Sunday, January 27, 2013

Maternal Health Care a Significant HIV Risk in Ethiopia

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

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

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

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

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

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

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

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

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

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

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


Thursday, January 24, 2013

PrePex at Loggerheads with Main Recipients of Circumcision Funding?

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

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

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

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

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

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

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

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

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


Tuesday, January 22, 2013

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

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

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

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

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

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

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


Saturday, January 19, 2013

Lynas Spanks One Out for Genetic Engineering, Again

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

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

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

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

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

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


Wednesday, January 9, 2013

Mass Male Circumcision: it's Not Done in Europe, So Why do we Tolerate it in Africa?

The current plan to circumcise 20 million African adults and countless millions of African infants arose purely from the prevailing view that HIV is almost always transmitted sexually in African countries. If we had tested that view years ago and modified it appropriately in the light of available evidence, the issue of aggressively promoting circumcision and spending billions of dollars of 'aid' money on it would never have arisen. It would have been clear that HIV is not exclusively transmitted through sexual contact, that it is also transmitted through unsafe healthcare, cosmetic and traditional practices.

If circumcision reduces HIV transmission, it could only reduce sexual transmission, not transmission through other modes. It is also only claimed to reduce sexual transmission from females to males; it may increase transmission from males to females and, given that prevalence is higher, often much higher among females in African countries, this may result in circumcision programs increasing HIV transmission overall. In addition, African countries' crumbling health systems would not be able to provide tens of millions of safe male circumcisions; the most basic health services are denied to most people and available services are known to be very unsafe.

We have privileged HIV above all other diseases and we have privileged sexual transmission above all other modes of transmission. By doing this, we have stigmatized every African as sexually promiscuous and every HIV positive African as paying the price for their own behavior; yet we fail to acknowledge that HIV is not always transmitted sexually. So why are circumcisions now carried out so readily in countries where most other kinds of operation and medical procedure are unavailable? Even where other procedures may save people's lives, disproportionate amounts of money are spent on sexually transmitted HIV, including in areas where HIV is certainly not the highest priority, sometimes not even a low priority.

Therefore, in the interest of safe healthcare for all, it is necessary to oppose mass male circumcision programs. They will not reduce HIV transmission much, if at all; they will not be carried out in contexts where safe healthcare is generally available; and they will be carried out in countries where the most common causes of illness and death are generally ignored, despite being far higher priorities than HIV or sexual health. For example, there is an urgent need to address reproductive health more broadly, the overall health of women, infants and children and the health of men who are not HIV positive, nor at risk of being infected through their sexual behavior. Diseases that relate to living conditions, such as TB, that infect far more people than in countries where living conditions are better, also need to be addressed. There are also water-borne diseases that infect, debilitate and kill millions because of lack of access to clean water and sanitation.

HIV needs to be put in perspective; it is a virus, one of many, sometimes sexually transmitted, sometimes non-sexually transmitted. We don't even have any idea of the extent of non-sexual transmission, so we can neither tell how much transmission mass male circumcision could avert, if any, nor can we tell how many people are likely to be infected and/or to infect others as a result of the circumcision programs. Mass male circumcision is part of a much bigger picture, and it's because the bigger picture of HIV is distorted by Western obsession with 'African' sexual behavior that we've ended up with something as stupid as mass male circumcision. People are being denied their right to health care, to safe healthcare, to bodily integrity and to many other things. Circumcision is just one problem and the mass male circumcision problem grew out of our failure to address non-sexually transmitted HIV, safe healthcare and all the more important development areas in developing countries.

I am not an 'intactivist' and I don't advocate for 'intactivism', not because genital integrity is too small or too unimportant an issue; it's because it is just a part of a much bigger picture. Most human rights are being denied in some developing countries, not just a handful of rights. Genital integrity is just a part of something that is too big to ignore: bodily integrity and the other human rights that are being denied to those who are denied their right to bodily integrity. Circumcision itself may do harm, it may do good, it may do nothing. But it is the aggressive promotion of mass male circumcision programs in places where most forms of healthcare are unavailable and most available healthcare is not safe that is most objectionable.

If anyone tells you that healthcare services fail people in high HIV prevalence countries because of stigma, health seeking behaviors, culture, education, tradition, or anything else, remember that healthcare services are far more likely to fail because they are not available to most people; where they are available, they are likely to be unsafe. This is not to say that stigma is not an issue, but it is one that arises from the view, mentioned above, that HIV is almost always transmitted through heterosexual sex in African countries. Education also fails people, and not just in relation to health. Health seeking behaviors, culture, tradition and other issues may well be important issues. But they are of less importance where access to healthcare is poor and where that healthcare is not safe.

Despite lengthy (and lucrative) campaigns telling us that everyone is at equal risk of being infected with HIV, that HIV is an 'equal opportunities' virus, that it's all about sexual behavior, etc, it has long been clear that risk is most definitely not 'equal'. Both men and women who are receptive sexual partners face a very high sexual risk. Men who only engage in insertive sex (i.e. most heterosexual men) and who have no other risks are very unlikely to become infected, so women face higher sexual risks than men. Intravenous drug use is the second biggest risk in most rich countries. But the extent of non-sexual infection through unsafe healthcare, cosmetic and traditional practices in high HIV prevalence countries is not well known and is often not even acknowledged.

In wealthy countries circumcision stands out as an anomaly, where female genital mutilation (FGM) is viewed as a denial of the right to bodily integrity. We don't need to argue against FGM on the grounds that it causes physical (and psychological) damage, or that it may present problems later on in life. The fact that there is a right to bodily integrity is enough, but the anomaly stems from the fact that male circumcision is not seen as a denial of the right to bodily integrity. Some argue for male circumcision as a religious or cultural right, and that is not a problem, as long as it is the adult individual who makes the decision, not the parent.

But in developing countries, there is nothing anomalous about programs funded by Western governments telling people what is good for their health, regardless of broken down and unsafe health facilities, cultural and religious practices, or even human rights. FGM is opposed on grounds that should also be used to argue against male circumcision, yet male circumcision is promoted with the claim that it reduces sexual transmission of a virus, in the full knowledge that the virus is not always transmitted sexually and that it may be transmitted through circumcision itself. Western countries were once opposed to breastfeeding. Indeed, it may have been Western churches that once opposed circumcision in parts of Africa, or at least deemed it unnecessary for people who had been converted to Western religions. Claimed health benefits do not justify mass male circumcision programs.

In developing countries, circumcision is just one issue out of many, the tip of the iceberg. If we were to forget circumcision and concentrate all our attention on some other issue tomorrow no one would be any worse off. Singling out HIV, circumcision or any other issue, divorced from the context that gives rise to the issue, is part of the problem. If we didn't believe the lie that HIV is almost always transmitted sexually in African countries, we wouldn't even be questioning the wisdom of mass male circumcision, and those promoting it would not have received billions of dollars to ride roughshod over African people.

If it was decided that some other kind of intervention reduced HIV transmission, such as giving HIV positive people ARVs long before there is a clinical benefit (it's called Treatment as Prevention) or giving HIV negative people ARVs because they have or may have a HIV positive partner (it's called PrEP, pre-exposure prophylaxis) or give lifelong ARV treatment to pregnant women, rather than a short course of ARVs (it's called B+), those may become as aggressively promoted as circumcision. Sadly, all three of these are already being aggressively promoted even though the net benefit may be low and there may be very serious consequences in terms of transmission rates and health more broadly.

We don't have to do research to know that people need safe healthcare, education, infrastructure and the like, but we seem to avoid getting involved in these basic human rights and instead allude to things like corruption and culture and whatever else journalists and academics tell us is pertinent. Mass male circumcision programs are not wrong because they won't work or because circumcision reduces sensitivity or has anything else to do with sex or the penis. They are wrong because people have a right to bodily integrity, to safe healthcare and to many other things that are currently denied to them.

This is not merely a logical or academic argument against circumcision; we know that we couldn't carry out such programs on our own fellow country people, regardless of any claimed benefits, public health or otherwise; so why are we even discussing doing so in African countries? Aggressive promotion of mass male circumcision programs in African countries, mainly funded and carried out using US money, has got to stop.

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


Monday, January 7, 2013

TB and Gold Mining: Sending Them Home To Die

A message from the director of the film 'They Go to Die' (YouTube video).

Jonathan P Smith, an American epidemiologist, is making a film about the kind of scenario mentioned in yesterday's blog post: South African miners and their families being infected with TB as a result of living and working in appalling conditions, and the failure of crumbling health services to offer the level of treatment that would cure people of the disease, prevent it from spreading and avoid drug resistant strains developing.

Smith follows four former gold miners who have contracted resistant TB while working at a gold mine. The gold mine's hospital has failed to treat the men and they are now being sent home. It is likely they will die from TB, but also that they will infect a number of other people first. As they have a resistant strain, they can also transmit this resistance. Treatment will therefore be difficult, very expensive and unlikely to be available. Their immediate family will probably be most at risk.

Mine owners are under no obligation to treat miners infected with TB. But government programs to eradicate the disease are unable to influence the working and living conditions that result in TB spreading rapidly and resistant strains of TB from developing and spreading. Eradication programs are often separate from other health services, because health services are unable to cope even with far less threatening diseases, and funding levels mean that TB eradication often amounts to little more than free drugs.

Squalid living and working conditions ensure that a disease like TB will remain endemic, and that people will remain highly susceptible. Circular migration from home to work and back ensure that TB will be spread widely. Intermittent health services ensure that resistant strains will develop and be spread, to infect and reinfect people of all ages. Add to this a high disease burden and an underfunded health sector, and you have a production line of sick people, packaged up to receive whatever pharmaceutical companies have to offer.

The figures Smith cites are staggering: TB rates among South African gold miners are 1,400 times rates in western countries. Western countries may be willing to send money and drugs for TB eradication programs, but we also enjoy cheap consumer goods, which depend on costs for raw materials being kept as low as possible. As a result, conditions in mines remain hazardous and miners and their families suffer the consequences. Even HIV, which attracts more funding than any other disease, is rampant in mining areas.

Smith notes that those infected with HIV are very vulnerable to TB but he doesn't mention if those with TB are more likely to be infected with HIV. TB has always infected poorer people in higher numbers whereas HIV has often been more closely associated with wealthier, better educated people. But HIV prevalence also tends to be higher among employed people, especially those in formal employment, such as mining. The received view of HIV transmission, that it is mainly a result of unsafe heterosexual sex, would suggest that employed people take more sexual risks. But perhaps employment related health facility conditions may play a role here?

People working in mines do have access to health services, but those services tend to be basic. It is unlikely that safe healthcare is a high priority. Miners suffering from diseases that are common in terrible living and working conditions, such as TB, respiratory infections, intestinal parasites, nutritional deficiencies, water-borne diseases and sexually transmitted infections (STI), may face additional risks in health facilities. Do those facilities have enough basic supplies, such as gloves, injecting equipment, sterilizing fluid, gauze, etc? Are there enough well-trained personnel? Can safety be guaranteed? Or are mining hospitals as unsafe as most hospitals in high HIV prevalence countries?

Some of the highest TB figures are found in countries that have significant mining interests, and in countries that supply the migrant labor. But some of the highest HIV figures are also found in these countries. Much has been written about the role of sexual behavior in an effort to explain these epidemics. But a lot less has been written about the possible role of unsafe healthcare. There is a great fondness for writing about and reading about sexual behavior, but this could mask the elevated levels of non-sexual risk that miners and others must face.

TB spreads easily among people who live together, especially in overcrowded slums. It also spreads easily among people who work in badly ventilated mines. But HIV does not spread so readily through unsafe sex alone. Perhaps transmission through unsafe healthcare could help to account for some of the worst epidemics in the world? Perhaps unsafe healthcare could explain why many infants are infected when their mother is not and why so many people with a HIV negative partner become infected where there is no obvious sexual risk?

Smith writes: “What is the point of public health research if there is no public health benefit? We, as researchers, have an ethical obligation to not simply perform epidemiological research, but advocate a positive change in our research population... [T]o conduct research without the intention of betterment within that population makes a mockery of our public health researches.” This could equally be applied to all research, such as human rights, development, anthropology, even industry related research.

[For more about non-sexual HIV transmission through unsafe healthcare, see the Don't Get Stuck With HIV site.]


Sunday, January 6, 2013

TB: the Emergency is that We Have Failed, Time for a Different Approach

The English Daily Mail is not a source I would usually turn to for articles about global health issues, but the English MP Peter Hain does have some interesting remarks to make about TB. Following the government's decision to postpone mass culling of badgers to cut transmission of bovine TB to cattle, Hain reminds us that human TB kills about 1.4 million people every year.

Hain also mentions the issue that excites the pharmaceutical industry the most: drug-resistant strains of TB, which are developing and spreading rapidly. If ever there were a demonstration of the foolishness of believing that health was just a matter of fighting disease and that fighting disease is just a matter of throwing drugs at a handful of headline-grabbing diseases, TB is one.

There have been TB eradication programs around for decades and it is the failure of these programs to do any more than throw drugs at people that allows resistance to develop so readily. TB could have been contained a long time ago. But health is not just a matter of fighting disease and TB eradication (or HIV eradication, or any other disease) is not just a matter of drugs.

For a start, people live in appalling conditions. TB spreads rapidly in appalling living conditions, just as water-borne diseases spread rapidly among people who have little or no access to clean water and good sanitation. As long as people live in such conditions, they will continue to suffer from and die from diseases, many of which are preventable and/or treatable. Leaving people in their current conditions means that throwing drugs at them will be of little benefit; for every vaccine they receive, there are hundreds, perhaps thousands of other diseases they can suffer and die from.

Then there are people's working conditions. Hain notes that some of the worst TB epidemics are in South Africa's gold, diamond and coal mining areas, which are said to be responsible for 760,000 new cases of TB every year and the highest death rates for TB in the world. The conditions in which miners work are ideal for the spread of TB. As migrant laborers, most of them return to their families frequently, and they risk spreading TB to anyone with whom they come into contact.

According to Hain, a "migrant worker with TB will typically spread the infection to 10 to 15 other people each year that he’s sick". (Compare this to the 1.2-1.4 people to whom a HIV positive person will typically transmit the virus.) Worse still, "When he returns to his home community, he may not have access to health services capable of putting patients through the necessary six months of TB treatment". Though TB sometimes attracts enough funding for 'treatment' to be free to many people, drugs alone are generally not enough.

The living and working conditions people experience are not conducive to lengthy and expensive drug regimes. Treatment interruptions and treatment failures can quickly give rise to resistant strains of TB developing, which can also be transmitted to others. As resistant TB can be up to 100 times more expensive to treat than non-resistant strains, many will die of the disease. And because it is so readily transmitted, others will be infected with this resistant strain, also.

That's the bit that makes pharmaceutical companies so happy. There's no doubt that they will make a lot more money out of resistant TB. But one of the reasons throwing drugs at the problem does not work is because living and working conditions are not generally addressed by TB eradication programs. Most people don't have access to the sort of health services that will ensure they receive everything they need to clear them of TB. But most also live in conditions where they are highly susceptible to transmitting TB and to being infected, or reinfected, with TB and resistant TB.

Mine owners are not called upon to make conditions healthier. Western buyers of South African raw materials are not keen to increase their costs. The 'economy' of South Africa may depend on mining revenue, but unless that is translated into better living and working conditions for miners, TB and other diseases are not just going to disappear. Good for Big Pharma, not so bad for wealthy South Africans, but not so good for ordinary South Africans.

Hain is incorrect if he assumes that a thriving mining sector results in a stronger economy and that this results in better healthcare systems. The TB epidemic is costing the country a lot of money. So it may seem like a good investment to throw drugs at those with TB. But it's not just healthcare systems that are lacking, it's also education, water and sanitation, habitation and working conditions that are making and keeping people sick.

Hain's suggested approach sounds good, but it is inaccurate to say that an emergency response is needed. Poor living and working conditions mean that emergencies frequently arise, do a lot of damage and can not easily be remedied. But lack of health structures, health personnel, infrastructure and other things mean that TB and other diseases can not be eradicated.

Even ridiculous programs that consist of little more than showering people with drugs could do a lot of good, but not if other conditions are not improved first. There's little to be gained from eradicating one disease only for people to suffer from and die from other diseases, particularly resistant versions of more easily eradicated diseases.

TB, like HIV, is not an emergency in the way that a hurricane or tsunami is. These epidemics result from the conditions in which people live. Massive epidemics are a consequence of most people living in terrible conditions. These are long term trends, many people have never experienced anything but poverty and struggle. Perhaps an emergency can be declared in response to endemic diseases, one by one, as seems to be the favored approach by international institutions. But why not address the conditions in which people live and work, the rights they are denied, the determinants of health and the rest?

The emergency is that we have tried and failed to eradicate some of the most serious diseases by addressing them one by one and merely throwing drugs at them. The emergency is that realizing there is a problem and setting up institutions in wealthy countries is not enough. Countries like South Africa need health systems, education, infrastructure and decent living and working conditions. Addressing TB on its own will continue to fail unless other development areas are also addressed. If there is an emergency, it is that we have known all this for decades and have systematically failed to act on that information.

Peter Hain is not wrong, but we don't need to address basic health and social services and various other problems in order to eradicate TB, we need to do all these to eradicate any disease. We also need to address these issues to ensure that people enjoy good health, which is not merely the absence of disease. Of course, these are also conditions under which diseases can be controlled, and that includes TB. Throwing drugs at people and sending them back to the conditions in which diseases thrive, what we are doing right now, is clearly not the right approach.

[For more about non-sexual HIV transmission through unsafe healthcare, see the Don't Get Stuck With HIV site.]