Saturday, January 30, 2010

Let Them Drink Sewage, As Long As They Buy Our Drugs

There's a suburb, a slum area, not far South of the town of Nakuru and it always smells bad. Well, perhaps all slums smell bad, but some smell worse than others. As you walk through the main street of Kaptembwa, there are deep trenches at the side of the road, apparently having something to do with the 'sewage system!. But all around, there is stagnant water and raw sewage. When there is a lot of rain, this effluent flows through the streets and even into people's houses. It also mixes with the water supply, such as it is.

I don't know how long Kaptembwa has been like this. People who have been there a long time say there has never been any proper sewage disposal. Now, children play in foul smelling puddles, with terrible consequences for their health. Adults also have to walk through the mess and put up with the smell, the dirt and even the diseases.

Places like Kaptembwa are ideal breeding grounds for water borne diseases. You could vaccinate every child against something like rotavirus and you would still have lots of them sickening and dying of water borne diseases. Both the children and the adults living in such areas need adequate sanitation and reliable supplies of clean water. No amount of vaccine will get rid of the health hazards caused by such conditions.

But also, people are entitled to some level of dignity. They should not have to live in dreadful and threatening conditions. Those who claim to be concerned about their health should consider these conditions first, not the headline grabbing but ultimately weak solution of vaccines or drugs. People shouldn't have to drink water that smells of sewage.

But for some reason, rotavirus vaccine has been much reported recently. Perhaps it's because the Gates Foundation has mentioned the development of the vaccine as one of their primary goals, perhaps it's because the pharmaceutical companies who are behind this lucrative prospect are good at issuing press releases. Journalists are certainly good at citing press releases, regardless of the levels of sales puff they may contain.

Among the three articles I came across today about Gates, Glaxo Smith Kline (and others) and their rotavirus vaccines, all say very little about water and sanitation. They ooze on about how brilliant all this medical technology is but they don't mention, or are not quoted as mentioning, that vaccines will be useless without high levels of spending on water and sanitation infrastructure. It could be wondered if all these groupies care, one way or the other, about how people are forced to live.

One of these articles cites an academic as saying that vaccines "represent the best hope for preventing the severe consequences of rotavirus infection". There is probably a sense in which this 'expert' is right but failing to mention water and sanitation renders the statement hot air. Vague mention is made of water and sanitation in the other articles but the focus is on the vaccine, as if children who are suffering from poor nutrition, multiple vitamin deficiencies and various parasites are going to be magically made healthy by a vaccination for one of the many water borne conditions that are endemic in developing countries.

One of the articles even mentions some the problems of rolling out large scale vaccinations, and the rotavirus vaccine in particular, in countries that have poor health systems and inadequate infrastructure. This article even mentions the high cost of vaccination programmes. Why is it that the Gates Foundation and other institutions don't seem to mind high costs when the main beneficiaries are pharmaceutical companies and other rich establishments?

All the articles list figures for how many lives could be saved by a rotavirus vaccine and the usual sort of stuff. But they don't list the figures for how many lives could be saved by spending money on a cheaper but far more urgent way of reducing deaths from water and sanitation related causes. I can't think why.


Thursday, January 28, 2010

Religion and Health: Interference or Complementarity

Following my speculations about why some people seem to imagine that they can be made very rich by a miracle, a friend sent me an article entitled Religion, Spirituality, and Medicine. This article is a "comprehensive, though not systematic, review of the empirical evidence and ethical issues" and concludes that "the evidence of an association between religion, spirituality, and health is weak and inconsistent".

Perhaps more importantly, the authors question the ethics of mixing religion and medicine, a question that would still arise even if there was stronger evidence of an association between religion and health. One could ask, which religion would a doctor recommend or agree to discuss? What would they do with someone who didn't believe in any religion? Would each medical professional require special training and what kind of special training? (The authors of the paper did not raise all these questions, but they arise from considering the problems of combining medicine with religion).

Even if people go to a doctor without any expectation that the doctor is, to a large extent, a scientist, that doctor is obliged to do things that are supported by scientific evidence and avoid things that are not so supported. The fields of science and religion are completely different and the practitioners of each field work in different ways. Is it even feasible for doctors to also become experts in religion (as if religion were just one thing!)?

If I was renting a damp room that affected my health badly, should my doctor write a letter to my landlord and ask for my conditions to be improved? Medical advice could be brought to bear on an employer who was exposing me to health risks, but this is a matter for employment laws. The doctor doesn't intervene directly. Yet we know that environmental conditions are closely connected with people's health. We know that economic circumstances are closely connected with people's health but we don't expect our doctor to recommend a pay rise. Even government health advice about healthy eating is considered to be taking things too far by some.

I accept that certain beliefs can be comforting and I certainly wouldn't suggest that people should be told what to believe and what not to believe or how to express their beliefs. If they see praying as part of their recovery from illness or as helpful in bearing an illness from which they will not recover, no one has the right to interfere. But when it comes to prescribing medication, the doctor is the expert, not the religious leader. And when it comes to praying and giving religious advice, the religious leader is the expert.

In fact, I find it exasperating that there are many churches in developing countries who don't seem to be able to make that distinction. They feel they are experts in marriage, reproduction, sexual behaviour and protecting against sexually transmitted infections (STI). They are not experts, generally they know even less than lay people and should certainly have less experience. If you can't persuade someone to give up having sex or sex outside marriage, the least you can do is tell them how to avoid becoming infected with an STI, infecting someone else with one or giving rise to an unplanned pregnancy. Otherwise, these leaders are failing to do what they can to prevent serious consequences.

If religious leaders wish to give medical advice, they had better know what they are talking about. As for advice about sexual behaviour, contraception and reducing the spread of STIs and unwanted pregnancies, many don't seem to have had a lot of success and should leave the job to someone who has the appropriate knowledge and training. In the same token, doctors should discuss religious matters with patients if they feel able to do so and if they are requested to do so but it should never be seen as a type of medical care or treatment.

If someone has a particular set of religious beliefs, presumably they hold those beliefs regardless of their health or lack of health. It seems unlikely that they just 'adopt' those beliefs in the hope that they will get well. Whether someone is religious or not, some will suffer illnesses and injuries and all will die eventually. If the 'belief' is purely conditional on their health, the person's piety would be quite questionable. So I don't see why a religious person would be interested in whether religion is in any way connected with health outcomes in the first place.


Tuesday, January 26, 2010

Poverty Breeds Religion? Religion Breeds Poverty? Both?

Firstly, I must make it clear that I don't mean to appear biased, that I am just writing from my point of view. But this is hard for me. I have no problem questioning the motives of very powerful people like Bill Gates or the ethics of multinational industries, such as pharmaceuticals or biotechnology or even those of international institutions, such as the World Bank, the International Monetary Fund (IMF) or UNAIDS. But when it comes to talking about the ordinary people that I meet and interact with every day, I realise I could sound like I'm making some pretty unwarranted assumptions.

I am trying to understand certain things here (in the world, but also in Kenya), that's partly why I'm here. I think that we in the Western world, people and institutions and practices and other entities, do a lot to impoverish people in developing countries. I have argued the point on many occasions and will do so in the future. My whole concept of 'Development by Omission' is based on many instances of this very phenomenon. But I also wonder why some people seem to choose certain kinds of impoverishment or choose not to do things that are well within their capability that may raise their living standards and those of their dependents.

Rather than giving lots of examples, though there are many, I'd like to concentrate on one. I wonder if people who see their situation as desperate turn to what can be a very extreme adherence to some religion. I'm thinking especially of Christianity, in particular the more evangelical ones, though they all seem to be evangelical here. Some people give money they can ill afford to a church, some give it to a pastor. Some even give everything they have got in the hope that a miracle will change their lives. Many pastors and churches encourage these beliefs, it's how they make their money. However, all churches depend on donations for most of their income (or wealth).

Belief in miracles seems to be very widespread, not that miracles can occur, but that anyone and everyone may well have their lives transformed if they just pray a lot and, of course, send lots of money to churches and pastors who claim to be able to make this a reality. Even if I believed that miracles can occur, I don't accept that you can simply wish them to occur, pray for them to occur and least of all pay for them to occur.

I don't see people's wish to have their lives transformed, even their wish to be very rich, as greed. I think if I had nothing I might be more likely to want a lot than I would be to want just enough. Perhaps it's because I've had enough for so long and generally find that fine, a lot would be great, but it's unlikely to feel that much better than enough. I don't wish to preach (God forbid!), I'd love to have an income or, at least, the guarantee that I will one day have an income. But for now, I'm getting by. But I'm not just talking about what people wish for, which can be indefinitely great; I'm talking about what some people seem to sincerely believe they may one day attain.

Greed is what we see in the pastors and churches themselves who extort money out of poor people with promises of great wealth. Greed is what we see in the people who spread misleading information about pyramid schemes and the like and thereby prey on poor people. Greed is the biotechnology multinationals, who want people to think they are getting a good deal when they are in fact entering a form of indentured slavery. Greed is the pharmaceutical companies who keep their prices artificially high and lobby governments of rich countries, who obligingly use public money to subsidise these products and call it aid.

Desperation could be one reason for turning to a religion, even believing quite irrational things or accepting irrational interpretations of the bible. But maybe there are many reasons. Many terrible things are being done every day in the name of religion but maybe only some of them are meant to be terrible. The people running a 'children's home' we came across recently may well believe they are following the word of the bible. They certainly say they are. True, they have stolen most of the donations to the home and put the lives of many children at risk, but it is vaguely possible they started out trying to do something good, while at the same time making enough money to keep their own households and send their children to (relatively expensive) schools.

Perhaps there is just a lot of religious fervour in Kenya, for various interpretations of the bible, for various different churches and for various different religious personalities, perhaps it's not desperation at all. But similarly irrational beliefs seem to be held about foreign people and how rich they all are and how they just come here to give out money. Ok, some foreigners do that, but several times every week, sometimes several times in the day, I am asked for money, often by people who have asked me many times before. And I know others who have had the same experience.

Some people seem to believe that if only they could get a scholarship or if only someone would sponsor them to go to Europe or the US (or somewhere else) or if someone would set them up in business, or if they would marry them, they would be ok, they would be very happy. Maybe people everywhere believe these things, I don't know, maybe people here are just more honest about it. But I think there is a difference between wishing for something and actually expecting it to happen.

Is it desperation that fuels this apparent devotion (or whatever it is)? Or does devotion to the belief that material wealth will be thrust upon all those who pray enough or give enough to pastors and churches or ask enough foreigners keep people from doing things to change their own circumstances? They could question preachers who keep promising them what is just material wealth. They could question where all the money they give goes to when they are poor and the preachers are wealthy, often staggeringly wealthy. I'm not saying there is work aplenty for everyone, sadly, there is not. And though there is wealth enough for everyone those who have most of it, and they are few, are not likely to part with it quickly.

I don't feel I'm much closer to understanding people's seemingly pathological attachment to religion, miracles, pastors and churches. Biased I may be, but I blame churches, not for poverty, but for influencing people in such a way that many people here behave quite irrationally. I blame religion for people's apparent belief that, although they can do nothing to change their own situation, someone, God, rich people, pastors or someone else, can make their lives better. I think the evidence is fairly clear that there is no one who will help most people except those people themselves. But then, when has evidence or experience ever had much impact on religion?


Monday, January 25, 2010

Gates the Autocrat: Malignant or Benign?

It's nice to get a long letter, except perhaps when it comes from Bill Gates and it's 14 pages long. But I feel obliged to try and keep up to date with what he and his foundation are up to. Their various concerns are very interesting but I'm always curious about the ways the foundation chooses to approach these concerns.

For example, the foundation is particularly interested in vaccines for pneumonia and rotavirus and concentrates much of its attention and funding on a relatively small group of diseases. This vertical approach to health, which could better be called a vertical approach to disease, is not one that everyone would be comfortable with. Huge amounts of money and resources for a few diseases could easily result in people suffering from or dying from some of the many other diseases commonly found in developing countries.

Indeed, people's health (as opposed to their diseases) have a lot to do with their environment, their living and working conditions, water and sanitation and, of course, nutrition and food security. The determinants of health are arguably more important than a few of the individual diseases that are seen as particularly worth funding. Even susceptibility to the diseases the foundation is funding is to a large extent governed by, for example, nutritional levels and food security. These, as I shall claim below, are being seriously compromised by the same foundation.

When it comes to TB and HIV, especially, this vertical approach runs a high risk of widespread resistance developing to whatever drugs are made available in large enough quantities. The Gates Foundation puts a lot of faith in technology, in vaccines and the like. These are all very expensive approaches, both to prevention and treatment. It is absolutely necessary to treat people who are ill, but it could be questioned how sustainable, as a whole, the foundation's approach is. Or maybe sustainability is not an issue and resistance can be dealt with by newer round of (even more expensive) drugs.

After all, rotavirus, polio, pneumonia and to a different extent malaria and HIV, are very closely related to the conditions in which poor people live, not just to a group of disease agents or pathogens. Can a high dependence on drugs for prevention and treatment of diseases work to save lives and reduce suffering when, at the same time, health services, education systems, infrastructures, food and food security and social services are almost non existent?

Of course, this is not necessarily the foundation's concern. But Gates and Co. must want their expensive interventions to work. They hardly put huge amounts of money into something that doesn't work. But what results do they expect? They surely expect a lot more people to be cured of diseases and a lot more people to be vaccinated against diseases. But it could be argued that another 'result' of the foundation's work is to enrich the pharmaceutical and other companies that receive much of the money being handed out.

I am not claiming that the money is just being handed over to multinationals. But the foundation's money that is not being disbursed is being invested to maximize its profit. It is being invested in pharmaceutical companies and others, regardless of their impact on poverty levels, distortion of markets, the environment, etc. There is a danger that the foundation is funding some of the problems it purports to be remedying.

So much for health, I'm finding it hard to get my head around whether the foundation is doing good work or if it is, at best, diluting its possible benefits, at worst, sneakily throwing money at multinationals that are closely tied to the foundation's wealth. But when it comes to genetically modified (GM) organisms and the multinationals who produce GM products, I have less doubt about what to think.

GM crops have not succeeded in giving any of the benefits claimed by industry hype. All GM crops grown on a large scale have had massive drawbacks that farmers in poor countries cannot afford. Developing country farmers are mostly subsistence farmers. They get enough from their land to eat and to trade for the following year's costs and perhaps a few other household costs. Even small additional costs will eat into money that they need for school fees, health, food and whatever else.

Taking on GM crops means that the costs that have to be met every year by farmers is higher than the costs of traditional crops. But also, the costs go up every year. GM seeds have to be bought every year and they have increased in cost much faster than traditional seeds. Fertilizers need to be purchased in higher quantities every year and their cost is also much higher than organic methods of fertilizing. Pesticides are more expensive and not only do more and more have to be used every year but eventually, the farmer needs to find new ways or new pesticides to continue growing the GM crop.

The Gates Foundation doesn't seem to favour sustainable ways of approaching diseases. They certainly don't favour sustainable agricultural practices (something that is flatly denied by Gates in his letter). And they don't seem to favour increasing self reliance among people in developing countries. Perhaps I'm judging the foundation too harshly but I think these questions need to be raised because there are too many people who are making so much money out of this type of philanthropy that they will never raise them.

I think we'll have to wait a long time to find out who gains most from the Gates Foundation but I suspect some of the most powerful companies in the world will do very well indeed. After all, if they don't do well, the foundation's investments will not do well and it's funds will eventually be eroded away. I would question the aim to give what Gates calls 'recognition' to these multinationals when recognition usually seems to mean profits. At present, the foundation appears to be paying the inflated costs demanded by these multinationals and making it worth their while keeping their prices high.

Maybe people in poor countries will gain more than they will lose from some of the foundation's projects, but it will be hard to tell. And there will certainly be huge losses for any country that buys in to the hype of GM. Countries that are already suffering from these losses, such as the US and Canada, may be able to afford them but developing countries can not. It seems as if many people in the developing world are depending on the whim of an autocrat. All they can do is hope that he is a benign one.


Sunday, January 24, 2010

Income Generation Activities Galore

Just over a year ago I appealed to people I know, especially on Facebook, to help me to identify possible income generation activities suitable for developing countries where little capital, skills or infrastructure are available. I was overwhelmed by the slightly fewer than two responses I received and the first one didn't fly. So I set about researching on the internet, contacting people and talking to anyone who was prepared to discuss the subject. Now that I have started making a list, I decided to post it here on my blog so that others trying to research the same thing won't have to start right at the beginning. And maybe some people will even contribute to the list!

The list is by no means exhaustive and the categories are just based on the way things look from here. They overlap to some extent and they are in no particular order, though I think the first two are particularly important because local acceptability can make or break an income generation activity, no matter how 'good' it may seem. And some of the activities that are already widely carried out have a lot to recommend them. The community based organisation I work with, Ribbon of Hope, already grow a number of crops and have financed several livestock programmes. But it's time to branch out, try new things, diversify and ensure that people get the maximum benefit possible.

The approach we are likely to take is to ask our clients what gaps they feel there are in their local market, what local materials are available or could be made available. Also, what skills are there, what do people already know how to do. There must be local products that we don't know about and sometimes it turns out that people can make or do things but just hadn't realised the value of that skill. I'm not sure in advance what we will gain from this or how we are going to elicit the sort of information we want, but I think it could be a valuable exercise. Rather than just teaching people a skill or a few skills, we would also like them to be able to assess all the opportunities that exist and consider acquiring as many skills as possible. So that's the first category.

The second category is to get people to help us make an inventory of what could be produced in the area and sold in a local market or business. I'm thinking of things like sunflower or sesame oil, peanut butter, jam from seasonal fruits, honey, butter, cheese or anything else, even things that are already produced but for which there is little or no market, yet. I'm thinking of a campsite I stayed at in Tanzania which sourced things like this in a relatively remote area. The result was spectacular because many of these products here are only available in highly processed, branded forms (which taste disgusting). They should be produced locally if at all possible.

Ribbon of Hope already supports several shambas (smallholdings), which I have mentioned several times on this blog. Those smallholdings should produce everyday foods that people in the area need but they could also produce high value crops, such as sesame and sunflower seed, where clients can also produce the sesame or sunflower oil. These have the advantage of yielding highly nutritious oil cake as a by-product, which makes excellent animal feed. We should produce animal fodder, especially fodder that can be stored for use during dry periods, which are all too regular and protracted here. And there are all sorts of interesting crops we could consider growing, just to keep things diverse.

Dairy cattle, goats and chickens are a well tried income generation scheme and they are usually successful. Because they are such a good bet, they can require a fair amount of capital, which some of the more risky and less well tried schemes don't. But not everyone can afford to take risks. I'd say, get the low risk schemes started first and then add the others in at leisure. We mustn't forget the hides and furs of stock such as cattle, goats and sheep, either. Certainly, there are many uses for sheep wool, regardless of the quality. But another type of livestock that you don't see so much around here is rabbits, especially the very big ones that are bred for meat. There must be many uses for their fur, too.

There are good opportunities for different types of food processing here, especially food drying. Fruit and vegetables can be solar dried at very low cost. Many crops, such as mango, pineapple, banana and tomato flood the market at certain times of the year and a lot is dumped. These are all good when dried. Ribbon of Hope produced a beautiful crop of coriander in the last few weeks and this would be as good dried as fresh, except that it would be a far more viable crop if we could dry large amounts of it. Mushrooms are grown locally and are a potentially lucrative and nutritious crop that is also good dried. Yoghurt is already widely produced, cheese isn't so popular and maybe there's a reason for that. But many things could be made with local ingredients, such as biscuits, cakes, bread, cassava chips and the like.

Some of the areas here are blighted with a monoculture, especially sisal. But I'm sure people could be persuaded to make things of higher value rather than rope, which is how most of the local sisal ends up. We'll see what people who have been surrounded with sisal all their lives come up with. Not too far from here, silk worms are farmed, so that's another possibility. I've mentioned before the possibility of producing reusable sanitary pads. There are probably going to be lots of objections but many people, especially young girls, can't afford disposable ones so it's worth some effort. Leather goods may be another possibility, especially if local people are successfully breeding relevant livestock. No doubt there are other artisanal products, such as pottery, candles and whatever else. Sorry for being vague but the gaps will be filled in eventually.

Ribbon of Hope has already funded a successful project selling water and this raised surprisingly large amounts of money. Another possibility would be to pasteurize water using solar cookers or solar heaters and selling it. Included in this category, not many people in this dry province of Rift Valley use irrigation, nor do many people harvest rainwater. This is short-sighted and even journalists are apt to bemoan the fact that there is an unwise dependency on rain fed agriculture throughout Kenya (if journalists notice, it’s probably been a problem for decades). It's time to change this, even if it's only to a small extent. Equally, many people don't irrigate their land, even when there is a source of water close by. Since Ribbon of Hope started irrigating its fields, neighbouring farmers have started borrowing their pump. So it is catching on!

One of my favourite types of income generation activity or cost saving activity relates to fuel or energy. I have mentioned solar cookers, such as simple reflective boxes or more complicated parabolic cookers. These are great for cooking food, drying food and for pasteurizing water or milk. Some of our projects involve milk production so free pasteurization would help reduce costs a lot. I've also mentioned fuel briquettes made from waste of various kinds. People could produce these for their own household but they could also produce them for sale in the local area. Wood and charcoal, the most common cooking fuels, are expensive and likely to go up in price. Solar is cheaper, cleaner and better for the environment and could be used to supplement other sources of fuel. Biogas is more difficult to produce but we are hoping to get some to train us in how to produce the stuff.

Some trees and shrubs could be a useful addition to any shamba. The Kenyan government is thinking of introducing a law about people growing a certain number of trees per acre. True to form, they are not giving any advice as to what trees should be grown and which should be avoided (there are some serious problems that result from choosing the wrong trees). And people with very small, possibly rented shambas, will not want to risk reducing their yield by sticking something unproductive in their fields. But there are productive trees and ones that are good for the soil. There are some that produce fruit without compromising the field crops and others that produce oils and even animal fodder. There are trees that can benefit in various ways, so these should be carefully selected.

Finally, some organisations end up with assets that they only sometimes use, such as equipment and tools. These could be rented out to neighbouring farmers or swapped for other benefits, such as labour or tools that are lacking. Tools and machinery are prohibitively expensive here, which is why so many farmers try to fly by the seat of their pants and sometimes fail. Even rainwater harvesting and irrigation involve costs that small farmers can't always meet. But they might be able to share, for a fee, of course. Ribbon of Hope's neighbours have increased their yields so much in the last few months by using their petrol pump that they could easily afford to pay a small fee.

Well, that's it for the moment, but that's quite a list. I'll continue researching and noting progress (and problems) and I'll add links to further information when I can get around to it. I hope people find this list useful and if anyone has other ideas for income generation activities, please let me know. Thank you in anticipation!


Thursday, January 21, 2010

Relative Deprivation in Urban and Rural Settings

It's been a mixed week so far for Ribbon of Hope in Nakuru. We spent the first few days in the hot, dry Mogotio, a few hundred metres from the equator. Despite the heat and lack of rain, there is a river nearby. Ribbon of Hope purchased a petrol powered pump, and later a foot operated pump, to irrigate their fields there. The results on our fields was so good that owners of neighbouring fields have been borrowing the pump to irrigate their crops, again, with encouraging results.

We have started trying to harvest the sizable crop of beans but very heavy rains at the end of the growing season resulted in extensive new growth, which means that each bean plant contains a mixture of beans that are ready to harvest and beans that are still green. The ones that are ready to harvest are starting to pop out of their pods and the green ones need to stay in the ground for another few days or even weeks. It's a bit of a dilemma and we are looking for ways to work around this. But the field has produced and continues to produce other vegetables and, in the end, it will more than pay for this year's and perhaps next year's costs.

The recently rented field that has been planted with watermelons is doing well and the constant irrigation, weeding and other work required gives casual employment to several local people. Mogotio is very short of jobs, most people do casual work of some kind and that's scarce enough as well. The area has depended for a long time on the sisal industry, which dominates the area completely but product output is very low and, for some reason, the sisal factories don't seem to like paying their employees. For some employees, arrears go back years.

So there are people who are happy to work in fields and there is a ready market for the produce. The soil is very good and with proper tending, seems to be well suited to quite a range of vegetables. Some of Ribbon of Hope's modest aims of reducing poverty and dependency to a small extent in Mogotio have been realised and we hope that this progress continues well into the future. It is a credit to the people there who have been so willing to work hard to ensure that things have worked out well.

There are several other similar projects in other villages and they have not all worked out so well. One perfectly viable smallholding has been neglected to the extent that there is little there now but weeds. My colleague and I felt ashamed when we walked around it because it stands out from the surrounding fields, which are packed with greenery, maize, beans, fodder crops and others. This sort of wastage of money, labour, resources and opportunity needs to be avoided, but how? Lots of people say they want help but Ribbon of Hope has limited resources. The only way they can help is by starting sustainable projects, ones that require a small initial outlay that can eventually be returned to the organisation.

One of my colleagues pointed out to me when I arrived in Nakuru that the rural based projects tend to do well but urban based projects, or projects involving urban based people, tend to fail. This has been demonstrated to me over and over again. Big NGOs don't tend to go to villages, even ones quite close to big towns. Villages and rural areas seem to be overlooked by funds, schemes, initiatives and projects, yet many people there welcome any opportunities that present themselves.

But people who are based in urban areas seem to have NGOs knocking at their doors (beating them down, even). It is not an exaggeration to say that there are people who join each and every group in order to see what they can get from it. Some have several different group meetings every day of the working week. If they don't get something to take home, something immediate and tangible, they lose interest very quickly. Ribbon of Hope runs relatively short term projects but even three to four months is too long for some people who are used to receiving cash handouts, food, clothing, per diems, courses in making things (which they subsequently never make) and who knows what else.

There is a lot of poverty in urban areas, I wouldn't wish to suggest otherwise. And I'm pretty sure there are plenty of people who know nothing about this system of 'support group hopping' and are unaware of benefits that they could really do with. But small community based organisations who can't provide people with something to take home cannot compete with organisations who can. So perhaps, given our size and means, we should concentrate on rural based groups. Perhaps we shouldn't try to box above our weight.

The last remaining urban based group that we worked with may now be drifting away and I won't be shedding any tears for them. As for the remaining rural based groups, most are doing well, not as well as Mogotio, but it's early days. We have some great ideas to try out over the next year or so. There have been more encouraging signs than discouraging ones and perhaps now is a good time to do some selective pruning and simply rip out the plants that will hold back the others in the long run. Sorry for the cheesy ending but it seems apt.


Wednesday, January 20, 2010

Kenyans Don't Need Rights, Especially if They Are Women

The Kenyan MPs reviewing the draft constitution have decided that women will not have equal rights to men in marriage. They don't at present, so no change there. And a big missed opportunity in the fight against domestic violence, family impoverishment and indeed, the spread of HIV and other sexually transmitted infections (STI), along with unplanned pregnancies, including those among women who are HIV positive.

These extremely well paid MPs have decided to exclude much in the constitution that relates to rights and the role of civil society. This includes religious groups (and the Kenyan National Commission on Human Rights), so I'm sure the MPs will be persuaded to change their minds about the former! But Kenyans certainly, these MPs feel, don't need rights to water, housing or food (or social security, health, founding a family, safe environment, access to quality goods or efficient administrative action). It could be wondered what rights Kenyans are deemed to be entitled to by these (Kenyan) MPs.

One of the reasons that the use of condoms for reducing the spread of HIV, STIs and unplanned pregnancies has not been too successful is that women say they don't have the option to refuse to have unprotected sex with their husbands or partners. Effectively, they don't have the option to avoid becoming pregnant, even when they don't want more children or when they know they or their partners are HIV positive.

The Christian churches, the ones whose part in running the country may or may not be threatened by this constitutional review, of course, object to the use of contraception. The fact that it could prevent all sorts of social problems, such as the ones mentioned above, is irrelevant. Harm reduction will probably never cut any ice with Christian dogma. But it is unlikely that women's rights will fare any better in the ultimate male dominated institution.

However, on the insistence of the same Christian churches, the controversial paragraph that mentions the right to life without stating when life begins has been altered to stipulate that life begins at conception. Are all Kenyans Christians? Clearly not, but some vocal sectors of the civil society that these MPs seem to want to silence appear to have a lot more say in the new constitution than others.

Abortion is already illegal in Kenya. With very few exceptions, the hundreds of thousands of abortions that take place in Kenya every year are, therefore, unsafe. These unsafe abortions contribute to the maternal death rate of 30% and an estimated 2000 women die every year from unsafe abortions.

So the Christian churches are interested in the right to life of the unborn, but they don't seem to be so interested in the right of women to choose whether to become pregnant or even to choose who can make them pregnant or when. Women who know their partner or husband is HIV positive do not have the right to refuse to have sex or to insist on the use of a condom. Why are these Christian churches not as concerned about the rights of the very women who are expected to carry, give birth to and raise children where they do not choose to, perhaps because they or their partner is HIV positive?

A canon who was interviewed about this matter said that 'pregnancy is God's design' and that men and women are 'responsible to control themselves and engage in sex as a husband and wife', which, if you are a Christian, may well be true. But is the canon not aware that a lot of sexual activity doesn't take place between husbands and wives, that a lot of people have sex with people other than their husbands and wives, that some people don't get to choose when, where and with whom they have sex? The Christian churches, of all churches, should be aware of things like this.

If the Christian churches wish to oppose the use of contraception and a woman's right to choose, they need to pay some attention to the rights that women are currently being denied. Because it is in part the denial of these rights that is giving rise to huge numbers of unplanned pregnancies in the first place. If they sincerely want to reduce unplanned pregnancies, transmission of HIV and other STIs, sexual and gender based violence and other social problems, they would need to reconsider their position on contraception, for a start. If they are unable or unwilling to do that, these churches will find their relevance to the majority of Kenyans, especially poor Kenyans, diminishing as quickly as it has done in Western countries over the past few decades.


Monday, January 18, 2010

Compulsory HIV Testing for Pregnant Women is Counterproductive

It's probably a good thing that Uganda has merged the provision of sexual and reproductive health with HIV programmes. It remains to be seen whether they do a good job of it and the fact that both functions will still be provided by two different government departments doesn't bode well.

But the proposed introduction of mandatory HIV testing for pregnant women is worrying. Most countries in the world have considered mandatory testing at some time and many have resisted it. The WHO has opposed it and, as far as I know, continues to oppose it. Not only is it considered to be a human rights abuse, but it is also thought to be counterproductive.

If it is a human rights abuse to carry out mandatory testing for specific groups for any disease, then it is an abuse to single out pregnant women for HIV testing. One of the dangers is that fewer women will attend ante natal clinics, with potentially disastrous consequences. But at present, Uganda is not providing ante natal care for all pregnant women. Will they start to provide it? Where will they get the money? And will ante natal care become mandatory too?

All people have the right to medical care, to treatment for illnesses, prevention of diseases, general health, reproductive and sexual health, etc. But what Uganda is proposing is that it will no longer be a woman's right to choose to be tested for HIV if she is pregnant, nor will it be her right to choose whether to be treated or not, nor will it even be her right to keep her HIV status confidential.

Ugandan health and social services are not able to cope with current levels of HIV, they have had constant problems testing people, treating people and maintaining supplies of medication. The country's health services function poorly and wouldn't function at all if it wasn't for high levels of donor support. But someone has now decided to make it even less likely that a large and vulnerable section of the population will seek health care just when they are most vulnerable. It is not just the pregnant women who are put in danger by such a proposal, it is also their unborn babies, perhaps their children, their partners and others.

The Ugandan government is not able to guarantee the safety of women who have been diagnosed as HIV positive. It is not able to guarantee that they will not be rejected or even persecuted by family and neighbours. It is not even able to guarantee that women will get adequate care to live a healthy life and raise their children to be healthy and strong.

HIV testing needs to remain an option to all people, including pregnant women. It needs to remain something people freely choose, something to which they can give their informed consent. That means they need to be counseled and advised before testing and supported after testing. This is the only way to ensure that the maximum number of people will agree to be tested for HIV. It is also the only way to support people in continuing to live a healthy and peaceful life in their own community and to take every step to avoid infecting others.

Compulsory HIV testing will not stop HIV from spreading. It will only make people fear testing, especially those most likely to be infected. Compulsion will result in the very people who most need to be tested avoiding testing centres and any place else where they may have to face a test, such as ante natal clinics and hospitals. Then, by the time people infected with HIV are identified, they may already be at an advanced stage of the disease and may well have infected many others.

The Ugandan government needs to encourage women to attend ante natal clinics when they are pregnant, not compel them to do so. People, whether pregnant or not, need to be advised to know their status, with regard to HIV and any other transmissible disease. If there is any chance of influencing people's sexual and reproductive behaviour, it is more likely to be achieved through education and support. It will certainly not be achieved through coercion, as Uganda and other countries have already spent nearly three decades finding out.


Sunday, January 17, 2010

Fiddling with Technical Fixes While People Continue to Die

Time reports on a study which raises concerns about HIV drug resistance. Most Kenya government documentation about HIV treatment is concerned with getting as many people on treatment as possible, or appearing to do so. Where the aim is to get as many drugs out to as many people as possible, resistance is probably not so visible. After all, you need to monitor people regularly and carefully for signs of resistance and funding doesn't always stretch to that.

It's not really clear how many people in Kenya are currently on HIV treatment. Figures vary a lot and don't always make it clear whether people who were once on treatment but have since died are included. Probably a few hundred thousand are on treatment at the moment, maybe three hundred thousand. But it's even less clear how many are on second line treatment. Second line treatment is given to those who have developed resistance to first line treatment and it's prohibitively expensive.

Most of the hundreds of millions of dollars of HIV money is spent on drugs, either for treatment or prevention. No one would want to deny people who are suffering from HIV/Aids access to necessary drugs, of course, but there must be a limit to how much money can be spent on drugs to the almost total exclusion of other aspects of treatment and prevention. I don't know what that limit is but there are proposals to put even more people on drugs and the sustainability of these proposals is highly questionable.

At present, people whose HIV infection has reached a particular stage are usually put on antiretroviral drugs (ARV). Perhaps about half the HIV positive Kenyans who have reached this stage are currently receiving treatment. Pregnant women who are infected with HIV are put on a short course of ARVs and this results in most babies growing up HIV negative. Less frequently, people who may have been accidentally infected with HIV can be given a short course of ARV treatment called post exposure prophylaxis (PEP).

But there are proposals to roll out ARV drugs to more and more people. For example, it was proposed just over a year ago to test everyone, or as many people as possible, and to put anyone found to be HIV positive on ARVs. If this could be done, the number of people on treatment would go up several hundred percent.

Another proposal is to roll out what is called pre-exposure prophylaxis (PrEP). This would involve putting HIV negative people on ARVs in the hope that this would protect them from becoming infected. The target of this kind of programme would be those seen to be most at risk of contracting HIV. This could involve sex workers, men who have sex with men, prisoners, intravenous drug users and perhaps the clients of sex workers, people who have many parters and people who have concurrent sexual partners, relationships that overlap with other relationships.

The number of people who would be targeted would be hard to estimate. How many men who have sex with men are there in Kenya? Is it five percent of the population or 10 percent (2-4 million)? Men who have sex with men are hardly going to identify themselves in the current homophobic climate anyway. An obvious target of PrEP is people who are HIV negative but are in a relationship of some kind with someone who is HIV positive, called discordant relationships. This could number some 350000 people.

Similarly for sex workers, how many are there? Is it hundreds of thousands and does that include people who occasionally engage in sex work or who don't consider themselves to be sex workers? And what about identifying their clients, how many million would there be? Is it really feasible to identify those most at risk of becoming infected with HIV? The recently published modes of transmission survey shows that, for years, HIV programming has been seriously misdirected and also that those who are most at risk is a very mixed and constantly changing group.

There are questions about the possible effectiveness of PrEP but there must also be questions about the feasibility of identifying all the people who could benefit from it, given the numbers of people who are infected with HIV and the numbers of people who are in danger of becoming infected. If resistance is a problem at current levels of ARV rollout, what kind of problem would it be if ARVs were rolled out to all people at risk or thought to be at risk of contracting or of transmitting HIV?

All the uses of ARV run the risk of resistance. Those who are HIV positive and on ARVs are at risk, but so are the women who receive short courses of ARVs to prevent mother to child transmission, so are those who receive post exposure prophylaxis, so are those who receive pre exposure prophylaxis. With resistance comes increased sickness and death unless second line treatment is rolled out. And second line treatment means increases in cost of several hundred percent. Again, questions about sustainability arise.

The question of whether we can treat our way out of the HIV epidemic is constantly raised but the answer is unclear. I would suggest that the answer is no and that even efforts at preventing the spread of HIV should steer clear as much as possible from technical fixes, such as ARV drugs. Drug treatment of HIV, let alone drug prevention, may not be sustainable and is already seriously affecting the amount of money available for preventing HIV transmission.

Instead of the almost inconceivable amounts of money being proposed to pay for drugs for treatment and prevention, far lower sums of money could be spent on improving the overall health, education and welfare of Kenyans and of those in other high HIV prevalence countries. It is immoral to continue pretending that there is a technical fix just around the corner and that everything will be OK. As long as we continue to look for technical fixes and ignore the lives of people in underdeveloped countries, people will continue to become sick and to die from treatable and/or preventable conditions.

(For further discussion of PrEP, see my other blog,


Friday, January 15, 2010

Uganda Won't Allow Mere Principles to Compromise Foreign Aid

Uganda's President Museveni is not known for being forbearing or fair minded, especially when it comes to men who have sex with men (or, presumably, women who have sex with women). But he has decided to distance himself from David Bahati's bill, which proposes the death penalty for certain offenses relating to homosexual behaviour and prison sentences for others who fail to report homosexual behaviour. It even proposes life imprisonment for persons engaging in same sex relationships.

This is not an instance of Museveni suddenly becoming softhearted, either. There are existing Ugandan laws against homosexuality with very long prison sentences. The country that claims to have had so much success in fighting the HIV epidemic continues to fail some of the people most at risk of becoming infected with HIV and of infecting others. Bahati's bill was certainly heading in the wrong direction but Museveni needs to do a lot more than oppose the work of a power crazed bigot.

Sadly, the Bahati bill had a lot of popular support in Uganda. Other East African countries have similarly punitive laws and there was the fear that if Uganda passed such a law, other countries would follow. It's frightening that most African countries outlaw homosexuality but even more frightening when you hear about the level of persecution homosexuals and those suspected of being homosexuals must put up with from the public, professionals, officers of the law and just about anyone else.

Museveni is said to have been reacting to international protests, especially from countries from which large amounts of donor money come. He mentions pressure from Canadian, American and British leaders and refers to the bill as a 'foreign policy issue', which it clearly is not. It's good that Museveni has decided to question the bill, but it would be more heartening to hear that he had some objection to persecution of and discrimination against homosexuals.

However, earlier on in the debate, people like Bahati said the country should forgo some foreign aid if donors objected. The debate has moved on a little and there was probably never any danger of Uganda refusing foreign aid. Their HIV efforts, and those of most high prevalence African countries, are almost totally dependent on foreign donations. But even some of the American fascist evangelists who originally supported the bill have now started to criticize it.

The best we can hope for right now is for Museveni to succeed in persuading Bahati to withdraw the bill or in persuading people not to support it. That would put Uganda back in the position it is in now with regard to homosexuality. That's not good, but it could be worse. But more pressure is needed, like the pressure against the Bahati bill, in order to ensure that the rights of homosexuals and other minority groups are recognised.

All the talk about Ugandan's and other Africans being so Christian, right minded, conservative and the rest is just so much posturing when you view it alongside people's attitudes towards those who are seen as somehow different. There's something scary about a religion whose adherents seem to behave in ways that are directly contrary to the religion's preachings.

To the Ugandans and other Africans who argue that homosexuality is an export from the West, it could be pointed out that the sort of double standards that allow avowed Christians to persecute their fellow human beings may actually be the worrying export from the West. These double standards are doing and will continue to do a lot of damage; unlike homosexuality, which has always existed in all known human societies, including African ones.

And Museveni has the cheek to talk about not compromising the country's 'principles', while at the same time taking into account 'foreign policy interests', presumably referring to hundreds of millions of dollars of aid money. Yes, it would be totally unchristian to do otherwise.


Thursday, January 14, 2010

Kenya Makes a Start in Addressing the HIV Epidemic

For the first time, I have come across an official Kenyan Government publication relating to HIV that is readable, credible and well thought out. Their survey entitled'HIV Prevention Response and Modes of Transmission Analysis' is available now (despite being dated March 2009). It address many of the worries about Kenya's HIV epidemic that have only been briefly mentioned before, but never adequately dealt with.

For example, it questions the fact that a far larger percentage of HIV spending goes on treatment and care than on reducing transmission; it questions the fact that HIV prevention programmes are top down and the same everywhere, even though the HIV epidemic affects areas very differently; it questions the fact that much of the HIV prevention spending seems to go to those who are not most at risk of being infected with or of transmitting HIV; many of those who are most at risk or in need of specific prevention programming receive little or none.

At last, the fact that there are men who have sex with men in Kenya and that they contribute to the epidemic is admitted and it is concluded that they need to be targetted. A recent report (too recent for this survey) shows that men who have sex with men live in all provinces and in urban and rural areas. It also shows that the clients of male sex workers providing services for other men are predominantly Kenyan. Previously, it was said that men having sex with men was a foreign phenomenon and that it mostly occurred along the coast.

Indeed, HIV transmission by men who have sex with men may be even higher than estimated by the Modes of Transmission Survey. But it's good that the issue is being discussed, rather than denied or ignored. The paper also admits that much of the money that goes into prevention goes towards interventions that have not been shown to have any impact on transmission. It admits that specific interventions may not have had much impact yet, even though some indicators are positive. It acknowledges that programmes and services are concentrated in areas where the need is not greatest.

So, people who are most at risk of becoming infected and of infecting others, such as men who have sex with men, commercial sex workers (and those who engage in any kind of transactional sex), intravenous drug users, long distance drivers, members of the fishing community and others are being acknowledged as being in need of prevention services. Let's hope that will be translated into the provision of these services. This survey is a very important step in Kenya's approach to HIV prevention.

But before some of these groups can be targeted, there are other problems that need to be addressed. It is illegal for men to have sex with men, certain aspects of commercial sex work are illegal and intravenous drug use is illegal. Members of these groups are rightly afraid to identify themselves and to risk being identified because they are the victims of persecution by members of the public, clients, professionals, police and others. But the survey mentions these issues and makes recommendations relating to them.

It remains to be seen whether any of the improvements recommended by this survey are made by the current government. But reading this survey gives me hope because maybe now there are some people in a position to do something who are willing to even discuss phenomena that have so long been ignored.


Wednesday, January 13, 2010

We Don't Need Evidence that Health, Education and Other Social Services Are Good

You might think that HIV prevention interventions have some bearing on the context in which they are implemented. For example, you might think that interventions to persuade people to have fewer partners are concentrated in areas where it has been shown that people have many sexual partners. Or you might think that about interventions to persuade people to avoid concurrent relationships, sexual relationships with more than one person at a time.

But in fact, interventions are mostly the same wherever you go, whether it's a developed country or an underdeveloped one. The little research that has been done into sexual behaviour suggests that in some places people have far more lifetime sexual partners than in others and even that in some places people have more concurrent sexual relationships. But no research shows that areas where people have more sexual partners or more concurrent sexual relationships actually correspond closely with areas of high HIV prevalence.

It's just an assumption that if HIV prevalence is high, people there much have more sex, more partners and more concurrent relationships. Some of the research that has been done clearly demonstrates that areas with high levels of HIV have lower levels of multiple partnerships and concurrent partnerships. It also demonstrates that areas with high levels of multiple partnerships and concurrent partnerships have lower rates of HIV. Clearly, unsafe sex is unsafe, wherever it occurs and however, but specific prevention programmes would need to be clear about what kind of 'unsafe' sexual behaviour, precisely, is occurring and how to change that.

But HIV prevention interventions are more likely to be dreamed up by those with political, religious or commercial interests, in complete isolation from anything that could be called evidence. And so far, they have almost all worked equally badly, whether it's in South Africa, which has the highest number of people living with HIV in the world or the US, which has the highest HIV prevalence in the developed world. These failures are not because of lack of available evidence about what would work and what would not work, though there is a lack of evidence. The failure is because HIV prevention funding has been seen as a matter of 'morals', petty politics and a good way to make some money.

If these circumstances were to change, what hope would there be that the high rates of HIV transmission in many countries of the world could be reduced? The issue of concurrent partners is hotly debated by the foremost academics in the field. But what these people don't disagree on is whether condoms work. There is no evidence that condoms don't work, though they are not 100% efficient. There is only a prejudice against the use of condoms because people who use condoms are having sex. But if people weren't having sex there would be no HIV pandemic.

I have never heard an academic, or anyone else, arguing that education, health education and sexual health education are bad and producing evidence to support their arguments. I have only heard bigoted politicians and religious leaders who seem to know little and care less about what their country's children know about sex and sexuality. Over and over again, it has been shown that children who know about sex and sexuality are more likely to delay their first sexual experience and to take precautions against unplanned pregnancy, HIV and other sexually transmitted infections.

Research into sexual behaviour is not just scarce, it's hard to do and the results are rightly hotly debated. But we don't need to wait for this difficult and costly research to be completed to aim to cut the transmission of HIV. It would be immoral to wait for this research. We know now that people have sex and they need sex education and contraception. They need health services, especially sexual and reproductive health services. The majority of new cases of HIV transmission in developing countries are still sexually transmitted, so to those who say HIV prevention is difficult or that evidence is lacking: this is not completely true.

Sure, there are controversies and there is research that badly needs to be done. But ignoring the efficacy of condoms, education, health and other social services in cutting the transmission is not only wrong, it is also disingenuous. Access to education, health and other social services are human rights so no 'evidence' is needed for these areas to be funded straight away. And while we're considering these human rights, we could also take a look at gender imbalances of all kinds, but especially relating to employment, family law, inheritance and marital power imbalances.

High HIV prevalence relates to the broad determinants of sexual and other types of behaviour, to the overall conditions in which people live, to their levels of health, education, wealth and many other things. HIV prevention has mainly concentrated on individual sexual behaviour and this is one of the things that makes reducing HIV transmission appear to be so intractable.

As the authors of a paper published in The Lancet over three years ago conclude: "No general approach to sexual-health promotion will work everywhere, and no single-component intervention will work anywhere. We need to know not only whether interventions work, but why and how they do so in particular social contexts. Comprehensive behavioural interventions are needed that take account of the social context, attempt to modify social norms to support uptake and maintenance of behaviour change, and tackle the structural factors that contribute to risky sexual behaviour."


Tuesday, January 12, 2010

How Long Can We Continue to Ignore Those Who Are Still HIV Negative?

I was back in Mogotio with Ribbon of Hope today, weeding the watermelon beds in our latest shamba (smallholding). There were eight of us there today, three who were getting paid for the work. Others will get payment in kind. I have to be honest, I managed to do a few hard hours under the hot equatorial sun but I had to give up at lunchtime and I'm now stiff and sore. And there was at least two thirds of the field left to weed when I left!

But it's good to see the project get off the ground because it will provide some casual employment in an area that sees little work and it will provide some good food crops at low prices at a time when food prices are particularly high. In the next few months the shamba will require a lot of looking after, weeding, irrigating and security. There will be plenty of people willing to do some of that work.

Mogotio is only about 30 kilometers out of Nakuru, so it is by no means the most isolated place you'll find. But it feels isolated. There are very few NGOs that ever visit the place and I haven't been able to find out about anything they do. I saw a World Vision four wheel drive but none of the community leaders I asked could say what the organisation does there. UNHCR has been active in the area recently because hundreds were displaced by the heavy El Nino rains. There are over one hundred white UNHCR tents just outside the village, but that's an exception.

The area is almost entirely dominated by the sisal industry. There are a few factories, most of which don't operate very much. There is little money to be made by growing sisal and people who live in these areas don't make much of that money anyway, it's mostly made by the estate owner, who lives in Nairobi and rarely visits the area. Some of the people who work for or have worked for the factories are owed wages going back many years. Every now and again they get some money, but just a fraction of what they are owed.

Like a lot of parts of Kenya, HIV is widespread here but it receives little attention. Most NGOs are based in the cities and bigger towns. They work in or close to wealthy suburbs and rarely leave those areas for long. When they do, it's like a state visit, a convoy of huge, air conditioned, white, oversized vehicles, stirring up the dust and little else. HIV spreads more slowly in rural areas and that may be one of the reasons that less attention is paid to them than to urban areas. However, the majority of Kenyans, over 80%, live in rural areas.

And many more people in rural areas don't go to school or don't go to school very much, many don't have access to mainstream media, they don't have access to health or other social services and they have little or no connection with the benefits of the cities and towns. They are more isolated than their distance can explain. Every now and again something comes their way, probably not much, then the project or organisation leaves and loses touch.

But even some of these isolated areas have access to some HIV testing and counseling facilities and even the HIV drugs that most people are supposed to receive for free. They usually don't have access to any other kind of drugs and they are lucky if they can stay healthy, but it's a start. But treating more and more HIV positive people every year has little impact on reducing HIV transmission. Many more people become infected for every one person who gets treatment.

And HIV prevention really is a strange animal. In all the time HIV has been around, few methods of HIV prevention have been developed. A fraction of the money that goes into HIV goes towards prevention, less than 25% in Kenya. About half of that goes on prevention of mother to child transmission and the 12% that's left is spent on rather dubious projects that are known to be of little or no benefit.

A series of findings were presented at the 2006 Aids Conference that demonstrated that most kinds of HIV prevention programmes have a very small effect, some have a negative effect and the majority don't do anything. Consider the list: Voluntary Counseling and Testing, Condom Social Marketing, Mass Media, Abstinence-Based Interventions, Peer Education, Family Planning Counseling for HIV-Infected Women, Needle Exchange Programs, and the Effect of HIV Treatment on Risk Behavior.

The only one in the above list that has proved itself is needle exchange programmes. These have been known to be effective for a long time but they are strongly disapproved of by many funders, especially US funders, who feel that they increase drug use. They don't increase drug use, they reduce it and they have an impact on HIV transmission. But such programmes are of little relevance in Kenya as a whole and of virtually no relevance in a place like Mogotio.

The majority of HIV infections in Kenya come from heterosexual intercourse. A sizeable percentage comes from male to male intercourse. A debatable, possibly high percentage, comes from medical treatment, such as injections. But in rural areas, like Mogotio, people are in need of good education, health services, ordinary health services, not vertical interventions that treat HIV (or something else) alone, basic social services, infrastructure and things like that. There is no mystery about HIV transmission that makes its reduction intractable. People need a reasonable standard of living, they need security in their lives, especially food security, they need work, for which they get paid; just basic things that people in developed countries take for granted.

Yet more and more money continues to be poured into programmes that are unlikely to work or even ones that have been demonstrated not to work. In the case of Mogotio, of course, they don't even get these programmes most of the time. Money intended for the constituency appears to get stuck elsewhere and people are forced to plod along without even the most basic of their rights being realized. As long as people have so many problems in their lives and so little to aspire to, HIV will continue to be low on their list of priorities. If HIV is low on their list of priorities, even effective prevention programmes, if effective programmes exist, are destined to fail.


Monday, January 11, 2010

Ribbon of Hope's Mogotio Shamba

Photo: Beans, almost ready to harvest.

Today was a good day for Ribbon of Hope in Nakuru. We went to the Mogotio shamba (smallholding) to see how everything was growing. Much of the one and a half acre plot is planted with beans that were put down a few months ago. It was hard work planting them because they are packed in close together. It was harder work irrigating the crop through the dry months, but it was worth is as the field became lush and green. Now the beans are almost ready to harvest in the next couple of weeks, as long as the heavy rains don't destroy them. The rains have already beaten some of the crop into the ground but we'll hope for the best.

Photo: Amaranth, almost shoulder height.

And there are other crops in the field, also almost ready to harvest. There's coriander, kale, amaranth, tomatoes and spinach. These were planted later than the beans, but they are growing quickly because of the heavy rains. Earlier crops that were planted, such as onions, green peppers and kunde have more or less peaked and are declining now, but they were worth the effort, especially the green peppers.

Photo: In the foreground, coriander and some members of Ribbon of Hope.

The idea of growing these common foods is that local people will do the work and they will then sell the produce or buy it at low prices. About five or six people have been involved in producing all this food so they will now be able to use it themselves, sell it to friends or sell it in the market. It's surprisingly reasonable to rent land in this part of Kenya and surprisingly expensive to buy land. Unfortunately, it's hard to keep up the work and provide security and the like on rented land and this has been an uphill struggle from the start. But again, we hope for the best.

Photo: A fine looking bed of kale or 'sukuma wiki', as it's called here.

We have rented another plot of land, also a bit over an acre, in a field nearby. This is also close to the river and so should be easy enough to irrigate. It is now completely planted with watermelon plants. It took a short time to plant the whole field but it will take a lot of work to look after this valuable crop. For now, there's not much to see in the field, a few spots of green. Actually, too many spots of green and we have to weed the whole thing tomorrow. But in a few weeks time the field should be covered in melon vines and in a few months, a beautiful and fragrant crop.

Photo: A recently planted field of watermelon.

Ribbon of Hope has other shambas but this one has been the most successful, so far. This is probably because the same people come to do the work, week in, week out. Other shambas don't always receive the same dedication, though they should work out, eventually.

In addition to producing onions, green peppers and kunde, this shamba produced a fantastic crop of butternut squash last year. Ribbon has been able to invest in a petrol pump and, later on, a foot pump. The petrol pump is great but it does cost a lot to run and also it seems to suffer from a lot of engine problems. The foot pump is a great addition and uses no fuel (!) but we haven't had it long enough to really say how good it is. It just feels nice to have a pump that doesn't require petrol, given the disadvantages of having to use fossil fuels, as if we were fossils ourselves.

Photo: Tomatoes, filling up nicely as a result of the El Nino rains.

It's a bit early to say how cost effective these small economic interventions are. The amount of money spent is not huge but it remains to be seen how good the harvest is and if there is a good market for the various produce. Undoubtedly, such projects increase self-reliance considerably, even where they don't produce much. But in the long run, we would like to be able to increase the number of such projects and have more successful harvests than unsuccessful ones. I'll post up any further news and progress as and when.


Sunday, January 10, 2010

PSI: Throwing Bad Money After Bad

At one time, the leading paradigm of development was the control of population, the belief that poor countries would develop if they would only have fewer children. One of the foremost organizations persuading people to use condoms and employ other family planning techniques was Population Services International (PSI). They were not very successful and family planning and reproductive health in developing countries is still woeful, despite large sums of money being thrown at these problems.

PSI is still a powerful organization with lots of money to throw at the problems of development. But now, much of their money goes into HIV, where they (along with various other powerful and rich organizations) have also been relatively unsuccessful. PSI's aim is to use the 'power of marketing' to persuade people to change their sexual behaviour and use condoms and other modern contraceptive methods.

Strangely enough, PSI don't seem to know that the road up is also the road down, that contraception to prevent unplanned pregnancy can also prevent sexually transmitted infections (STI), such as HIV. The goal of reducing unplanned pregnancy was lost in the scramble to persuade people to change their sexual behaviour to avoid being infected with HIV (never mind about other STIs). However, many HIV positive women having babies did not plan to get pregnant in the first place. And the whole issue of sexual activity and reproduction has become so confused that people are apt to concentrate on one thing, such as unplanned pregnancy, and completely ignore two other important considerations: HIV and other STIs.

Not that long ago, it was reported that many women would prefer to run the risk of contracting HIV than that of getting pregnant. They would have unprotected sex with a partner, often a person they didn't know very well, then they would resort to emergency contraception (EC). This EC is not appropriate as a general contraceptive and it does not protect from HIV or other STIs.

Why would people be willing to take this risk? Is it because they simply don't see contracting HIV as a very high risk? They could be right, they may be more likely to become pregnant than to contract HIV or some other STI, but the risk is still there and the odds go against them the longer they continue to have unprotected sex. Actually, the chances of becoming pregnant also become higher the longer they continue to use EC as a substitute for more appropriate contraception.

I'm singling out PSI because they have been big fans of marketing EC in developing countries and because of their dependence on marketing. Marketing may well be appropriate in the commercial world, where everything has to seem cooler or newer or better than what went before. But contraception, family planning, reproductive health and things like that are not good because they are cool or funky or with it, they are good because they work.

If PSI have been successful at marketing EC, they have done so irresponsibly. After all their decades in developing countries they should know by now that what people need is good basic education, good basic health services and good sexual health services, particularly for women and girls. Fancy (and expensive) marketing is not a substitute for proper education and health. The message has now been fluffed, so that people have all sorts of muddled ideas about contraception, sexualy behaviour, pregnancy and anything else organizations like PSI have been involved in.

If organizations like PSI are really interested in people's health and welfare, they should pay a little less attention to marketing expensive products and services and spend some time advocating for the levels of health and education spending that countries like Kenya really need. Contraception such as condoms is not cool, it's vital for people to be able to live their lives without risking serious disease or unplanned pregnancy.

People, adults and children alike, just don't know enough about HIV, reproductive or sexual health. There is no amount of advertising and campaigning that will give them access to the information, services and products they need to ensure their sexual and reproductive health. HIV, and even high levels of unplanned pregnancies, are not emergencies. They are part of everyday life and a factor of how little has been done to improve people's health and education over the past few decades.

Contraception of any kind is useless without adequate levels of spending on education and health, especially those relating to sexual and reproductive health.


Saturday, January 9, 2010

The Odds Are Not Stacked Enough in Our Favour, Say Big Pharma

The 'Counterfeit Act' signed by the Kenyan government last year is being challenged as unconstitutional, violating the right to health. This act was not really necessary because it was already an offense to make and distribute fake goods and there are already officials whose job it is to enforce existing laws.

In fact, the act seems to have been cobbled together and rushed through parliament at the behest of big industry, especially big pharma. The last thing they would want is competition, except where the odds are well stacked in their favour. So they whinged to the government (a process called lobbying in some countries) about how things were so unfair and the government kindly came up with a piece of legislation that fails to distinguish between fake goods and generic goods.

As a result, generic versions of drugs destined for Kenya have been held up in various countries on the grounds that they may not be legally distributed in Kenya. This is great for big pharma, they never wanted generic versions of drugs to be produced unless they themselves produced them, at inflated prices. But they were forced to reduce their prices when producers won the right to produce generics and big pharma have been fighting them ever since.

GlaxoSmithKline has come up with the expedient of reducing a few well known products, such as some of their antibiotics, to try to undercut generic versions. However, they don't seem to understand the concept of undercutting: their prices need to be lower. They have reduced their prices, sure, but they are still far more expensive than generic versions. What they are offering are hardly loss leaders, rather some kind of token gesture, to which journalists give the expected publicity and praise. And it's still not even certain if the reductions will be passed on to consumers.

The result of Kenya's self-serving piece of legislation is that there is widespread confusion about pharmaceutical products. People really have no way of knowing what is fake and what is not. The fact that something has a well known manufacturer's name on it does not guarantee that it is not fake. But if it is genuine, you are still robbed of the extra cost that going for the branded product involves.

People are just not able to afford many of the branded products. Slight reductions here and there, or even substantial reductions, miss this point. What is never so clear is what people have to sacrifice if they do go for the expensive branded product. But that's of little interest to organisations like GlaxoSmithKline or to the journalists who flock to report on whatever titillating rubbish is being reported on by all other journalists.

I'm glad to hear this despicable act is being challenged and hope those opposing it succeed. Because other countries, such as Uganda, are considering similar acts, no doubt in response to lobbyists for big pharma and other industry interests.


Friday, January 8, 2010

Will PEPFAR Become a Fund for Health?

It sounds as if PEPFAR (President's Emergency Fund for Aids Relief) is about to change a bit under the Obama administration. These changes are all long overdue. For a start, Aids is no longer to be seen as an emergency. It wasn't an emergency before PEPFAR started, so this is good to hear.

The 'exceptionalisation' of Aids, treating it as if it is a disease that is separate from health in general, should have its own institutions and funding, is to disappear. Again, this move is long overdue, but still welcome. Hopefully, it will mean that some of the huge sums that have been raised for Aids will be spent on health services. Those who think Aids issues will lose out needn't worry, people with Aids also have general health needs. So everyone will gain.

The head of PEPFAR, Eric Goosby, is at last questioning the sustainability of putting everyone who is HIV positive on drugs that they will need for the rest of their lives. Of course, HIV positive people should be treated, but with far more people becoming newly infected for every one put on treatment, something really has to be done to reduce the number of new infections as well.

So HIV prevention should return to the agenda. The question is, what kind of prevention programmes will be funded by PEPFAR? In the past, prevention has included little but lecturing people on their sexual behaviour. There are few prevention programmes that have had much impact on HIV transmission. Of course, most well funded programmes will tell you that they have been very successful and show evidence that whatever mindless drivel they repeated to all and sundry can be trotted out at the ring of a bell, or whatever.

But rates of HIV transmission remain high in many countries, including the US, despite these questionable programmes. Does PEPFAR have anything new to bring to the table? If they don't, it would be good to hear that they are willing to talk about using condoms and employing other harm reduction approaches to HIV. For example, clean needle and syringe distribution and greater advocacy and support for sex workers, men who have sex with men and other vulnerable populations.

Another change proposed is that PEPFAR funds go to governments rather than, primarily, to NGOs. While it's true that NGOs may not have done very well in many cases, I'm not sure about the wisdom of handing large amounts of money to governments. Kenya has had a particularly bad history when it comes to administrating large amounts of money intended for HIV treatment, care and prevention (or any kind of funding). Time and time again, investigations have found administration of funds wanting, only for the money to flow in again once the row has died down. PEPFAR recently announced a doubling in Aids funding, amounting to 2.7 billion dollars over the next five years.(A Ugandan writer also worries about these changes ito PEPFAR.)

Disbursements of US aid for HIV don't relate to a country's need. The HIV epidemic in Kenya is by no means the worst in Africa, even in Sub-Saharan Africa but they are one of the top recipients of funding. No, disbursements seem to depend more on how cozy a country's relationship is with the US and for Kenya, the relationship has been very cozy since independence. Perhaps questions about how much of that money actually benefits people with HIV are irrelevant to PEPFAR, as long as cozy relationships remain, who knows? But let's hope the changes take place and my fears are not realised.