According to a BBC article, male inmates in a prison in KwaZulu-Natal are asking to be circumcised because they believe it will protect them from HIV. It sounds like they have been seriously misinformed. However prisoners may become infected with HIV, and however they may infect others, it is unlikely to be through heterosexual sex.
Figures for men who have sex with men (MSM) include prison populations in the Kenya Modes of Transmission Survey, so it's hard to tell which contributes more to the epidemic. The overall figure is an estimated 15%. However, it would be difficult to attempt to reduce transmission in these groups without really understanding exactly how transmission occurs.
In prison populations, if other countries are anything to go by, tattooing, forced or voluntary, may well play a significant role. If prisoners receive any invasive medical treatment, this may also play a part. Indeed, the very circumcision operation that is supposed to give them protection from HIV could be carried out under unsterile conditions. Prisoners may thereby increase their risk of being infected with HIV and other blood-borne viruses.
Intravenous drug use may also play a part in African prisons and access to adequate supplies of sterile injecting equipment is unlikely where such practices are forbidden. Condoms are also unlikely to be available on the grounds that sex of any kind is also forbidden.
If, as is often assumed, a large amount of HIV transmission in prisons is through men having sex with men, circumcision is unlikely to give any benefit. Circumcision has never been shown to give protection during anal sex. It might even increase risk of transmission. And circumcision will, of course, have no impact on non-sexual transmission whatsoever. This may seem obvious, but not that much is known about the extent to which HIV transmission is truly sexual, MSM related, non-sexual, etc; this is the case both in and out of prisons in African countries.
The BBC article seems to be unburdened by any research or any attempt at criticism. It's just another titillating article about HIV and its assumed associations with illicit sex. But it is particularly worrying that a health minister has said the prison hospital is overwhelmed. When a hospital is 'overwhelmed', do they cut corners, reuse equipment or take any other risks? The fact that the circumcisions are voluntary will be of little comfort to those who question the wisdom of circumcising as many men as possible because of some very dubious evidence that it reduces HIV transmission.
Despite the unconvincing arguments available for the effectiveness of male circumcision in reducing HIV transmission, the pro-circumcision brigade have produced 'evidence' that the operation will be even more effective than previously estimated. This evidence consists of some mathematical modelling, the likes of which has been used to justify all sorts of things, including the assumption that sexual behavior is responsible for almost all HIV transmission in African countries, though not in non-African countries.
That sounds like a pretty flimsy reason for having an invasive operation that may not work and that may carry more risks than it is expected to avert. But the pro-circumcision brigade is not averse to flimsy reasoning. After all, it's not their penises that are in question. They are not taking any risks themselves and are not considered to be the perpetrators of 'unsafe' sex, carelessly spreading HIV among their fellow Africans.
Interestingly, there is a rare voice of opposition to the mass male circumcision orthodoxy from Miriam Mannak. Unfortunately, Mannak seems to be persuaded by some of the pro-circumcision rhetoric that passes for evidence in the HIV world. But she raises a number of objections to the procedure and employs a rarely found quality in her thinking: compassion. The striking thing about adherents of the circumcision approach and the sexual behavior theory of HIV transmission is that they appear to have no compassion or sense of humanity.
As a result, a lot of HIV 'prevention' programing consists of what amount to punitive measures, designed to control an imagined animalistic attitude towards sex and towards sexual partners that only exist in African countries. Mass male circumcision is just one part of this set of punitive measures. It is likely to be as unsuccessful as previous measures to reduce HIV transmission. If epidemiologists fail to even think of people as people, their mathematical models will continue to be as useless as they have been in the past.
Showing posts with label epidemiology. Show all posts
Showing posts with label epidemiology. Show all posts
Monday, November 1, 2010
Wednesday, March 4, 2009
The Wisdom of Hacks
When a journalist goes 'in search' of a story, would it be more correct to say that they know what they want to write about but that they need a bit of scenery? Elizabeth Pisani seems to want to find stigma everywhere that she 'researched' her article (or is it a review?), so she just adds the word in at every opportunity. But had she bothered to read through her own article, she would have found stigma aplenty.
Pisani doesn't just write about stigma, she also stigmatises people with HIV, people she considers to be prostitutes and whores, gay men, anyone who has or may one day be infected with HIV. In her time as a journalist, has she never heard that people who have sex with other people are human beings, not whores or prostitutes? Did she never come across human beings in her career as a human being, journalist or epidemiologist?
Yes, she claims to have studied and worked in epidemiology. But don't worry, there is barely a hint of data or scientific reasoning in this article. It's all prejudice and gutter press cant. Where she didn't find the stigma she craved, she certainly left some behind on her way out. And brought some back home with her as well.
But did Pisani ask the woman she was talking to if she was a 'prostitute'? Well, we don't know, but she was in a bar. Certainly in bars in Kenya and Tanzania it is often assumed that women there must be prostitutes. Like any good journalist, she didn't feel the need to leave anything traceable, checkable or testable in her article. And this journalist is not afraid to exploit human misery and, in the process, contribute to that misery.
There are many reasons for not wanting to take a HIV test, aside from fear of stigma. People don't want to find out they are ill, whether it is with something easily treatable, something that will disappear in time or something that is death threatening. It's not pleasant to find you have a virus, cancer or any other condition, regardless of the effects it may have. There's the dependence on others and on unreliable health services to consider, as well.
But people are also afraid of medical professionals, afraid of giving a blood sample or being manhandled by professionals of any kind. This is true in any country, developing or developed. But in developing countries, where most people rarely or ever see a health professional, testing for HIV can be even more traumatic.
There may be some people who don't care whether they are HIV positive or not, they may think it is inevitable that they and others around them will eventually become infected. Maybe it's all the same whether they are infected with HIV or something else, because other diseases could kill them much more quickly. People become very fatalistic when they are in desperate situations.
There are people who believe myths about testing, such as that it is harmful, that it doesn't work for certain blood types, that it always means you will be positive, etc. Where do they get these myths? Well, many of them have been well propagated by newspapers since the epidemic was first recognised. The myth about condoms having holes in them came from some priests and other religious people. The one about condoms not working very well came from American politicians. The myth about using beetroot or having a cold shower came from some South African politicians, the list is endless. If you want to research them, just look through some newspaper archives.
People may not want to take a test because it is too expensive. Ok, the test itself is free but transport to the clinic is not. If a person is found to be HIV positive the drugs are free but the transport to and from the clinic every month, or every few months, is not free. Nor are the foods, food supplements and drugs people need during the course of their treatment, which is for the rest of their lives.
I have spoken to people who were prevented from testing by circumstances they could do nothing about, such as distance from the facility, lack of funding or opportunity, etc. I have also spoken to people who have become infected through circumstances they had no control over and people who are presently in great danger of becoming infected but can't do anything about it. I find it hard to believe that Pisani never came across such people.
And what do people do about protecting themselves, testing and treatment when there is a civil disturbance, a famine, a global financial crisis or all three in the same year? Well, they just about get by. People are used to getting by or dying in the attempt.
But HIV, like malaria, TB, various cancers, intestinal parasites, malnutrition and other endemic conditions, is not pleasant, even if it is treatable. I'm sure Pisani could come up with additional reasons for not wishing to take a HIV test, aside from stigma.
She goes on to ask "Why don't people ask casual sex partners if they have HIV before they strip off?" Just imagine the scene, last thing before taking off your clothes, the person you were considering sleeping with saying, "yes, I am HIV positive". If I was facing my first chance to make a few dollars in days and had no other source of income, I don't think I would ask, nor would I answer honestly if I was HIV positive and the question arose.
Pisani (and I, for that matter) have other options, we have a source of funding for our next meals and other comforts, we are not in a desperate situation. We are probably both HIV negative as well, so the need to lie about our status is not an issue either.
A 'quality' newspaper like the Guardian (and its readers) should realise a few things that they may not learn from their journalists: people who have sex with other people are not prostitutes and whores. Most people have sex with other people, Pisani's parents had sex, even if she doesn't. All over the world people have sex, yes, even unprotected sex.
But there is not a serious HIV epidemic in every country in the world. The Western country where Pisani lives doesn't have a problem with shortages of fuel or basic food (to the extent that people's health and lives are threatened on a daily basis), there just aren't as many desperate people there. Not yet, anyhow. So there will not be such huge numbers of people coming to Western cities to find work and, not finding it, turning to transactional sex. But that is the case in Nairobi and many other African cities.
There is not the same problem of having to move to a country like Botswana to work in terrible conditions in mines for very little money, away from home and family, where men are forced to live with other men, with no entertainment or comforts for long periods of time. But these problems exist in Tanzania, South Africa, DRC and other countries.
There were no serious episodes of post election violence in Western countries recently and there were certainly no conflicts like the ones in DRC, Sudan and Somalia. Not that Western governments didn't have a part to play in those conflicts, but the disturbances didn't occur in those Western countries. There are only serious HIV epidemics in some countries in the world, yet in all countries people have sex, even (the horror!) unprotected sex.
Don't the Guardian and their readers want to know about some of the many reasons for this?
Despite her alleged background in epidemiology, Pisani seems to adhere to the Victorian prudishness about HIV that assumes and sometimes even states that it is all a matter of people having sex and behaving stupidly. So all they have to do is to behave smartly and things will be ok, right?
But people in Western countries waste more food than people in developing countries eat, that's stupid. What they can't eat, they now want to burn in their cars, that's stupid. There are enough armaments produced in the West to wipe out everyone several times over, that's stupid. Contributions to global warming by Western countries (or in developing countries on behalf of Western countries) threaten the future of humanity, that's stupid. But HIV in Western countries is not the major threat that it is in developing countries.
Pisani is right about one thing, there is a lot of stigma. But her article merely adds to this. And as long as HIV is seen as just a matter of sex and stupidity (or any other simplistic explanation), we will make little progress in preventing the spread of the virus or providing treatment for those who are infected.
There are high rates of HIV in developing countries because people there are extremely vulnerable, whether it is through poverty, poor health, lack of education, labour practices, inequality or exploitation. Vulnerable people are more directly and more immediately affected by disease, global warming, financial crises, famine, water insecurity and anything else that's going around, whether these originated among vulnerable people or not.
Pisani doesn't just write about stigma, she also stigmatises people with HIV, people she considers to be prostitutes and whores, gay men, anyone who has or may one day be infected with HIV. In her time as a journalist, has she never heard that people who have sex with other people are human beings, not whores or prostitutes? Did she never come across human beings in her career as a human being, journalist or epidemiologist?
Yes, she claims to have studied and worked in epidemiology. But don't worry, there is barely a hint of data or scientific reasoning in this article. It's all prejudice and gutter press cant. Where she didn't find the stigma she craved, she certainly left some behind on her way out. And brought some back home with her as well.
But did Pisani ask the woman she was talking to if she was a 'prostitute'? Well, we don't know, but she was in a bar. Certainly in bars in Kenya and Tanzania it is often assumed that women there must be prostitutes. Like any good journalist, she didn't feel the need to leave anything traceable, checkable or testable in her article. And this journalist is not afraid to exploit human misery and, in the process, contribute to that misery.
There are many reasons for not wanting to take a HIV test, aside from fear of stigma. People don't want to find out they are ill, whether it is with something easily treatable, something that will disappear in time or something that is death threatening. It's not pleasant to find you have a virus, cancer or any other condition, regardless of the effects it may have. There's the dependence on others and on unreliable health services to consider, as well.
But people are also afraid of medical professionals, afraid of giving a blood sample or being manhandled by professionals of any kind. This is true in any country, developing or developed. But in developing countries, where most people rarely or ever see a health professional, testing for HIV can be even more traumatic.
There may be some people who don't care whether they are HIV positive or not, they may think it is inevitable that they and others around them will eventually become infected. Maybe it's all the same whether they are infected with HIV or something else, because other diseases could kill them much more quickly. People become very fatalistic when they are in desperate situations.
There are people who believe myths about testing, such as that it is harmful, that it doesn't work for certain blood types, that it always means you will be positive, etc. Where do they get these myths? Well, many of them have been well propagated by newspapers since the epidemic was first recognised. The myth about condoms having holes in them came from some priests and other religious people. The one about condoms not working very well came from American politicians. The myth about using beetroot or having a cold shower came from some South African politicians, the list is endless. If you want to research them, just look through some newspaper archives.
People may not want to take a test because it is too expensive. Ok, the test itself is free but transport to the clinic is not. If a person is found to be HIV positive the drugs are free but the transport to and from the clinic every month, or every few months, is not free. Nor are the foods, food supplements and drugs people need during the course of their treatment, which is for the rest of their lives.
I have spoken to people who were prevented from testing by circumstances they could do nothing about, such as distance from the facility, lack of funding or opportunity, etc. I have also spoken to people who have become infected through circumstances they had no control over and people who are presently in great danger of becoming infected but can't do anything about it. I find it hard to believe that Pisani never came across such people.
And what do people do about protecting themselves, testing and treatment when there is a civil disturbance, a famine, a global financial crisis or all three in the same year? Well, they just about get by. People are used to getting by or dying in the attempt.
But HIV, like malaria, TB, various cancers, intestinal parasites, malnutrition and other endemic conditions, is not pleasant, even if it is treatable. I'm sure Pisani could come up with additional reasons for not wishing to take a HIV test, aside from stigma.
She goes on to ask "Why don't people ask casual sex partners if they have HIV before they strip off?" Just imagine the scene, last thing before taking off your clothes, the person you were considering sleeping with saying, "yes, I am HIV positive". If I was facing my first chance to make a few dollars in days and had no other source of income, I don't think I would ask, nor would I answer honestly if I was HIV positive and the question arose.
Pisani (and I, for that matter) have other options, we have a source of funding for our next meals and other comforts, we are not in a desperate situation. We are probably both HIV negative as well, so the need to lie about our status is not an issue either.
A 'quality' newspaper like the Guardian (and its readers) should realise a few things that they may not learn from their journalists: people who have sex with other people are not prostitutes and whores. Most people have sex with other people, Pisani's parents had sex, even if she doesn't. All over the world people have sex, yes, even unprotected sex.
But there is not a serious HIV epidemic in every country in the world. The Western country where Pisani lives doesn't have a problem with shortages of fuel or basic food (to the extent that people's health and lives are threatened on a daily basis), there just aren't as many desperate people there. Not yet, anyhow. So there will not be such huge numbers of people coming to Western cities to find work and, not finding it, turning to transactional sex. But that is the case in Nairobi and many other African cities.
There is not the same problem of having to move to a country like Botswana to work in terrible conditions in mines for very little money, away from home and family, where men are forced to live with other men, with no entertainment or comforts for long periods of time. But these problems exist in Tanzania, South Africa, DRC and other countries.
There were no serious episodes of post election violence in Western countries recently and there were certainly no conflicts like the ones in DRC, Sudan and Somalia. Not that Western governments didn't have a part to play in those conflicts, but the disturbances didn't occur in those Western countries. There are only serious HIV epidemics in some countries in the world, yet in all countries people have sex, even (the horror!) unprotected sex.
Don't the Guardian and their readers want to know about some of the many reasons for this?
Despite her alleged background in epidemiology, Pisani seems to adhere to the Victorian prudishness about HIV that assumes and sometimes even states that it is all a matter of people having sex and behaving stupidly. So all they have to do is to behave smartly and things will be ok, right?
But people in Western countries waste more food than people in developing countries eat, that's stupid. What they can't eat, they now want to burn in their cars, that's stupid. There are enough armaments produced in the West to wipe out everyone several times over, that's stupid. Contributions to global warming by Western countries (or in developing countries on behalf of Western countries) threaten the future of humanity, that's stupid. But HIV in Western countries is not the major threat that it is in developing countries.
Pisani is right about one thing, there is a lot of stigma. But her article merely adds to this. And as long as HIV is seen as just a matter of sex and stupidity (or any other simplistic explanation), we will make little progress in preventing the spread of the virus or providing treatment for those who are infected.
There are high rates of HIV in developing countries because people there are extremely vulnerable, whether it is through poverty, poor health, lack of education, labour practices, inequality or exploitation. Vulnerable people are more directly and more immediately affected by disease, global warming, financial crises, famine, water insecurity and anything else that's going around, whether these originated among vulnerable people or not.
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