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?

HIV Treatment is Necessary, But Not Sufficient, For Prevention

Medicins Sans Frontieres (MSF) has published a report on reduced funding for HIV treatment, from the World Bank's Global Fund and the US Government's President's Emergency Fund for Aids Relief (PEPFAR) in particular. MSF have good reason to be worried.

The pharmaceutical industry successfully lobbied governments and international institutions to pay huge amounts of money for antiretroviral (ARV) drugs that most of the people suffering from HIV/Aids would never be able to afford. In fact, the governments of countries with high rates of HIV/Aids would never be able to afford these drugs, either.

Countries like Kenya have the option to produce generic versions of ARV drugs at a fraction of the price that is currently being paid. But most countries, including Kenya, have chosen not to exercise this right, preferring to enact laws that make it unlikely that the country can produce or even purchase such cheap generic versions. Good relations with the pharmaceutical industry seems to be more important to them than saving the lives of their citizens.

MSF are right, huge ARV rollouts cannot now be stopped without endangering the lives of millions of people who are HIV positive and even people who are, as yet, HIV negative. But rather than arguing for the money to keep coming, in fast increasing amounts, they could concentrate on finding ways of reducing the cost of treatment so that it can continue and even expand.

How much of the billions of dollars of aid money have been spent on building factories to produce drugs that people need in Kenya? I haven't heard of any. Most of the money has been spent in ways that don't go on to produce anything or increase the country's sustainability or self reliance. The funds have mostly been spent as if HIV is just an emergency.

Well, it is something of an emergency, but there are underlying factors that are not part of an emergency. The country has a decaying health service, decaying education sector and a small and decaying infrastructure. People are poor, unhealthy, badly educated and unable to access vital services, such as clean water and proper sanitation. These are the things that face the majority of Kenyans every day, whether they are HIV positive or not.

Money spent on drugs, regardless of the overall condition of health systems is, to a large extent, wasted. Many drugs go out of date before being distributed, they get to people unprepared to take them properly, they are taken by people who are dying of other, easily prevented and treated illnesses, etc. My argument is not that ARVs should not be purchased and distributed and prescribed; it is that there needs to be a proper, accessible health service for all this to happen.

There is not a proper health infrastructure in Kenya, there hasn't been for a long time and increased HIV/Aids funding has not brought about a health infrastructure that serves people's needs. True, there are many clinics and institutions that were not here before HIV/Aids and wouldn't have even appeared. But these mostly deal with HIV/Aids, not other, basic health problems that people face.

My argument is also directed at the emphasis on HIV/Aids treatment over prevention. MSF's Goemaere is right to object to the prevention/treatment 'dichotomy'. Of course treatment has a positive effect on prevention efforts. But it is not enough to try to treat our way out of the epidemic. This is clearly not working and much more needs to be done to prevent new infections. Otherwise, the aim to treat everyone who requires treatment becomes even less attainable and less sustainable that it is right now.

People who are HIV positive need more than just drugs, or even treatment. There are a lot of threats to their health and welfare than HIV. They are dying because they are too far from the hospital, because the hospital is not up to the job of caring for them, because they are entitled to benefits they don't know about or that have been stolen by someone else, because they are poor and isolated and not considered important enough. But there just aren't the services needed to support chronically sick people and these will not just appear because the country is swamped by HIV/Aids (treatment) related institutions and programmes.

Those who are HIV negative need to stay that way and this won't happen by rolling out ARVs, alone. They have needs that are far more important and urgent that the possibility that they may become infected by something that won't kill them for many years. Most won't live for very long anyway, for a huge variety of reasons that are not being addressed right now.

Goemaere recognises the false dichotomy of treatment/prevention, but fails to see that increasing treatment while effectively ignoring prevention will not combat HIV/Aids in the long run. Assuming that HIV treatment will also prevent infections is not enough because it doesn't prevent enough infections and it never will. And treatment will never be as efficient as it should be if health, education, infrastructure and other social services continue to be ignored.

Some Signs of Prosperity in Kaptembwa?

Kaptembwa is not that far from Nakuru but, for some reason, there was a more prosperous feel about some of the homesteads and fields. We were there to visit people who are HIV positive and taking antiretrovirals (ARV). But people taking ARVs can, in most cases, go back to the work they were doing before they became ill. One woman we visited kept hens, goats and sheep. She also grew maize and various vegetables and had a small shop, a hole in the side of the house, to sell food and other day to day items to neighbours. It is a long way from the nearest big shops, but that is handy for people who can be enterprising, as this woman is.

The picture is not as rosy for many people because once they have Aids, they can suffer a lot of illness. ARVs don't work as well for some people as they do for others. One family we visited had to move from a bigger house when the father and mother found they were both HIV positive and in need of treatment. The father of the family is unemployed, as is his wife. His young boy is also HIV positive and suffering from various illnesses as a result. The youngest in the family, a three month old girl, may turn out to be HIV negative, it's not always certain at that age.

It's no secret that catching HIV early, before it results in people losing their livelihoods, is something worth concentrating on. But for people who are very poor and perhaps unemployed before they become infected, an early diagnosis may not help much. The family with no income get free drugs but can't always afford trips to health centres to collect drugs and for other visits. They can't afford a good variety of food to keep themselves and the children healthy. Children need a good diet, especially. But also, people who are on ARV treatment suffer side effects if they don't have a good level of nutrition. Some suffer so badly that they just stop taking their drugs.

Much of the money spent on HIV/Aids goes to drugs but many people infected and affected by this disease need a lot more than drugs. They need good food, clean water, proper housing, health, education and social services. Some people are doing well despite being HIV positive. But some are doing no better than they were before becoming infected while most are a lot worse.

A Solution to Age Old Problems?

For many years now, writers on HIV and AIDS have been warning that all infectious diseases involve a pathogen, hosts and a certain type of environment. There's no reason why HIV should be an exception to this way of analysing disease. Yet many proposed approaches to HIV relate to the pathogen, some relate to the host, but very few relate to the environment.

Antiretrovirals (ARVs), proposed vaccines and microbicides are examples of fighting HIV at the level of the pathogen. Behaviour changes such as partner reduction, treatment of other sexually transmitted infections and mass male circumcision are examples of approaches that address the hosts. The first set of interventions are highly technical and very expensive. The second set are very difficult to evaluate, slow acting and potentially expensive. Also, they are not enough on their own, they do not provide 100% protection, not even 50%.

Examples of fighting disease by improving the broad environment in which people live is probably the most long term and expensive of all. Such improvements would include better health services, education, social services, infrastructure, economic conditions, lifestyle, air quality and many other things. Such improvements are not so often discussed and even less often implemented. Of course, these don't guarantee 100% protection either, but they are all good and desirable things in themselves. They will reduce many other diseases and types of human hardship.

The question is, to what extent can the first and second kind of approach work without the third kind also being involved? Take ARVs, for example. A certain level of health service is required to test and monitor a population; other treatments are often required, too. People taking ARVs must take them every day, at the right time, for the rest of their lives. They need to change their lifestyle and their diet and, doubtless, other things.

This requires some of the very environmental conditions listed above. Of course, it requires money, but maybe the international community are thinking of providing the money, as they are so keen on technical interventions. They already provide condoms and various other supplies and services needed for prevention, treatment and care of people infected with and affected by HIV.

Which takes me back to the proposal I mentioned a few days ago to roll out universal testing and universal ARV therapy for all infected individuals. How many countries have the structural conditions that would be necessary to achieve even a fraction of what this proposal intends? The countries with the highest HIV prevalence are developing countries. That means that they have poor and declining health services, they have high disease burdens, they have low literacy, they lack a proper infrastructure!

Putting it a different way, people are poor, many live in very small houses made of corrugated metal, have no access to clean water or sanitation, collect firewood to cook basic and relatively innutritious food and I could go on, I probably will, but maybe something I have said so far is clear?

These problems all existed before HIV was identified, we know a lot about how to alleviate them, but in Kenya, many of these conditions have been getting worse for several decades. Are we going to continue to ignore them just because clever scientists have come up with a solution to one of a vast number of diseases that infect many people?

A country where such a proposal would be feasible is a country where there wouldn't be high rates of HIV in the first place. It would be a rich, developed country, where people don't depend on commercial sex for their income, where people don't have to migrate to a dangerous, all male environment for much of the year to find work, where people have proper nourishment and health services, clean water, nice houses and all the things the more prominent members of the international community probably have.

This is not to say that universal testing and ARV therapy should not be rolled out. If the international community is willing to pay for everything that would be required for this proposal to work, I look forward to an end to world hunger, poverty, disease and human degradation. In fact, if the authors of this paper can just say how they will achieve universal testing (without the use of extreme force), I'll grant them all the rest and not question them any further.

Aid is for the poor? Really?

One of the most interesting people I met last week works for Solar Cookers International. I have long been interested in solar cookers because they appear to have numerous advantages. In the field of international development this is very significant. Some people see development as being just one thing, population control, globalisation, political circumstances, corruption or whatever. I don't wish to define development but rather to say that, if the problem is malnutrition, food security is an issue, if the problem is a health risk factor such as acute respiratory infections, health is an issue, etc. They all relate to development; development is not just one thing.

Solar Cookers International make cheap solar cookers and other 'intermediate' technologies. More importantly, they give demonstrations and courses on using these technologies. This could play a part in development because it addresses nutrition, health, the environment and many other things. Using a solar oven, then, is not just a matter of cooking; it has implications for the nutritional value of the food, the environment, the economic circumstances of the user, the health of the user, the amount of time spent on domestic tasks, water and sanitation, using recycled materials and a whole lot more. Here's a partial list:

1) They don't require expensive fuel (that means time saved and less environmental degradation)
2) Reduced levels of smoke inhalation, experienced by women cooking and other occupants of kitchen
3) They preserve nutrients in the food because the food cooks more slowly
4) They can be used to pasteurise water and other utensils in areas where water may be contaminated
5) They can be used to heat water for cleaning and washing
6) Training in their use gives people knowledge about many other practical health and social issues
7) Recycled and cheap materials can be used to construct solar ovens, creating employment
8) They are light, portable and take up very little space when stored, compared to other cookers
9) They contribute to increased self reliance and self sufficiency

Another organisation I visited was called SHOFCO, based in Kibera, Nairobi. They carry out a number of activities relating to HIV, education and poverty reduction. I found their details when I was researching the use of income generation schemes as a way of allowing women to reduce and even eliminate their need to resort to commercial sex work.

Kibera is not an ideal place for solar cookers. There is not much space and Nairobi has less sun than many areas. However, there are communal areas in Kibera and there is enough sun to cook on many days of the year. Given the costs and advantages, the cost of a solar cooker would be recouped in a couple of months, perhaps less.

In addition to reducing household costs, it is possible that solar cookers could be produced by people in Kibera as a way of raising income. That's what I'm hoping, anyway. The problem is that many people adopting income generation schemes are undercutting each other's market. In Kibera, some women make and sell bead jewellery. However, there are so many people making and selling bead jewellery that it's getting harder and harder to make any money from it.

If you can't make enough money from your job, whatever it happens to be, you still need to resort to commercial sex work. If times get hard, and they are getting harder in Kibera, each woman needs to have more clients and to engage in more dangerous kinds of sexual intercourse, for example, agreeing not to use a condom. Bad economic conditions increase the vulnerability of people who are already poor, exposing them to HIV and other risks.

I look forward to meeting and hearing from others who have tried out income generation schemes of various kinds, and those who have successfully adopted intermediate technologies.
Renewable energy, of course, is not the only type of intermediate technology. Solar Cookers International also sell cheap and easy to use water testing kits. Many diseases in a country like Kenya are water borne, eg. cholera, E Coli and the many diseases caused by various intestinal parasites. Water and sanitation also play a part in the spread of malaria as mosquitoes breed in stagnant water.

If I seem to hop from one subject to another, I apologise, but these matters are all connected, really!

Cholera and Malaria relate to one of the largest sources of funding for the search to eliminate these problems; I'm referring to the Bill and Melinda Gates Foundation. Far from wishing to criticize an organisation that contributes so much to good causes, I'd like to look at disease a different way. The Gates Foundation is putting a lot of money into finding a vaccine for cholera. Yet cholera only exists where there is little or no water and sanitation infrastructure, where people don't have access to clean water.

The cure for cholera is clean water. Dying from cholera means dying of dehydration, perhaps after repeatedly drinking contaminated water. Countries who once had a problem with cholera no longer have that problem because they have addressed water and sanitation issues. A vaccine would be brilliant, except that it would not solve all the other water borne diseases, and there are many. What is the point in surviving cholera only to die of E Coli or hepetitis E?

Malaria is not so simple but again, countries that now have good water and sanitation no longer have malaria. The Gates Foundation has, quite rightly IMHO, been criticized for taking human resources from other projects, overlapping with existing health projects and distorting health funding. The Foundation has prioritised a few diseases when it's not the diseases that are the main problem. It's the risk factors, such as water and sanitation or acute respiratory infections that we should be concentrating on.

There are two other concerns that receive a lot of the Foundation's money: HIV and genetically modified crops (GM). The foundation is interested in finding a cure for HIV or treating HIV positive people and 'feeding the starving', allegedly. But only if these solutions involve intellectual property, it seems, intellectual property being something very close to the Gates heart.

Anti retroviral drugs (ARVs) and GM technologies are pieces of intellectual property. There are very cheaply produced drugs that do the same thing, but US money goes into expensive ARVs, produced by Americans in America. Does this make you think of the free condoms distributed in Mumias?

GM corn is a modified version of the corn that you see hundreds of hectares of between Mumias and Eldoret. But it costs a lot of money and it belongs to the company that produces it, not the person who grows it. A farmer can grow one crop with GM corn before buying more seed, from the GM producer, of course. Using the non GM version, they can save seed and grow corn every year.

Where was I? Oh yes, intermediate technology, such as renewable sources of energy. This technology is owned by whoever uses it. This can be contrasted with high technology, which belongs to very rich multinationals. So, would you choose a cheap technology that eradicates cholera and most other water borne diseases and has many other advantages, or would you choose a very expensive one that only eradicates cholera for those who can afford it? It only works for as long resistance to it is not developed. But then, a new version can be found, at a cost.

Finally, for those working with HIV and AIDS, I hope you have a productive World Aids Day! I'll post the news from Mumias later today or tomorrow.