Plans Are Not Achievements, Not Yet

Recently, Ribbon of Hope started assessing families for an orphan and vulnerable children program (OVC). The idea is that the families will bring up the children and Ribbon will support them. The kinds of support Ribbon will give will include advice on health and welfare, budgeting and household cost management and anything else we can advise on. We will also provide some financial support so the families can supplement household income by running a small business. The finance comes from private donors.

The assessments are difficult because there's no question of finding the most needy 22 children. It's unlikely that three or four Ribbon members could identify the most needy in any of the villages we work in, no matter how long we spent there. All we can do is identify as many as we can support and assess them to ensure that we really can succeed in helping each family to give the children what they need until they become independent.

The initial assessments were mostly encouraging, although some guardians are more in need of assistance than the children they are caring for. Some are probably even incapable of looking after another child, perhaps even incapable of looking after their own children. But other families are very capable and they should, with some help, also be able to set up and run some kind of income generation activity.

In retrospect, we were naive in thinking that asking each guardian or family to write a business plan would result in anything tangible that we could work on. We discussed with each person what they would like to do and how they would approach setting up their activity, if they had the finance. The discussions went well but the written business plans, at best, consisted of a list of goods and prices, at worst, one word and a cost. Most people can read and write a bit but many have rarely done so since they left school.

Feeling a bit stupid, I started to look up advice on writing business plans online. Some of what I found, I would be hard pressed to write myself. They are complex and use a lot of technical vocabulary which, having studied project management and related areas, I suspect is mainly bullshit. But thankfully, one site gave a simple list of the sorts of information you need to know before attempting to set up a business.

I am aware that starting up a business is not easy and that many businesses fail. Many of the income generation activities we have set up or helped to set up have failed or lapsed or bumped along, producing little benefit. But we are attempting small things, growing food crops, fruit and vegetables, keeping a cow or a goat or a few chickens. There's no reason why people should be made to jump through hoops that will have little or no bearing on whether they succeed or not.

Having said that, we need to know a handful of basic details from everyone, such as why they are starting the business, what they will sell and to whom, why people will buy from them and how much, how this will make them better off, how they will prepare for risks and cope with problems and how to run their finances, which is not always straightforward if you try to do it all in your head. We don't want to burden our clients with information that we need to collect. But we need them to answer these questions, so we have a solid foundation on which to build a small income generation activity.

No matter how dangerous it is to make assumptions, it's hard to get through a day without making some. I've made assumptions about people's working knowledge of English and even their level of education. English is an 'official' language but many have little opportunity to use it and even when they do, technical terms can be just sounds. Even those who have spent long enough at school and have done well enough there have few opportunities to use what they learned, and 'Standard 8', 'Form 4' or 'fluent' are also just sounds; grades are just numbers, often completely meaningless.

We are two thirds of the way towards the Millennium Development Goals, which developing countries are expected to have reached by 2015. But what will it mean if countries like Kenya achieve some or all of those goals? If lots of children enrol for school but hardly ever attend, perhaps never; if they get good grades but have learned nothing because the tests are just pages of multiple choice questions with tick boxes; if the teacher is absent most of the time, either because there is a shortage of teachers or because the teacher doesn't bother turning up most of the time? And similar remarks apply to other education indicators. Will these achievements be nothing but sounds or boxes ticked?

In countries where education has been failing for decades, it takes several generations for things to improve. The children we are hoping will grow up to be independent have siblings and parents who had little education. Even some of the teachers had a relatively poor education and some of the young people going to teacher training colleges now have managed to get through the system without learning much. I hope the aim of the Millennium goals is to make genuine improvements in people's economic circumstances, education, health, environment and infrastructure. But what I have seen is not encouraging.

Repeating 'good news' over and over again doesn't make it so. Saying people's lives have been transformed doesn't transform them. And writing things down doesn't make them any truer. Ribbon's work seems to involve creating some kind of bridge but sometimes I feel that we are attempting to translate the concrete into the amorphous, hoping that things like education and healthcare will become part of people's everyday lives. Somehow, these promises that have been made for so long seem to remain amorphous, things attained by the fortunate few who live far away, out of sight.

I guess the most important question for a simple business plan is how you intend to go from having very little to having a bit more and hopefully, enough. How does selling fish, keeping a cow or owning a motorbike ensure that each member of your family grows up to be able to have their own independent family? Perhaps writing it down oversimplifies things because running a business is about doing things, not just saying, writing or thinking them. We need written business plans but if we mistake them for the achievement of the goals of the business itself, we'll have nothing but bits of paper in a year's time! The business plan is so vital and yet completely useless if it remains just a plan. Bit like the Millennium Development Goals.

Rambling in Kenya

Yesterday, I made the fairly familiar journey from Nakuru in Rift Valley province to Mumias in Western Province. There are many beautiful sights on the way and the weather was good for travelling, sunny but not too hot. The roads for some of the journey have been improved, some are sill in the process of being improved and others are disintegrating and in a very dangerous condition.

Infrastructure conditions in Kenya have a lot to do with structural adjustment policies imposed by the IMF (International Monetary Fund) and the World Bank. These were first imposed in the early 1980s and they are still used, but they go under different names sometimes. Whereas, the road and other infrastructure improvements have a lot to do with Chinese development, which is carried out without the same level of conditionality.

Much of the fertile land in Nakuru is owned by a handful of very rich people, many of whom are members of political families, the Mois and the Kenyattas, for example. And like a lot of rich landowners, they don't feel the need to grow food crops or, at least, not food crops for Kenyans. You might think that wheat, sorghum and millet are food but the large scale producers, apparently, grow these crops to sell to breweries.

A few hours from Nakuru, the next big non-food product is tea, which dominates Kericho. Most of the industry is foreign owned or run and Kenyans make very little from this monoculture. It may be a world renowned product, but employees are paid very little, live in bad conditions and have few labour rights. That applies to those who have real jobs, rather than the far larger number, who have to take whatever bit of work that crops up, however rarely and however badly paid.

One of the big employers there is Unilever. You can read up on their level of corporate social responsibility on the Corporate Watch website. Suffice to say, they tick all the boxes that you'd expect of a multinational; monopolistic practices, unsustainable agriculture, exploiting cheap resources and labour, environmental degradation, appalling health conditions and a whole lot of other things. It's a long and depressing read.

Long before you reach Mumias you begin to see the sugar cane fields, sugar being another of Kenya's handful of monocultures that have played a big part in keeping Kenya poor for many decades. While sugar cane has long been grown in Mumias to be used as sugar, now there are plans to grow even more sugar cane destined for the biofuel market. Yet more land that could be used for food is being sacrificed for the blessed export market. The profits will go to a handful of rich people. Mumias Sugar Company does pay its employees well but the majority of people who work for the Sugar Company are not considered to be employees. They are casuals, contractors, outgrowers, etc. The majority of them make bugger all.

It probably sounds like I have a thoroughly miserable time travelling through Kenya, thinking about how much of the country is dedicated to exploitation. Well, there are still a lot of beautiful sights, if you are in a position to enjoy them. There's a good reason why tourists come to places like Kenya and even the trip to Kakamega Rainforest, Mount Elgon and Lake Turkana can be a great way of seeing the country. But even the tourist industry is another case in point; very few people make most of the money. The majority eke out a living somehow, but much of the tourist revenue doesn't even stay in the country.

Such conditions in developing countries may be, to some extent, influenced by their own governments. There are, indeed, many corrupt politicians and other parties and they have made themselves very rich. But governments, multinationals and other parties in rich countries have also made themselves rich by grabbing much of the wealth to be made in developing countries. And institutions like the IMF and the World Bank (and the World Trade Organisation) are simply some of the tools by which the rich and powerful extract huge amounts of wealth from the poorest and most vulnerable people in the world.

Poverty and underdevelopment are not remote phenomena, far from Western style homes and living conditions. The forces that create and exacerbate poverty also bring to those living in comfortable conditions many of the cheap products that make their lifestyle possible. Tea, chocolate, coffee and other things that come, primarily, from developing countries, are only affordable because of policies created by undemocratic institutions (who, ironically, constantly talk about improving democracy in developing countries). Even Ipods, Iphones and Macs, made by a company that likes to boast about how responsible they are, depend on (high value) materials extracted cheaply from countries like the Democratic Republic of Congo.

Much of Western democracy itself, and much Western wealth, depend on the terrible conditions that are created and maintained by undemocratic international financial institutions, multinationals and powerful governments in developing countres. It doesn't seem possible for every country in the world to end up with the same kind of democracy enjoyed by a handful of the world's people. I don't want to argue that democracy is impossible or that it is wrong. Perhaps, as Amartya Sen has argued, there is not enough democracy. Perhaps it is not widely enough distributed.

But if Sen is right and there were more democracy in the world, I think it would look a lot different. The small number of countries that have enough, too much in fact, use more resources per head of population than the world can provide. The level of choice that some people enjoy, the range of goods and services, necessary and unnecessary, the opportunities to overconsume with impunity, could not be offered to all peoples, equally. But I haven't gone deeply enough into political philosophy yet to figure out what sort of democracy would be sustainable democracy. Perhaps I'm just rambling.

I'm in Mumias to visit a very fine NGO called SAIPEH (Support Activities in Poverty Eradication and Health). Like the community based organisation I work for, Ribbon of Hope, Nakuru, they work with HIV positive people and their families, people suffering from hardship, orphans and vulnerable children. (Except that SAIPEH has been going for about 14 years, Ribbon of Hope is still small and young, not much over a year old.) Anyhow, they run all kinds of income generation schemes, such as growing food crops and livestock, teaching people trades, such as tailoring and computing and various other initiatives.

I'm hoping that SAIPEH will be interested in schemes that reduce spending too, such as solar cookers, cooking baskets and fuel briquettes made from organic waste materials. For lack of a convincing political philosophy, I'll stick to a more Aristotelian form of home economics in the hope that, although people will not end up rich, they may end up with a bit more cash than they had before. After all, for Aristotle, all economics was home economics.

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.

Celebrate World Aids Day By Dismantling UNAIDS

UNAIDS has never been shy about producing long and colourful documents about HIV/Aids and in the last couple of days they have released two; the Outlook Report 2010 takes a look back and compares the HIV pandemic of today with that of the mid 1990s; the second document is the yearly AIDS Epidemic Update, which I haven't had the strength to read yet.

The Outlook Report, like many of the various articles commenting on one or other of the reports, sometimes takes a rosy view of how the international community and the AIDS community have dealt with the pandemic. In the sense that things have moved on, and finding that you are HIV positive no longer has the significance it once had, they are right. We have come a long way in treating what was once an untreatable illness that would lead to a certain and very unpleasant death.

But the worrying thing is how the Outlook Report, like many UNAIDS and other reports in the past, talk about the importance of HIV prevention. It has been obvious that HIV prevention is so important that the amount of HIV money spent on it needs to be increased considerably. But the amount has gone down and the prevention programmes that get most of the money have little or no effect and have never had much effect.

Defenders of the disproportionate amount spent on treatment and care of HIV positive people are fond of pointing out that this shouldn't be an either/or debate. True, it shouldn't, both treatment and care on the one hand and prevention on the other should receive more funding than they presently receive and the funding should be more equitably divided. Treatment and care contribute a certain amount to HIV prevention but they are not the same as prevention and they will never contribute more than a certain amount. That's why there are five new infections for every two people put on antiretroviral treatment.

The report goes on to allude to the work that has been done to show that prevention programmes, such as they are, fail to target those most at risk in populations. Most of the money is spent on populations as a whole and very little on, for example, men who have sex with men, commercial sex workers, intravenous drug users, prison populations, fishing communities around Lake Victoria, mining communities and various others, who are very often at risk because of their occupation or lifestyle.

The report seems aware that HIV transmission is not primarily about individual behaviour and that there are different kinds of HIV epidemic in different countries and that some people are more at risk than others. It even seems cognizant of the fact that it is the circumstances in which people live that makes them more or less likely to become infected with HIV. But it hasn't made the leap to realizing that in some countries, especially developing countries, most people live in such circumstances. Not everyone is at equal risk of becoming infected but most people live in conditions that mean they are already at high risk of becoming infected or that they will one day be at high risk of becoming infected.

That makes it sound like HIV prevention is unlikely to ever have much success, but the opposite is true. Treatment and care have been to a large extent dominated by commercial interests. Products, processes and services have been developed, many by those who are in a position to profit from them. But prevention has been dominated by the party-political and pseudo-moral debates of political and religious leaders. Their aim is to further their own agenda, which are far from being concerned about millions of people becoming sick and dying.

Raising awareness about HIV, sexually transmitted infections, sexual health, reproductive health and anything else is good and will go a long way towards protecting people from a number of dangers. But good overall health, healthcare, nutrition, food security, education, infrastructure and many other benefits would give people the maximum protection, not just from HIV, but from other illnesses and ills.

And this brings us to another often repeated pronouncement made by various senior HIV/Aids experts. They like to deny that HIV funding has distorted health and development funding and disrupted more general programmes that aimed to benefit societies as a whole. HIV/Aids funding is not too high, it needs to be higher. But there needs to be a similar move to spend the money more equitably. HIV will not be eradicated without health services, education and other social services, no matter how much money is thrown at it.

So, spending money on all other areas of development will also contribute to the fight against HIV/Aids. But continuing to spend disproportionate amounts on HIV/Aids will not benefit the many other development issues that have been hijacked by numerous commercial and political interests. HIV treatment and care is just one of many health issues that the world faces but HIV prevention is about health, not disease. Therefore it has far broader significance and affects far more people than one single disease. In fact, it affects everyone.

Ultimately a self-serving and very expensive organisation, UNAIDS needs to be reabsorbed back into the overall agenda of public health, or some agenda that encompasses the health of everyone, not the sickness of a few. This is not to say that HIV positive people should not be entitled to treatment or care. Rather, they and all other sick people should be entitled to treatment and care. But people who are not sick should be enabled to stay that way. UNAIDS is good at diverting a lot of money for people once they are HIV positive but this is denying the right of HIV negative people to stay that way.

Treatment As Prevention

An interesting discussion arose in Switzerland some months back. HIV positive people who are responding to antiretroviral therapy (ART) usually have an undetectable viral load. As a result, they are not very infectious. So discordant couples, where only one partner is HIV positive, are advised that they can enjoy a normal sex life, virtually as if neither was HIV positive.

It’s important to note that, even in countries like Switzerland, not everyone responds to ART to the extent that they have an undetectable viral load. And things can change. They need careful monitoring and advice. So this is great news for people living in countries where they get very good medical care, have good levels of nutrition, have enough money to pay for any kind of treatment and care and even have an adequate level of education to understand and discuss the implications of being in a HIV discordant relationship.

But most people don't live in rich, developed, Western countries. They are lucky to find out that they are HIV positive early enough for ART to work as well as it does in developed countries. They usually don't have access to good medical care, don't have adequate nutrition for any health status and can't afford any treatment or care, aside from the pills paid for by donor aid. And they are unlikely to have a standard of education that would allow them to follow the complex debates about sexual behaviour and lifestyle choices for HIV discordant couples and the like.

Who knows what percentage of HIV positive people on ART in developing countries are responding well and have an undetectable viral load. In most cases, nobody is checking. Things can change rapidly, like during the post election violence last year, when many people on ART were unable to get their drugs. There are stock outs, such as that experienced in Uganda on several occasions. And there is the current financial crisis, which has resulted in several countries finding that they are unable to guarantee supplies of drugs and related services, even to the minority currently on ART.

But in reality, for developing countries, the most worrying thing about the so called 'treatment as prevention' debate is that treatment is not prevention. The more people on treatment, the better, there's no doubt about that. But as more and more people are starting ART, there are still tens of thousands of people becoming infected with HIV in Kenya every year.

Treatment should support Kenya's prevention campaign but it should never become that campaign. At present, over 75% of the tens of millions of dollars being spent on HIV goes to treatment and care. 'Treatment and care', in this instance, mainly refers to drugs. Many areas of health are relevant to HIV treatment and care but once the grossly over priced pills have been paid for, there is not much left for anything else. That's why only about of third of the people who need ART at present are receiving it.

Nowhere near enough money is being spent on prevention and there is even a danger that the 'treatment as prevention' slogan could end up further skewing the way HIV funds are spent. People are being infected every day and they need education, health services, infrastructure, jobs, legal rights, equality and things like that. This is not just to do with HIV alone, it's also to do with ensuring people's human rights so they can enjoy a decent quality of life.

For too long, the development agenda has been determined by rich multinationals, such as pharmaceutical companies and the health care industry. Development has always been seen as a huge market for overpriced goods, which is why so much money goes 'into' developing countries without seeming to have much effect. It goes into the pockets of rich industrialists.

HIV treatment is vital, both for people who are already infected, those who are indirectly affected and those who are, as yet, uninfected and unaffected (if there are any of these). But prevention is also vital. And for treatment, care and prevention programmes to work properly, people need schools, teachers, hospitals, health professionals, legal protection, equality, employment and many other things.

The developing world is not populated with billions of customers; it is home to billions of extremely poor and vulnerable people. HIV needs to be prevented, not just treated.

More of the Basics, Please

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

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

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

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

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

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

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

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

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

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

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

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

Centres and Peripheries

The trip back from Mumias to Nairobi was long, hot and often bumpy. But there were no incidents, flat tyres, etc. Only the usual poorly surfaced roads and traffic jams in Nairobi. It’s only about 350km so nine hours is slow, but not the worst.

Infrastructure is a big problem in Kenya and East Africa in general. So many projects assume a certain level of telephone, mobile, rail and internet connections and quickly run into difficulties.

For example, there are hundreds of internet cafes in Nairobi but try to find one where you can do everything you need to do online and you may have difficulties. I tried today for three and a half hours and just as I was about to compromise and try to achieve only some of my objectives, there was a power failure throughout the city. How long it will last is anyone’s guess.

There is a tantalising possibility that the poor roads in Kenya, Tanzania and other countries played a part in protecting many people from becoming infected with HIV early on in the epidemic. People in more isolated areas were not infected in large numbers in the early years.

However, that is not the case any more. As mentioned in the last few days, people in rural areas and more isolated areas in both Kenya and Tanzania are being infected now in greater numbers than before. They are not receiving the prevention education that is sometimes found in towns and cities and testing facilities are scarce or non-existent.

Countries with relatively good infrastructures sometimes have much higher HIV prevalence than Kenya or Tanzania. Examples of this phenomenon are Zimbabwe, Malawi, South Africa and Botswana. Of course, there are probably other reasons why HIV prevalence is so much worse there, but demographic balance, mobility and circular migration play an important part in the transmission of HIV.

One of the reasons why urbanization may be so strongly associated with high and fast transmission rates of HIV is the high number of males in urban populations. Botswana, one of the richest countries in Africa, with one of the highest rates of HIV in the world, has also experienced rapid urbanization, economic growth, population growth, high levels of income inequality, a history of mobility and high levels of commerce with surrounding countries.

Botswana's economy depends to a large extent on extractive industries and they, typically, employ large numbers of men who live in all-male accommodation. This results in high levels of commercial sex and a consequently increased risk of contracting and spreading HIV and other STIs.

Employees are not just from Botswana, so when they return home, they can transmit HIV and other conditions to their home countries, which are often poor, with high unemployment rates.

Ok, Kenya doesn’t have a lot of mining, certainly not on the same scale as Botswana. But there are industries that give rise to circular migration and the resulting demographic imbalances and consequent spread of HIV and other diseases.

Kenya’s number one product is tea. As mentioned, Mumias is dominated by the sugar industry. Some coastal areas grow little but sisal. And there are natural resources here, such as soda and uranium. Other examples are the massive cut flower businesses around Lake Naivasha and the fruit and vegetable growing farms.

All these industries depend on large supplies of casual labour, very often for only part of the year. People arrive and stay for as long as the work lasts and then go back to their homes. Many of these economic migrants are male and they live away from their families for much of the year.

This kind of circular migration, often driven by rural poverty, is common in developing countries and is associated with many health hazards, for example, TB. Labour practices in South African diamond and gold mines result in similar conditions and again, the HIV related effects were transmitted to surrounding countries that suffered worse HIV prevalence than that of South Africa.

Eileen Stillwaggon, in AIDS and the Ecology of Poverty, talks of the “circular migrant streams” that are fuelled by mines, factories and plantations and the consequent slums and shanty towns with their poor sanitation and high rates of disease and malnutrition. It must also be noted that circular migration transmitted HIV from urban to rural regions in earlier years but later the transmission was in both directions.

John Iliffe, in A History of the African AIDS Epidemic, cites the “male predominance in urban populations” in East Africa as one of the reasons why levels of infection were higher there than in western equatorial Africa. In the early 1990s, “Kigali had 50 per cent more men than women aged 20-39” (page 21). In Nairobi in 1979 there were 138 males for every 100 females, the imbalance was even higher among adults and many of the males were unmarried.

A high male to female ratio in the population does not just affect urban dwellers. Fishing communities in rural areas around Lake Victoria were predominantly male and HIV rates there are very high. Nyanza province has the worst HIV rates in Kenya. Rural dwellers are also affected by these imbalances because the migration is temporary and people come and go, perhaps for much of their working life.

There are also certain occupations that involve high levels of mobility. Iliffe mentions urban immigrants, truck drivers, alluvial miners, their female partners and labour migration as examples of particularly mobile groups. Towns along trade routes often have higher rates of HIV than other towns.

This problem is especially prominent at borders. Border controls are very slow moving and truckers often have to spend several days in border towns because of slow administrative procedures. It can be cheaper for them to stay with a casual partner there than to put up in a hotel, so it’s an ideal place for commercial sex workers to look for business.

These are all major factors in the history of the transmission of HIV in Kenya and East Africa in general. They crop up constantly in the literature and mobile people were among the first ‘vulnerable groups’ to be studied, along with commercial sex workers.

It was Zimbabwe's “excellent transport system” and circular internal migration between urban and rural areas that transmitted HIV out into rural areas, according to Iliffe (page 39). In the case of Malawi, Iliffe makes a further connection between higher education and greater mobility, perhaps elucidating the phenomenon of higher HIV prevalence sometimes being associated with higher levels of education.

Iliffe tracks the transmission of HIV from Western Equatorial Africa to East Africa, Southern Africa and West Africa. He makes it clear that mobility is the chief driver of the epidemic at the regional level.

Indeed, obstacles to mobility from east to west is one of the possible reasons Iliffe suggests as to why West Africa's epidemic was less severe than that of some other African regions. Where HIV rates were high in West Africa, one of the principle drivers was mobility, especially among commercial sex workers.

Tantalising as it is to suggest that poor infrastructure reduces the spread of HIV, it is not really true. It is true, but trivially so, that complete isolation is a protection against HIV and any other transmissible disease. In reality, people are not completely isolated, even in the most remote parts of Kenya.

Isolation explains why HIV spread slowly to rural areas and more quickly and earlier in cities and densely populated areas. It also demonstrates the critical situation that many towns, villages and rural areas are in, right now.

The situation is critical because we really don’t know what HIV prevalence is in more remote areas. People there are less exposed to HIV prevention publicity, they have less access to health and other social services and especially, to voluntary counselling and testing centres.

The further people are from urban centres, the more isolated they are, the less we know about HIV rates in those areas. The difference in prevalence between urban and rural areas may be merely apparent.