous situation where far more children, mainly in developing countries, are dying from diarrhoeal diseases than from HIV, TB and malaria combined. Yet only $1.5bn was spent on developing water and sanitation in the years 2004-2006. In the same period, $10.8bn was spent on HIV/Aids. 1.8m children worldwide died of diarrhoea whereas only around 300,000 children died of HIV/Aids.

I want to draw attention to two separate issues here (without wanting to suggest that they are the only two issues!): there is the problem of donors fixating on certain problems and throwing huge amounts of money at interventions that often have little effect; then there is the issue of governments in countries like Kenya failing to target their most serious problems.

I think I can see why donors are so interested in HIV/Aids to the exclusion of almost anything else. They are often led by a powerful media and a powerful public that is also led by a powerful media. Being cool, up to date, with it, sexy, whatever the current term is, these are more important than any real issue. The mere fact that people are sick and dying is irrelevant.

But this doesn’t excuse governments from duplicating the work of donors by adopting the same priorities. Surely they see the many other far more pressing problems that are facing people every day? The fixation on HIV/Aids distorts the way countries allocate funding, it distorts the work that is carried out in the name of development and it distorts the way developing countries allocate their scarce financial resources. There is a distinct lack of autonomy and accountability here; why should an electorate accept the fact that foreign owned institutions with single and narrow interests have far more influence on their lives than their own governments?

HIV/Aids is just one disease of many and one sexually transmitted infection of many. Water and sanitation, in contrast, is vital to life. Diarrhoea is not a disease, it is a symptom, just one symptom of numerous conditions, many of which are caused by a lack of access to clean water and safe sanitation. If wealthy governments and NGOs want to address the most pressing issues they shouldn’t have far to go to find them. But it is not acceptable for them to just react to what is cool in the world of media, hype and political posturing.

Of course HIV/Aids is important, it’s just that people won’t live long enough to be infected or, if infected, they won’t live long enough to die from Aids if they don’t have other things such as adequate nutrition, water and sanitation, basic health and education and many other social services. Fighting HIV/Aids depends on developing countries having the capacity to provide these services first; they are not just optional extras or issues that can be dealt with later.

It’s true that we can’t easily solve the world’s major problems, such as hunger, poverty, lack of social services, disease, inequality, etc. But that doesn’t mean we should do nothing. Some of the money that now goes into dubious HIV prevention programmes could wipe out cholera in many countries, thus massively reducing mortality among children and infants. A fraction of the money that is being wasted on unproven agricultural technology, such as genetically modified organisms, could provide a sustainable solution to food shortages in many countries. The tens of billions that are proposed to fund the provision of one laptop to every child in developing countries could save several thousand children’s lives every day for the foreseeable future.

An estimated 10 million young children die every year from poverty related problems. These are serious problems and they will not go away soon. But there is a lot of money and capacity being wasted on things that are not nearly as urgent. No one would be stupid enough to spend all their money on HIV education for a child that is dying or may die of cholera or something equally easy to prevent or cure. We need to get away from the politics and media hype surrounding HIV/Aids and see that some of the problems people face in developing countries are much more basic and not quite so intractable.


Saturday, May 16, 2009

Moonlighting in Isiolo

I have observed VCT (voluntary counselling and testing) HIV clinics in various settings and various towns but last night I went to see a 'moonlight' clinic for the first time. Many people are cautious about going to the town VCT, for various reasons. So someone came up with the idea of running the clinics at night.

My friends who run Isiolo Youth Against Aids and Poverty set up the moonlight clinic in the centre of town. They placed themselves strategically near the biggest and busiest bars and clubs, where people wander around at night. The loud music and announcements from the PA system attract people, some of whom just watch or dance to the music, many of whom want to be tested.

There was something of a carnival atmosphere, with street children (sniffing glue), people working in the area (chewing miraa), drinkers, late night shoppers and miraa vendors all coming along to have a look.

More importantly, the clinic attracted as many people as they had the capacity to test, so the exercise was well worth the effort. Most of the people who turned up were in their twenties and there were a lot more men than women. This contrasts with other contexts, where far more women than men get tested. Some of the people were older, as old as fifty, and some were below 20. No one admitted to being below 18, but some of the girls looked a lot younger.

Around the corner there are several bars and a club. Women and girls (but mainly girls) walk up and down the street, some stand outside the bars, others go inside the bars; the men sit or stand around searching and waiting. There are lots of motorbikes, ready to transport people to wherever they want to go.

IYAP is a community based organisation that provides VCT and various other services for people who may be or are infected with HIV. The organisation also works with poor people, young people and sex workers. They aim to address the problems that people face in their everyday lives that may put them in danger, whether the danger is HIV, sexually transmitted infections, poverty, discrimination or anything else.

It may seem obvious that people are afraid to be tested or don't want others to know they are being tested for HIV but many clinics are static and make little or no provision for going out into the community to try to persuade more people to be tested. It is only recently that mobile units have been implemented in some areas, most areas don't have them yet.

It may also seem obvious that there are very different circumstances surrounding the transmission of HIV in different locations. There is sex tourism in Mombasa and on the coast, there are labour practices that are involved in transmission around the Mumias sugar growing area, the Kericho tea growing area and the Naivasha horticulture area, Nairobi is a big city, where people go to look for work, the borders are notorious for holdups that give rise to truckers and other drivers spending much of their time being bored, drinking and hanging out in bars.

Here in Isiolo, there are different pastoralist tribes, often forced to radically change the way they live because of political interference, civil disturbance, poverty, water shortages and other problems. The town has a big army barracks, many traders coming and going, it's on a major trucking route, there is a high level of poverty and there are very few jobs or opportunities for most people; these are just some of the issues involved.

IYAP, being an indegenous organisation, are well aware of the sort of things people face. They know most of the people that live in the town. And they go out into the community and talk to people who are very often ignored; street children, sex workers, alcoholics and homeless people, for example.

There are huge amounts of money coming into Kenya and other countries with serious HIV epidemics but little of this money seems to go to addressing the circumstances that result in people becoming vulnerable to HIV and other diseases, that result in people being poor and desperate.

Every village, town, city and rural area in the country has a different set of problems. Therefore the solutions need to address these specific problems, not the problems that donors think are most important.

HIV transmission is not just about people having sex or having too much sex or having sex with too many people; it is about people's lives, their circumstances, their vulnerabilities, poverty, hunger, poor water and sanitation, bad health, poor education and social services, inequality and discrimination.


Thursday, May 14, 2009

Islands of Deception

Are the president, prime minister and sitting MPs of Kenya aware that there are things happening in Kenya that are far more important than the ownership of a small island in Lake Victoria? In Uganda, too, this island is not really a priority. Both countries have large numbers of poor people, internally displaced people, sick people, children out of school, environmental problems and numerous other problems.

For example, both countries have a serious and worsening HIV epidemic. Prevalence stands at over 7% in Kenya and has been increasing for several years. Prevalence is under 6% in Uganda but there signs that it is increasing and the safe sex messages of the nineties are being forgotten.

Kenya and Uganda rank 127th and 132nd in the gender development index, suggesting that they have done little to improve the status and conditions of women and girls. In Kenya, only 7% of parliament seats were held by women in 2007. The figure was nearly 30% in Uganda. But the gap between female and male earnings is bigger in Uganda.

Health in general is poor in both countries. Expenditure on health is 1.8% in Kenya and 2.5% in Uganda, both figures well below an ideal target of 15% of GDP. There are hundreds of thousands of children still not receiving immunisation to TB and childhood diseases. The figures are especially high for the poorest Kenyans and Ugandans.

Infant mortality and under five morality are very high. These figures have only reduced a little since the nineteen seventies and, in some cases, have increased after an initial drop. Life expectancy is around 50 or below in both countries, despite showing improvements after independence. Again, the situation is far worse for the poorest people.

There are 14 doctors per 100,000 people in Kenya, only 8 in Uganda. 20% or fewer births are attended by skilled health personnel in the poorest sectors of society. Unsurprisingly, percentages of low birthweight, underweight and underheight children are high, as is undernourishment.

Uganda fares a bit better than Kenya in that only 37% of the population lives below the poverty line compared to over 50% in Kenya. But the level of inequality, the difference between the rich and poorest people, is higher in Uganda as well. In terms of gross domestic product and human development, Kenya fares better than Uganda but neither countries have much good news for the majority of their citizens.

Military expenditure is higher than health expenditure in both countries, despite both countries being, nominally, not at war. But Kenya has its simmering disputes, such as the ongoing battles among pastoralists in the north, the land disputes around Mount Elgon in the West and the various tribal disagreements. Although there is technically no war in Kenya, the police act as judge, jury and executioner; shootings and beatings are very common but how common is hard to say. No one is counting.

Both Kenya an Uganda have adult and youth literacy problems. For various reasons, many children are not at school or their attendance is poor. The aim to send every child to school is not being matched by adequate numbers of teachers or resources and many families cannot afford the costs. Some cannot afford to have all their children at school and some of them have to work. The ones who go out to work or stay at home to work are almost always female.

Many people, especially women, have little regular access to media such as TV, radio or newspapers. Access to mobile phones is often good and highly publicised, but access to electricity can be low. As for credit, many carry phones that can receive, if they have friends who have credit. Internet use is very low, despite much publicised increases. Infrastructure is too weak and people's knowledge of and access to technology is low.

Improvements in technology, communications and other things would be great but no one is worrying as long as they have no access to clean water and good sanitation. People who are dying of easily prevented and treated conditions, such as diarrhoea, have little use for high technology. As access to electricity is low for both countries, technology is almost irrelevant to many. Ok, many have access to electricity, but only in between the frequent power cuts.

If these overpaid, undertaxed Kenyans and Ugandans can't find things to do with their time, perhaps they should be introduced to their electorate. They don't seem to know much about them. But ordinary Kenyans and Ugandans will be able to find enough work to keep them occupied until the next elections. There probably isn't enough work to justify their inflated salaries but I think they could gain a lot of good will, perhaps even the confidence of their electorate.


Thursday, May 7, 2009

More of the Basics, Please

A recent report concludes that road traffic accidents (RTA) kill more people than malaria and recommends a worldwide improvement in road safety. RTAs kill 1.3 million, compared with 1 million deaths from malaria. The report authors estimate that a $300 million investment in road improvements, campaigns and more traffic police could save 5 million lives over a 10 year period. The cost of RTAs worldwide is estimated at $100 billion.

I took a bus from Arusha to Nairobi yesterday and most of the journey was on temporary roads, disintegrating roads and congested roads. It wasn’t the worst journey I have ever made in East Africa but it was fairly typical. There were many dangers and we passed many accident scenes, the usual story.

However, it seems ironic that the report recommends more traffic police. Vehicles are stopped every few kilometres by traffic police. In fact, they are a major cost for drivers and they simply slow everyone down, they don’t actually prevent accidents. The police are only interested in collecting the ‘revenue’ that drivers and conductors surreptitiously hand to them as they pass.

And if traffic police don’t ensure that people keep to the rules of the road, a campaign to raise awareness will be of little use. As for improving the roads, that may only result in people going faster. That sounds very defeatist and I don’t wish to be defeatist. I think road and other infrastructure improvements are vital. But there are other problems on the roads aside from their terrible state.

As for public spending on infrastructure, much of that is controlled by donors, such as the World Bank and the IMF (International Monetary Fund). They have for a long time been reducing the amount spent on infrastructure projects, social services, health, education and what not. They have applied wage caps for public sector workers, so even where facilities can be built, they are not usually supplied with enough of the requisite staff, resources or anything else needed to operate.

Improvements in roads and other infrastructure would have many benefits, in addition to reducing RTAs. Many businesses are struggling to distribute or sell their products because they are isolated by lack of good roads. Many areas don’t have any businesses or trade with the outside world because they are just not connected by road, rail, air or anything else; water and electricity supplies are infrequent or non-existent.

Another article considers the level of disaster preparedness in developing countries and finds it ‘woefully inadequate’. When that petrol tanker exploded in the Kenyan Rift Valley, partly as a result of the country’s poor infrastructure, there were predictable problems getting emergency services there and getting people to hospitals quickly. When Nakumatt was on fire, there were problems getting to the site, getting enough water and directing people away from the fire area safely.

Supposing large consignments of drugs are needed in isolated areas, say antiretroviral drugs, the cost of getting those drugs to the people who need them is made up to a large extent of the logistics of the exercise. Many antiretroviral and other drugs are funded by donors and a large part of the money will go on providing ad hoc and often temporary infrastructure. The health professionals that are needed to ensure the proper distribution and use of these drugs are also let down by the lack of infrastructure.

If a disease were to start spreading rapidly in Kenya, or any other developing country, it could spread far and wide before much could be done, perhaps even before anyone would notice. Some countries are expected to have a problem identifying diseases that have flu-like symptoms because there are so many of them. But a lot of health and other disasters could be averted if the country’s resilience were to be improved substantially. However, in the past in Kenya, people's immediate needs have been ignored and everything is left until it becomes a crisis. This which must be the most inefficient and expensive way of doing things.

Incidentally, there is a lot of hype at the moment about the new high speed internet connection that should cover the whole of Kenya some time in the middle of this year. It would be great if such coverage were to be achieved. But it seems unlikely to solve internet connection problems if the country continues to experience long periods of insufficient or unreliable power supply. Reliable power supply would seem to be a more immediate need than a high speed internet connection and it certainly needs to be in place for the internet connection to be of any use.

There may be a lot of scope for mobile internet but there are a lot of problems with mobile phones that need to be ironed out first, including the electricity supply problem. But what I find surprising is the number of people who hardly ever use the internet or who have never used it. Literacy and school achievement in some areas are very low. And the fact that many people can access the mobile internet does not mean that low literacy and academic achievement will become a thing of the past. I’m all for technology, I spent many years as an IT consultant, but it needs to be appropriate and people’s immediate needs have to be addressed. Development must not be dominated by a purely commercial agenda.

Give people more of the basics, more of the things they need immediately; things like roads, water, electricity, health, education and social services. Once they have these, the advanced technologies may have a place in developing countries.


Monday, May 4, 2009

Is the Catholic Church Afraid that Condoms May Work?

Recent research into condom use by adolescent males in Nairobi, Kenya, shows that the majority of participants in an online HIV awareness project did not use condoms the first time they had sex (69.9%). About half used a condom the last time they had sex but only one third use condoms most or all of the time.

Over 85% of these respondents were Christian; over two thirds were from middle or high income households; they were all attending secondary school; they were aged over 15 but the average age at first sex was just under 13 years old; nearly three quarters had already had 2 or more sexual partners.

It’s not as if we needed evidence that young people have sex, unsafe sex or sex at a very young age. We can fool ourselves that education is the key to preventing or reducing this sort of behaviour, but we have known for a long time that education on its own has little effect on sexual behaviour. Nor does wealth guarantee later sexual debut or safer sexual behaviour; the contrary may be more accurate.

Those who think that sex education is not appropriate for young people need to bear in mind what age many young people are when they start having sex. If they think sex education is only appropriate for those in their later teens, they will be too late for many.

It is also a mistake to think that children in their early teens do not need to know about condoms. Teenagers who have begun their sex lives without using condoms are less likely to use them later on. But those who use condoms the first time they have sex are more likely to continue doing so on all or most occasions. Learning about safe sex and condoms early on is a good thing.

Teaching children about abstaining from sex or delaying sexual initiation is also a good thing. Those who start sex at a later age are more likely to use condoms and are likely to behave more responsibly if they have received a good sex education. But if you teach children about abstaining from sex you need to tell them what sex is. They need to know many things so this is also a good time to tell them about condoms. They need to know about sex in order to abstain or even delay their sexual debut. If they don’t know much about sex, they will not know what to abstain from of what to delay.

The Catholic Church has a time honoured way of dealing with things that don’t fit its purposes (whether they be doctrinal, political, economic or whatever else): they say nothing or they lie. The church leader’s recent outburst about condoms making the HIV epidemic worse has been treated to amendments by those who surround him and he has done nothing to set the record straight. Perhaps in his eyes the record is already straight.

Since the HIV epidemic started, the Catholic and other Christian churches have done everything possible to frustrate the attempts of health professionals and others to prevent the spread of HIV, sexually transmitted infections (STI) and unwanted pregnancies. They have lied and pontificated about an interpretation of Christian morality that would see people suffer and die rather than ‘sin’. Even those who don’t do the sinning must suffer and die rather than allow ‘sin’ to occur.

Respondents in the survey hold views that are hard to reconcile. Well, who doesn’t hold views that are difficult to reconcile? So, over half believe HIV is a problem in Nairobi, but over 85% believe that their chance of being infected is 50% or less. They think HIV is a problem but they don’t think it’s a problem for them.

More worryingly, slightly under 40% believe that condoms prevent HIV. Thankfully, three quarters believe that condoms prevent pregnancy. But over 45% of respondents say that condoms often break. This suggests a need for more education on how to use condoms safely and perhaps even some work on ascertaining the quality of condoms that are available to people. Many of the condoms available to young people are donated by wealthy Western countries.

But despite so many thinking that condoms break or don’t prevent HIV or pregnancy, at least some of the same people still use them. The fact is, there isn’t much else available to prevent HIV. Of course, if people abstain from sex they are not at high risk of contracting HIV. That’s as long as they always get to choose whether or not to have sex, a questionable assumption. But most people will have sex eventually and waiting till you are married as a strategy has been well discredited over the years.

People living in a high HIV prevalence country like Kenya who think that they are not at risk of contracting HIV should consider the risk of those around them. They have sex with those around them, therefore they themselves are at risk. And if they don’t worry about HIV, they need to be reminded about other STIs, such as herpes, gonorrhoea, syphilis, chlamydia, genital warts and any others. Some STIs are far more common in Kenya than HIV. Some are also incurable and many put one at increased risk of contracting HIV.

People should also consider the risk of early pregnancy. Girls who get pregnant when they are still at school are, typically, excluded from school until they have given birth. They are said to be a bad example to the other students including, presumably, the one who made her pregnant. Once excluded from school, many girls never return. Early pregnancy has many social consequences and the value of the condom for reducing HIV and other STIs should not overshadow the value of the condom as a contraceptive.

It’s time for the Catholic and other Christian churches to see that children (as well as adults) are at risk of HIV, other STIs and early and unwanted pregnancies. They need all the help they can get and they certainly don’t need contradictory messages about the fact that they face many risks. They also need to be clear about the steps they can take to reduce their risk. If they are completely free to choose their sexual experiences and how those experiences take place, they are lucky. But even if they are not lucky, they can still take care.

To preach against the use of condoms is to expose people to unwanted pregnancy, deadly disease, suffering and numerous direct and indirect social consequences. To state one’s doctrine is fine, but don’t use lies to back it up and to scare people into doing what suits that doctrine.


Saturday, May 2, 2009

Fakes, Counterfeits, Used Goods, Generics and Hazards

There was a confused and confusing article in Tanzania's Daily News on Thursday. It starts off with an account of how much tax revenue the government loses as a result of counterfeit and substandard goods. For a start, I don't think it is because goods are substandard that tax is withheld, but no matter; the country badly needs tax revenue and everyone should be protected from substandard goods.

But if the Tanzanian government is so worried about tax revenue, they should take a careful look at the foreign owned extractive industries. They make huge profits and they legitimately pay very little tax or duty. But many who don't even bother paying anything at all. In fact, indigenous industrialists cannot compete against the benefits that foreign owned businesses enjoy. I guess that's the 'free market', which penalises small businesses and rewards big, foreign multinationals. Indigenous businesses are asking for fairness, not protection.

In Kenya, the government could take a look at its cut flower and horticulture sector, much of it foreign owned. Many of the company owners neither pay tax in Kenya nor in any other country. In fact, both Kenya an dTanzania need advice on raising revenue. So perhaps they could ask leaders of the burgeoning Christian church industry, which extracts punitive levels of dues from the poorest people in East Africa. Just an idea.

The article purports to be about counterfeiting. However, it fails to distinguish between counterfeit products, used goods, generic products and fake products, even hazardous products. If I put a brand name on a product and try to pass it off as genuine, that's a counterfeit. If I produce an equivalent product with a different brand name, that's a generic. Goods that have already been used are used goods, of course. And if I produce something that doesn't do what it purports to do, that's a fake. Thus, the newspaper’s photo of a 'fake pair of shoes' really depicts shoes that may be counterfeit or they may be generic. I doubt if they are fake. A hazardous product would be something like the malaria pills that have been found to have no active ingredients.

The recently passed Kenya Counterfeit Bill also fails to distinguish between these basic concepts. It is legitimate to charge 100 dollars for a pair of shoes that have a particular logo on them if you are the owner of that piece of intellectual property. The fact that the shoes cost less than 5 dollars to make (in a sweatshop that pays peanuts to underage employees) and could profitably be sold for 10 dollars, is irrelevant. These overpriced shoes could also be substandard, but this affects the consumer, not government tax revenue.

If you have an income of between 30 and 60 dollars a month, you won't be buying the 'genuine' article. You may buy something second hand, a generic equivalent, a counterfeit version, whatever. People produce generics and counterfeits because there is a market for them. The market for cheap products is created by the existence of overpriced goods that can only charge these inflated prices because intellectual property laws protect intellectual property owners. They claim to protect consumers but, in fact, they only protect consumers who can afford the inflated prices.

Wealthy and very greedy multinationals create the market that results in the production of cheaper goods and that guarantees that they will often be bought in preference to 'genuine' goods. Ironically, the 'deregulation' insisted on by international financial institutions and by free market dogmatists also means that national governments have very little control over trade. But unfortunately, the same laws that were designed to protect people from dangerous goods, poor working conditions, exploitation, etc, also fell under the hatchet of 'deregulation'. Countries didn't suddenly become lawless, as this article would have us believe; they were rendered lawless by the growth of globalization and other ideologies.

Consumers need to be protected from fake products that don't do any good or ones that do harm. That's true whether they be branded products, generics, counterfeits or second hand goods. People also need to be protected from trade practices that favour rich multinationals over poor consumers. Labour forces need to be protected from unscrupulous employers who expose them to physical danger, exploitation, long hours, low pay and casualisation. Why single out a few objectionable practices and ignore others?

The deception involved in calling a radio Sqny or Phillips may really deceive, though I doubt it. The consumer gets a product they can afford and the owners of the intellectual property don't. Perhaps they could consider reducing their prices. They don't pay much in wages and they do very well but they seem to want to price themselves out of the market and, at the same time, penalise anyone else who tries to take up the business that they themselves don't seem to want.

But personally, I object to the deception of charging 100 dollars for a pair of shoes that could cost a lot less. The price, protected by international laws, hangs on people valuing a particular fashion. Great, if they can pay for it. If they can't, they just need shoes and there are people willing to supply them. There is more than one deception here and I’m out of sympathy with the owner of the ubiquitous smudge that happens to be their logo.

And on the subject of fakes, products purporting to be something they are not, there's an article in Kenya's Saturday Nation about genetically modified maize (GM) possibly making up 90% of the maize imported into the country every year. Maize is the country's staple food but, apparently, Kenyan's don't know they are eating GM maize. There is a deception here that seems far more significant than a mere name, brand or logo. People are entitled to make the choice as to whether they consume GM products and it sounds as if they are not being given that choice in Kenya at present.

Kenya has also just passed a Biosafety Act, to allow the safe use of GM crops. But it seems a bit late if the market is already swamped with contaminated foods. If regulations are such that it's not even certain how much of the country's imports are GM, there is already a serious problem. How much GM food has been distributed, to whom and what has it been used for? If people have used GM foods to try to grow crops, they will be in trouble when the owners of those technologies find out, they will have to pay for the 'privilege'. And many GM seeds will not germinate. Right now, crops are failing because of low levels of rainfall. In the future, will crops fail because they are 'terminator' crops, ones designed so that the seed cannot be collected and used for the next season?

It's a dangerous trick. GM products are hazardous in the sense that their safety has never been demonstrated but sneaking them in without people's knowledge, even if there is a low concentration of GM organisms, only increases the danger further.

There are many threats to our welfare and safety, often masquerading as 'genuine', 'approved' and 'legal'. Consumers need legislation that protects them, not legislation designed to allow certain producers to maximise and protect their profits at all costs.