Has anyone come across evidence that access to adequate food supplies reduces acute malnutrition? How about access to good health services reducing illness or good education reducing illiteracy? Should we believe that good water and sanitation reduces water borne diseases or that a clean environment can help to reduce acute respiratory infections?
The answers to the above questions are all 'yes'; there is overwhelming evidence for an affirmative answer to each one. But does Kenya or any other developing country have any of these benefits? Well, no, that is why they are called developing countries. Underdevelopment and retrogressive development are not new and these issues have been discussed in one form or other for many decades.
But just recognising their desirability doesn't give rise to development. The knowledge that these are all good things, necessary for development and for the insurance of human rights, has not given rise to their promotion. So when I see an article entitled '[Male c]ircumcision does reduce the risk of HIV, say researchers' I am pleased to hear it. But which developing country has the facilities, resources and personnel to carry out millions of circumcisions safely and to continue to circumcise all newborn males (either shortly after birth or later, when informed consent is possible)?
Kenya does not have presently have the health capacity required. Evidence has shown that the level of adverse effects relating to circumcision is nearly 20% when the operation is carried out in a clinical setting and around 35% in traditional settings. Those who presently don't go for circumcision, usually for reasons associated with the traditions of their tribe, may be more likely to choose a clinical setting. But with statistics like that they could be forgiven for opting to remain uncircumcised.
Kenya does not have the capacity required to control most of the infectious diseases that are endemic in the country, diseases that kill more people and diseases that have been around for far longer than HIV. If Kenya had good health, education and other social services, the HIV epidemic would never have got so out of control and some of the expensive prevention measures that are being carried out might have achieved some success by now.
In fact, the problem here is not the Cochrane Collaboration publication, entitled Male Circumcision for Prevention of Heterosexual Acquisition of HIV in Men, it's the newspaper article that reports on the original publication. The newspaper article only adds in the final sentence that policy makers need to consider the culture and environment in which MMC is carried out. This is crucial and the Cochrane abstract makes this clear, asking if "[a]t a local level, further research will be needed to assess whether implementing the intervention is feasible, appropriate, and cost-effective in different settings."
One might conclude from the newspaper article that because male circumcision can reduce the risk of HIV, that mass male circumcision (MMC) is a good thing, especially in countries that have high HIV prevalence. Circumcision may also protect against herpes simplex virus (HSV), which increases susceptibility to HIV, human papilloma virus (HPV) and various other sexually transmitted infections (STI). But the Cochrane review notes that incidence of adverse events was low in the trials they examined. One would expect the incidence of adverse events to be low, these were randomised controlled trials! The review concludes that circumcision "under these conditions" is a safe procedure.
The Cochrane review may have found the evidence conclusive and that could eventually be very significant. But the studies they refer to still raise many unanswered questions. I will not rehearse the various problems with the circumcision trials in question. A quick search of other sites and blogs will give you as much information as you could possibly want. (I haven't had access to the full Cochrane paper, although I am familiar with some of the literature and trials involved.)
Mass Male Circumcision (MMC) will not be carried out in ideal conditions in Kenya, not given the present state of Kenyan health services. If there were ideal conditions in Kenya it is unlikely that the country would have need to implement such a huge and costly project as MMC.
But a second objection to MMC is the problem of 'disinhibition'. Some circumcised people think they are, more or less, immune to HIV. People have told me that they don't need to use condoms because they are circumcised or even that condoms don't work because they are circumcised. There is a worry that MMC could result in a large number of people believing that they don't need condoms or that they don't need to be careful because they are circumcised. This will not be an easy problem to deal with.
There’s often a ‘eureka!’ quality to articles about MMC as a means of reducing transmission of HIV. Why not the same cry with regard to development issues where the solutions are more obvious, such food and food security for the starving, healthcare for the sick and healthy, alike, education for all, safe water and sanitation and a healthy environment? The Cochrane report also concludes with a need for further research. Let's hope policy makers are not as selective as journalists in what they glean from scientific papers.
Showing posts with label male. Show all posts
Showing posts with label male. Show all posts
Saturday, April 18, 2009
Sunday, December 28, 2008
Gender and HIV
There are numerous factors involved in the spread of HIV in Kenya. For example, high levels of disease and bad health, especially sexual and reproductive health, under funded health systems, poor nutrition, low levels of food security and sanitation, crumbling education systems, high levels of urbanisation, high population density and demographic imbalances, high levels of circular migration and dangerous labour practices.
A lot is known about curing some diseases but, more importantly, it is well known that many diseases are avoided by good nutrition, sanitation and healthy lifestyles. Again, it doesn't take a genius to work out that large groups of men working in cities and around mines will eventually be followed by small groups of commercial sex workers. It's not difficult to provide transport for the men to return home regularly or even to provide accommodation for wives, families and partners. It's not difficult, just rare. The point is, we know what would alleviate some of these factors, even if we don't necessarily know how to implement these measures or are not in a position to do so at present.
However, all these factors have played a part in the transmission of HIV because, for various reasons, they have been given very little attention (unless lip service counts as attention). The reasons for this could include poor leadership and governance or greed and selfishness on the part of a powerful few. The powerful few are not just leaders and other people in Kenya; one must include interested parties who neither come from nor live in Kenya, nation states, economic partnerships, multinationals and even international organisations that usually represent the wealthy, despite a pretence of representing everyone equally.
But one of the less tractable factors in the spread of HIV is gender, a factor operating at many levels. From the top down, slightly more than half of all Kenyans are female. Yet only around 7% of Kenya's MPs are female. Females are also more likely to be poor, have less access to education and health services, are less likely to be employed in the formal sector and are more likely to be dependent, economically and in other ways (usually on men).
At a guess, 100% of Kenyan MPs are in the wealthiest 20% of the population. In contrast, nearly 50% of Kenyans live on less than 2 dollars a day. Put all this together and most Kenyans are not particularly well represented by their elected leaders, this being especially true of Kenyan women.
From the bottom up, around half of Kenyan women have experienced violence as adults, around one quarter in the 12 months preceding the interview (Kenya Demographic and Health Survey, 2003). There are high levels of gender violence across income brackets, employment status, educational levels, rural or urban residence and province, although levels do vary somewhat. This violence is most likely to be perpetrated by a partner, though teachers and mothers are second and third, respectively, in the list of most likely perpetrators.
A specific form of violence that most affects females is Female Genital Mutilation (FGM), sometimes referred to as 'female circumcision'. This is thought to affect more than 30% of females. It is still practiced in some areas, despite being prohibited by law for some years. As well as violating human rights, FGM renders women more susceptible to infection with HIV and other sexually transmitted infections (STI). FGM also contributes to maternal deaths and many serious reproductive health problems. The operation is usually carried out by women but the demand for it is said to come from men.
The practice of FGM is declining but it is far higher in Kenya than neighbouring Uganda or Tanzania. Another practice, which is also said to be declining, is violence against children. It, too, is prohibited by law but still practiced and defended on the grounds that children need to be disciplined. Of course, violence against children is not gender based but it is odd that what is seen as justified on the grounds of discipline in the case of children is also seen as justified on the grounds of discipline in the case of women, but not in the case of men.
But perhaps the most worrying thing about gender violence is the percentage of people, including women, who think it is acceptable for husbands to beat their wives, either as punishment or to assert authority. It is not hard to find people who defend violence against women (and children) or who see it as a normal part of life and not, therefore, a problem.
Nor are these the only gender issues. Women often have little or no right to inherit land or property from their husband. In some places, when a woman is widowed, she herself is 'inherited' by a member of her husband's family. Girls are often encouraged to marry early, sometimes to save their family the cost of their upkeep. They often marry older men who are more likely to be sexually experienced and even infected with HIV or other STIs. In fact, despite the popularity of 'abstinence only until marriage' HIV prevention programmes, married women in Kenya are more likely to be infected by their husbands than unmarried, sexually active women.
Despite being more likely to be responsible for the health and education of children and dependents (including those infected with HIV), women have less access to education, health and other health services and they are, partly for those very reasons, more vulnerable to HIV and other STIs.
So the issue of gender and how it relates to the spread of HIV is not just intractable, it is also multifaceted. I am not able to do it full justice in such a short space. I hope to return to it, often. But I don't want to end with the impression that 'gender' only refers to the female gender.
For several years after HIV was identified, more men were found to be infected than women. In some areas, that is probably still the case. If a small number of commercial sex workers gather round a mining town where the population is predominantly male, more men than women may end up infected. However, if those men return home and infect their partners, it is likely that there will eventually be more HIV positive women.
In Kenya, the ratio of infections was 1 female to 1.2 males in 1986. In 2006 that ratio was 2 females to 1 male. However, in 2007, the ratio had moved in the opposite direction again and now stands at 1.6 females to 1 male.
This may have happened because men are taking more risks and/or fewer precautions, because women are taking fewer risks and/or more precautions or some other reason. I admit, this analysis is fairly speculative. But if a higher proportion of males are infected now, the potential for them going on to infect other women, perhaps several women each, is very high. (In Kenya, most women are infected by men, as opposed to intravenous drug use, blood transfusion, etc). In addition to reversing the ratio of females to males infected, this could also result in a substantial increase in national prevalence.
Now, men, generally, are less likely to become infected with HIV, are likely to become infected later in life than women, are often in a better position to protect themselves (and, therefore, their partners) against HIV and other STIs and they have often received more education.
Therefore, it may be possible to intervene with measures that specifically target men. Men may need to be targeted with different HIV messages than women and, for various reasons, there may be more time and opportunity for effecting such interventions.
For example:
- men who work away from home for long periods, in tea, sugar or cut flower industries, need to be able to return home regularly (using affordable transport); or their family needs to be able to visit or live with them (in decent, affordable accommodation)
- delays at borders that give rise to men visiting commercial sex workers need to be reduced, presumably by those interested in reducing the costs of, and barriers to, trade
- men need to be engaged in dialogue with women and other men to identify and influence attitudes that result in women’s lower status in commerce, politics, marriage, sexual relations and many other areas
There are others (and I must make it clear, I adapted these examples from Eileen Stillwaggon’s AIDS and the Ecology of Poverty), but most intervention efforts at present seem to emphasize a ‘one size fits all’ approach. There are many problems involved in HIV prevention but also, many approaches.
A lot is known about curing some diseases but, more importantly, it is well known that many diseases are avoided by good nutrition, sanitation and healthy lifestyles. Again, it doesn't take a genius to work out that large groups of men working in cities and around mines will eventually be followed by small groups of commercial sex workers. It's not difficult to provide transport for the men to return home regularly or even to provide accommodation for wives, families and partners. It's not difficult, just rare. The point is, we know what would alleviate some of these factors, even if we don't necessarily know how to implement these measures or are not in a position to do so at present.
However, all these factors have played a part in the transmission of HIV because, for various reasons, they have been given very little attention (unless lip service counts as attention). The reasons for this could include poor leadership and governance or greed and selfishness on the part of a powerful few. The powerful few are not just leaders and other people in Kenya; one must include interested parties who neither come from nor live in Kenya, nation states, economic partnerships, multinationals and even international organisations that usually represent the wealthy, despite a pretence of representing everyone equally.
But one of the less tractable factors in the spread of HIV is gender, a factor operating at many levels. From the top down, slightly more than half of all Kenyans are female. Yet only around 7% of Kenya's MPs are female. Females are also more likely to be poor, have less access to education and health services, are less likely to be employed in the formal sector and are more likely to be dependent, economically and in other ways (usually on men).
At a guess, 100% of Kenyan MPs are in the wealthiest 20% of the population. In contrast, nearly 50% of Kenyans live on less than 2 dollars a day. Put all this together and most Kenyans are not particularly well represented by their elected leaders, this being especially true of Kenyan women.
From the bottom up, around half of Kenyan women have experienced violence as adults, around one quarter in the 12 months preceding the interview (Kenya Demographic and Health Survey, 2003). There are high levels of gender violence across income brackets, employment status, educational levels, rural or urban residence and province, although levels do vary somewhat. This violence is most likely to be perpetrated by a partner, though teachers and mothers are second and third, respectively, in the list of most likely perpetrators.
A specific form of violence that most affects females is Female Genital Mutilation (FGM), sometimes referred to as 'female circumcision'. This is thought to affect more than 30% of females. It is still practiced in some areas, despite being prohibited by law for some years. As well as violating human rights, FGM renders women more susceptible to infection with HIV and other sexually transmitted infections (STI). FGM also contributes to maternal deaths and many serious reproductive health problems. The operation is usually carried out by women but the demand for it is said to come from men.
The practice of FGM is declining but it is far higher in Kenya than neighbouring Uganda or Tanzania. Another practice, which is also said to be declining, is violence against children. It, too, is prohibited by law but still practiced and defended on the grounds that children need to be disciplined. Of course, violence against children is not gender based but it is odd that what is seen as justified on the grounds of discipline in the case of children is also seen as justified on the grounds of discipline in the case of women, but not in the case of men.
But perhaps the most worrying thing about gender violence is the percentage of people, including women, who think it is acceptable for husbands to beat their wives, either as punishment or to assert authority. It is not hard to find people who defend violence against women (and children) or who see it as a normal part of life and not, therefore, a problem.
Nor are these the only gender issues. Women often have little or no right to inherit land or property from their husband. In some places, when a woman is widowed, she herself is 'inherited' by a member of her husband's family. Girls are often encouraged to marry early, sometimes to save their family the cost of their upkeep. They often marry older men who are more likely to be sexually experienced and even infected with HIV or other STIs. In fact, despite the popularity of 'abstinence only until marriage' HIV prevention programmes, married women in Kenya are more likely to be infected by their husbands than unmarried, sexually active women.
Despite being more likely to be responsible for the health and education of children and dependents (including those infected with HIV), women have less access to education, health and other health services and they are, partly for those very reasons, more vulnerable to HIV and other STIs.
So the issue of gender and how it relates to the spread of HIV is not just intractable, it is also multifaceted. I am not able to do it full justice in such a short space. I hope to return to it, often. But I don't want to end with the impression that 'gender' only refers to the female gender.
For several years after HIV was identified, more men were found to be infected than women. In some areas, that is probably still the case. If a small number of commercial sex workers gather round a mining town where the population is predominantly male, more men than women may end up infected. However, if those men return home and infect their partners, it is likely that there will eventually be more HIV positive women.
In Kenya, the ratio of infections was 1 female to 1.2 males in 1986. In 2006 that ratio was 2 females to 1 male. However, in 2007, the ratio had moved in the opposite direction again and now stands at 1.6 females to 1 male.
This may have happened because men are taking more risks and/or fewer precautions, because women are taking fewer risks and/or more precautions or some other reason. I admit, this analysis is fairly speculative. But if a higher proportion of males are infected now, the potential for them going on to infect other women, perhaps several women each, is very high. (In Kenya, most women are infected by men, as opposed to intravenous drug use, blood transfusion, etc). In addition to reversing the ratio of females to males infected, this could also result in a substantial increase in national prevalence.
Now, men, generally, are less likely to become infected with HIV, are likely to become infected later in life than women, are often in a better position to protect themselves (and, therefore, their partners) against HIV and other STIs and they have often received more education.
Therefore, it may be possible to intervene with measures that specifically target men. Men may need to be targeted with different HIV messages than women and, for various reasons, there may be more time and opportunity for effecting such interventions.
For example:
- men who work away from home for long periods, in tea, sugar or cut flower industries, need to be able to return home regularly (using affordable transport); or their family needs to be able to visit or live with them (in decent, affordable accommodation)
- delays at borders that give rise to men visiting commercial sex workers need to be reduced, presumably by those interested in reducing the costs of, and barriers to, trade
- men need to be engaged in dialogue with women and other men to identify and influence attitudes that result in women’s lower status in commerce, politics, marriage, sexual relations and many other areas
There are others (and I must make it clear, I adapted these examples from Eileen Stillwaggon’s AIDS and the Ecology of Poverty), but most intervention efforts at present seem to emphasize a ‘one size fits all’ approach. There are many problems involved in HIV prevention but also, many approaches.
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