Don't Blame the Poor for Diseases of Poverty

Diabetes is often referred to as a disease of the relatively affluent because it can be caused by some of the habits that are common in better off, urbanized areas. It can be associated with foods that have high levels of sugar, often highly processed foods, along with a sedentary lifestyle.

However, it can also be a disease of the very poor, those who have little choice over which staple food they rely on for almost all of their nutritional needs. In Tanzania and Kenya, for example, many people rely on staples that are high in starch, and little else. Maize, white rice, white bread and a small number of other foods can make up the bulk of the daily diet of most people.

An article in the New York Times may give the impression that there are lots of Africans suffering from diseases of affluence. I'm not sure why this article is about such a small sector of the East African population, though it may well be true that there are more wealthy people now than before. But diabetes is far more common than affluence.

I accept that the article is quite clearly about the African middle class, but the association of diabetes with increasing wealth is disingenuous. There are people suffering from diabetes who are neither affluent, urbanized nor sedentary. Are we supposed to see people in such circumstances as being responsible for their suffering from the disease?

The same article mentions lung cancer. One of the biggest killers in developing countries is acute respiratory conditions. This is not because most people smoke cigarettes, live close to a polluting but highly lucrative (for them) industry, live in a city or do anything else that relates to affluence. It is because they are exposed to living conditions that render them susceptible to serious lung problems. It is also because health facilities are poor and inaccessible.

In fact, if any generalization can be made about diarrhea, water-borne diseases in general, nutritional deficiencies and acute respiratory conditions, it is that they affect more babies and infants than adults. In adults, respiratory conditions affect women more than men. Also women and children are far more likely to be living in poverty than men.

The majority of people do not have access to private transport, some don't even have access to public transport. Most do not work in offices, most don't even have formal jobs of any kind. Most still have to walk to health facilities and social services, or even do without them. There are, presumably, risk factors for cancer, heart disease and strokes that relate to poverty as well as to affluence.

Urbanization has been a trend for a long time but it is unlikely to contribute that much to diseases of affluence in East Africa. Urban dwelling poor people are probably even more deprived than rural dwelling poor people and they face additional health hazards that those in rural areas don't face. These hazards include air quality, pollution, road traffic accidents, occupational hazards, violence and others.

I don't wish to belittle common health conditions, regardless of who suffers from them. But it is poor people who need better and more accessible health services, whether urban or rural dwelling. And many people are suffering from preventable and curable conditions that relate to their diet, their environment, their economic circumstances and adverse social conditions, not just from their 'lifestyle'.

An article about health in Zimbabwe illustrates the point: "70% of diseases and deaths in the country, caused by malnutrition, diarrhea, malaria and pregnancy-related complications, are preventable." Similar figures can be found for Kenya and Tanzania. It's a popular game in the press, in development and in politics to deflect attention from the problems people face that are beyond their control and to concentrate on issues that are, ostensibly, a matter of individual responsibility. There is a lot of public health work that needs to be done. Poor countries are not 'like' rich countries when it comes to health.

Lack of Logic in the Received View of the HIV Pandemic

Something I have always found mysterious about UNAIDS' view (it's something of a received view) of the course of the HIV epidemic is that they estimate that the number of new infections peaked in Sub-Saharan Africa (SSA) some time in the mid 1990s. And they reckon that the reason new infections began to drop from then on can be put down to the success of HIV prevention and education programmes in changing the sexual behaviour of people, especially men who have sex with men (MSM), commercial sex workers (CSW), intravenous drug users (IDU) and young women.

With few exceptions, most SSA countries were doing very little to treat people with HIV or to prevent the transmission of HIV in the 1990s. Treatment was in its infancy and was inaccessible to the majority of Africans. And where prevention programmes had been implemented, they consisted of little more than mass education campaigns. They had very little influence on people's behaviour in the 1990s. And why would they have much influence? They had only started and only in a few countries, Uganda being one of the countries that started HIV prevention early. But even the nature and effectiveness of Uganda's HIV prevention campaign is still being hotly debated. Prevalence there has changed little in years and sexual behaviour indicators have long been sliding in the wrong direction.

What bothers me is that even if widespread prevention activities started in the mid 1990s, it would take many years for them to have much effect. That's if they actually had any effect at all. Ok, I can't research every country in SSA, but in the case of Kenya, very little was being done in the 1990s. It was only in the early 2000s that some serious work started, say 2002 or 2003. And the Kenya Aids Indicator Survey (KAIS) makes it quite clear that HIV prevalence, which had been dropping before 2003, actually increased and is now higher, after half a decade of HIV prevention work.

What I'm getting at is this: if rates of HIV transmission peaked in the mid nineties, then it did so for some reason other than the fact that every country had implemented widespread prevention programmes. The reason I suggest this is because prevention just wasn't a big thing then, at least, not big enough to explain why the epidemic started to 'decline'. I'm not saying that rates of transmission didn't drop, just that they didn't drop because of prevention programmes.

Another reason for thinking that prevention programmes didn't have much influence on rates of HIV transmission is because even after they did start, there is little evidence that they could have been the cause of the drop. There is plenty of evidence that most current HIV prevention programmes have little or no effect. In Kenya's case, scaling up HIV prevention programmes seem to have resulted in an increase in prevalence, the total number of people living with HIV. This doesn't tell us if transmission rates have decreased, so what about transmission? Are there still lots of people becoming newly infected?

According to the KAIS, transmission patterns are changing. Numbers infected in urban areas have dropped but numbers infected in rural areas have increased, especially among men. The majority of Kenyans, 75% or more, live in rural areas. Poorer and less well educated people are now being infected in greater numbers. The majority of poor and less well educated people live in rural areas and most Kenyans are poor and badly educated. These trends all follow what KAIS refer to as a 'rapid scale up of HIV prevention, care and treatment services'.

A recent article in AllAfrica.com quotes UNAIDS as claiming that their successful prevention and education programmes have *finally* begun to change the behaviour of those who are most at risk. If this is only happening in recent times, how can they claim that it had anything to do with a decline in incidence that began in the mid 1990s. But Kenya, along with many other SSA countries, have explicitly not targeted some of the groups who are thought to be most at risk, MSM, CSWs, IDUs and young women. The well presented 'Modes of Transmission Survey' for Kenya makes it quite clear that these groups are still being ignored.

There may be isolated signs of people's behaviour changing in some ways. All sorts of movements may have achieved great things, especially relating to HIV treatment and increasing access to treatment. I certainly wouldn't claim that all the billions that have been poured into HIV for over two decades has been wasted. But I have yet to see clear evidence that HIV transmission has declined as a result of prevention efforts. I think the epidemic has its own dynamics, like any epidemic, but I am not convinced that the enormous Aids industry has had much influence on its course. I just hope I'm wrong.

Distance No Object, We Just Don't Go There

The majority of HIV positive people in Kenya live in rural areas. Granted, the percentage of people who are HIV positive in urban areas is higher than the percentage in rural areas. But most people, perhaps as many as 80%, live in rural areas.

So why are most big NGOs, including ones who are mainly concerned with HIV, based in urban areas? In fact, most health facilities, social services, government offices and just about anything else you can think of are based in urban or semi-urban areas.

Here's an example of the ridiculousness of this phenomenon: Nairobi, the capital city, is high up and therefore not very hot. There are mosquitoes there, aplenty, but malaria is not very common. The climate is just not right for the malaria bearing mosquitoes, though there is plenty of stagnant water around to support huge colonies of insects and other disease vectors.

Yet, the highest rate of mosquito net ownership is also in Nairobi. Could this be connected to the centralization of health, social services and various benefits and amenities in the capital? It's hard to tell, but it's certainly a bizarre situation. Many, perhaps most, of the mosquito nets in this country are donated by NGOs. How do so many of them end up getting stuck in the areas where they are least needed?

Nakuru is not huge, by any means. But as it's only a few hours from the capital and has its own academic institutions, it also has many academic and social projects. There are numerous NGOs doing all sorts of things here. It has far more visible street children than the much bigger capital city but it is not the most neglected of areas, either.

But travel an hour (or less if you have your own transport) out of town and you will come across villages where people rarely see NGOs or receive any of their largess. And in these villages, there are people needlessly suffering. They have the same problems as people in villages and towns closer to the privileged areas but they do not have the means to reach those areas.

Today we saw a boy whose face is terribly disfigured from burns he received several years ago. His burns were not treated in time. When they were treated, they were not treated properly. After spending over one and half years in hospital, he now has one eye, which may also be under threat, his nose is disfigured and threatened, his mouth is deformed and, most alarmingly, his skull was fractured as a result of the medical treatment he received, the medical treatment which seems not have worked yet. And the treatment cost about the equivalent of seven years salary.

There are HIV positive people who can't afford the transport to get tested, because the testing centres are in the towns and cities. There are those who know they are HIV positive but who can't afford the transport or the costs that need to be met before they can receive the, admittedly free, antiretroviral treatment (ART). There are people who need cheap drugs and treatment that they will not receive because they are in isolated areas. Many have died because of their isolation and many more will die for the same reasons.

Even the organisation I was supposed to work for is based in Nairobi. Why? I have no idea. They have no projects there. They do have five road worthy vehicles and eight motor bikes. Why? I have no idea. I don't know when any of them last visited Nakuru. I don't think any of them in head office have ever visited the village we were in today, nor would they even have heard of it. Why? I have no idea. They don't respond to my emails and I am supposed to be working for them.