What Would Be a Legitimate Role for Western Development Workers in Developing Countries?

There's an interview with Yash Tandon on Pambazuka.org that is well worth reading for people working in development or thinking of doing so. I find it relatively rare to hear what Africans really think of development. My aim in coming to East Africa to work in development was to find out from people working in development here what form development should take. Given that both recipients (as opposed to beneficiaries) of development programs and those working on the programs often agree that things have been going wrong for a long time, how should things be put right?

Tandon criticizes the Paris Declaration on aid effectiveness on the grounds that it was "conceptualized by the donors, and not by the people that were supposed to be assisted". Which is little different from a lot of development decisions, before and after the declaration. Tandon goes on to say that "the so-called development aid never did promote development" and that " The result is that the aid industry has no longer any legitimacy."

It's ironic, considering how often people working in development use the term 'dependency' when referring to recipients of aid, how Tandon turns things around and points out that there are "at least a million people in the Western countries that live off the aid industry". Tandon feels that aid, or whatever term it goes under, was always intended to serve the interests of donor countries. I agree, and Tanzania, with its massive potential for gold, uranium, natural gas, arable land and other resources, is a case in point. The resources remain underdeveloped and underexploited until some wealthy foreign country comes to do the exploiting.

Tandon singles out Oxfam for criticizm as an organization that started out with good intentions but is now part of the very machinery that ensures the smooth operation of aid policies that are intended to benefit Western countries. And he raises a very interesting question: why do we call a lot of 'aid' programming by that name when it is actually just business? The Chinese and the Indians call it business, so why do many Western countries wish to dress it up as philanthropy? It must be a slap in the face to big Western donors to be told that the Chinese do it better when they seem hell-bent on persuading people here that the Chinese are only out for what they can get!

Another couple of sacred cows Tandon slaughters are the imposition of certain 'values', perhaps by church based organizations, which are dressed up as 'solidarity' or some other touchy-feely concept; also the assumption that Western aid agencies have the right to "encourage women who raise their voices against practices that violate their human rights" (for example). Tandon says the latter is not the business of outsiders, that "the initiatives of rural women in Africa against oppression are very strong and very strategic. They know what will work and what will not". I hope his last statement is right; I have not been exposed to initiatives against oppression that are strong and strategic, though I would very much like to be.

These are all perplexing issues for people who wish to work in development without becoming part of the problem, serving as mere instruments of the self-interested Western agenda. Much though I would love to follow Tandon's advice, I have not come across many people who say 'this is what we want and this is how we intend to achieve it'. Rather they tend to say 'how do we get some of this money/assistance/resources'? Perhaps they are now also mere instruments and are currently unable to serve the intersts of those they hope to serve. But how do they change course and set the agenda? If there is an indigenous aid agenda in East Africa, where is it articulated?

I wholeheartedly agree with Tandon's conclusion that "All development is self-development", but I want to work with self-development, with self-developers. I think that the development industry can do a lot more good in developing countries by advocating against certain things, such as land-grabbing, resource theft, imposition of genetically modified organisms and other inappropriate and failed technologies, Western use of cheap labour, exploitation of lax human rights legislation, commodity dumping, unfair trade agreements, etc, something I have called 'Development by Omission' for want of a better phrase. But I wonder if Tandon thinks there is a legitimate role for people who work in development to continue with, as long as they are committed to an agenda set by their adopted country, and if so, what is this role?

Huge Birth Control Programs Don't Work: Time to Give Education a Chance

I recently moved from a job as grant proposal writer for an NGO working in several different development areas to a similar job in a secondary boarding school for girls, which is being built in a country where many girls don't even finish primary school. So I was comforted to find an article entitled 'Women's Education Slows Population Growth'. That women's education can have such profound and positive consequences is not the issue, that has been recognized for a long time, at least by those working in education. But the priority is so often given to population growth, rather than to education or any other development area.

A shocking proportion of 'development' money and a disturbing number of development related insitutions concentrate almost exclusively on population control, in some form or other. They bang on about an unmet need for contraception as if many women will have depleted health or lives as a result of lacking birth control methods, when they are likely to be in far greater need of better nutrition, healthcare, security, governance, equality, infrastructure and, indeed, education. Shovelling contraceptives into rural communities may be a lot easier than providing people with what they need, but without the education and other development areas being addressed, the only gain will accure to the pharmaceutical companies who produce contraceptives.

Similar remarks apply to a lot of other 'health' programs, which target whatever health issue is currently fashionable and well funded; many of them are also necessary, but they would work a lot better if people had the level of education to capitalize on them. Otherwise, they can just go through the motions of attending numerous courses, often for the per diem they may be paid or the free lunch or other minor benefits on offer. I have met people who have been to various 'training courses' only to attend the same course several more times, sometimes provided by the same NGO as before. Training courses are a great way to spend money and it's easy enough to gather data that allows the donor to pronounce the intervention successful. Some health drives pick out some particular disease, perhaps a water borne disease, without addressing water and sanitation in the area. The current drive to 'eliminate' polio is a cases in point; those who attend immunization drives go home to drink contaminated water and contract something else.

Education itself, as we found in my own country, Ireland, is not enough when there are no jobs to go to. And here in Tanzania, women are not considered to be able to do many jobs that they would in fact be well able to do, if they had the education. Sadly, they are considered to be able to do many jobs that are not particularly appropriate for them when they are too young, too old, pregnant, childraising or breastfeeding, but that's another matter. I always feel a bit dishonest when I tell people about how important education is when there is little guarantee many of them will ever get to use it, especially girls and women.

As if there are not enough obstacles, also, school-going girls who become pregnant are excluded from school. In the rare instances where they are allowed to return to school, most do not. This is to 'set an example', we are told. And it does. It shows that girls who get pregnant will be treated very harshly, whereas the boys or men who make them pregnant, generally, will not. The fact that underage girls being made pregnant by older men is a serious crime doesn't get the girls off the hook. Men don't appear to be prosecuted, boys are generally not excluded from school and the strong prejudice against females appears to be practiced by the very institutions that might be in a position to change things.

According to the article, the average birth rate is less than half in regions where education is valued; as I'm working in one of those regions, I'm hoping that birth rates are lower because education is valued. However, even expensive schools with nice, well-funded buildings and facilities, don't always have especially high educational standards. As a fundraiser, sometimes I can see funds for all sorts of things, but not so many that clearly improve education. There is not so much available for good teachers or other provisions that would make a difference. And many fundraisers are tasked with raising money for the buildings, which is important, but often distracts from the ultimate purpose of these buildings.

So, as the article suggests, it's not the correlation between higher standards of education and lower birth rates that is important; it is the priority that is given to education. Proponents of the population control theory of development, so beloved throughout the last fifty years (and still loved by the Rockefeller Foundation, the Gutmacher Institute, the Gates Foundation, Population Services International, Family health Internationa and many more), never appeared to realize what needed to come first, that with development of education, health, infrastructure and the rest, lower birth rates would follow. Similarly, poverty is pervasive in Tanzania, but lower birth rates does not have much direct effect on poverty; rather, lower poverty rates result in improved health, education and the like.

For education to be of benefit, many other things need to be in place as well. But one thing is for sure; reducing birth rates and hoping that other development areas will benefit accordingly has not worked. The funding these charlatans have received urgently needs to be directed towards people's true needs, which are still education, health, a decent standard of living, security, food security and the rest, just as these are the true needs of all people.

Deceived and Misled, HIV Positive People Can Only Speculate About Their Infection

I was intigued by the title of a Kenyan newspaper article: "When a Woman Feels She Is Not 'Rightfully Infected'". I thought that maybe someone was asking how they could have been infected with a virus that is not easy to transmit sexually even though they have never had unsafe sex, very little sex or perhaps no sex at all. Demographic and Health Surveys usually find that a considerable number of people are infected with HIV even though they have no obvious sexual risks. Non-sexual risks are rarely considered and it is usually assumed that people have lied about their sexual behavior.

Anyhow, the article doesn't go that far. A HIV positive woman reflects on the fact that she didn't have enough sex during her marriage to warrent HIV infection. Her husband was working in South Africa and he only came home every six months, which is the only time they had sex. After 22 years of marriage, the woman was diagnosed HIV positive and found that her husband had another wife. Was her husband infected? We are not told. We also don't know if he was infected sexually, whether he infected his wife (the one writing the article) or whether she was even infected sexually.

Leaving aside the fact that the man had another 'wife', in order to establish how someone is infected it is necessary to work out what risks each HIV positive person faces. Even if the man was infected sexually, that does not mean he infected his first wife. She deserves to know how she became infected because if it turns out that her husband is not, and this is commonly the case, it will be implied that she was infected by having sex with someone who was not her husband. This is the HIV orthodoxy: 80-90% of HIV is heterosexually transmitted in medium and high prevalence African countries, though nowhere else. The consequences can be disasterous, with women thrown out of their homes, beaten, dispossessed, even killed.

Far more women than men are infected with HIV in high prevalence countries. Far more men than women engage in 'unsafe' sex. In discordant couples, those where only one partner is infected, it is as often the female partner that is infected as the male; it's approximately 50/50. when genetic typing has been carried out, many couples where both partners are infected are infected with a different subtype of the virus. In other words, one probably didn't infect the other. And even where both have the same subtype, they might not have both been infected sexually. Perhaps neither were infected sexually.

(On the subject of the ratio of male to female prevalence, it's also worth noting that male high HIV prevalence groups are not part of the general population. For example, many men who have sex with men don't have sex with women. Most intravenous drug users are men. Even prison populations, among which prevalence is said to be remarkably high, probably face serious non-sexual risks, such as tattooing, oathing, traditional medicine, intravenous drug use, etc. The actual percentage of HIV positive males who are infected heterosexually is probably a lot lower than the percentage of infected males.)

It may be a long shot, but it's worth checking who infected whom because if it's not the 'obvious' person, it needs to be established how the virus is being transmitted. If someone doesn't often have sex, only has sex with someone who is HIV negative, or has never had sex at all, they should not be infected. There are likely to be non-sexual risks that need to be investigated, particularly healthcare related risks. It's not acceptable to assume that people who are infected with HIV and are African are necessarily liars. But this is generally what happens.

The two women in the article discuss the fact that some people who have little sexual exposure can be infected while those with a lot can remain uninfected. But they seem unaware that some people face substantial non-sexual exposures. They are right that someone could be infected though having sex with a HIV positive person just once; right in theory. But it's highly unlikely. And highly unlikely occurrences like that give rise to few infections. Yet millions of people in some African countries are infected. Something that is highly likely to transmit HIV occurs frequently enough in some countries to give rise to hyperendemic HIV.

So what is it? Unsafe healthcare? Unsafe cosmetic or other skin-piercing procedures? To reduce HIV transmission, we need to know how it is being transmitted. By assuming that it is always sexually transmitted we end up implementing, at best, prevention strategies that may have no influence on non-sexual transmission, whatever influence they have on sexual transmission. At worst, we are just standing by while people become infected and go on to infect others.

To Reduce HIV Transmission From Mothers to Children, Reduce Transmission to Women

In the many articles about eliminating (or virtually eliminating) mother to child transmission of HIV (MTCT), the one strategy I haven't heard mentioned seems like it might be the simplest and most effective of all: eliminate, or at least reduce, HIV in mothers. It has been shown that even very high uptake of prevention of MTCT services will still not allow a country such as Zimbabwe to achieve virtual elimination, which would mean reducing the risk to less than 5%. Even an increase in uptake of services from 36% to 56% only resulted in a drop in MTCT from 20.3% to 18%.

The article states that only an estimated 53% of pregnant women globally got any kind of PMTCT treatment in 2009, which resulted in around 400,000 infants being infected, over 90% of which were in sub-Saharan Africa. But the problem with a lot of HIV programs, PMTCT programs being no exception, is that they are instances of 'vertical' healthcare. HIV related healthcare is, effectively, a parallel health service catering for one disease, while other health services, for better or for worse, cater for anything else the country's health system has the capacity to deal with. But this doesn't mean that HIV services are necessarily good, despite all their funding.

As a result, reproductive health services may or may not include HIV services and HIV facilities may or may not include other reproductive health services. While some HIV facilities may be relatively well funded, at least for their intended purposes, other health facilities are unlikely to be very well funded. In a country like Zimbabwe many people have some access to care but the quality of care is not high, unless you can afford private services. So PMTCT services often don't coordinate well with other services that pregnant woman receive; some receive services early in their pregnancy and drop out, others get later services, but still drop out.

The option of improving all health services and making HIV just one disease among many that reproductive health and general health facilities provide has never been popular in the HIV industry, not wishing to share the funding it receives, which often dwarfs what other serious health conditions receive. So quite a number of women are being infected during pregnancy, even late in pregnancy or just after giving birth. And it appears to be assumed that they were infected sexually, probably while already pregnant, though they may have been in the 'window' period when tested earlier, which could explain why they appeared to be HIV negative.

As a Ugandan woman working with safety in health facilities said to me: 'I refuse to believe that young women (the mean age in the Zimbabwean research was 24), finding themselves pregnant, whether for the first or fifth time, have unsafe sex with strange men on a regular basis; or that women who are in the late stages of pregnancy, or even women who have just given birth, have unsafe sex with strangers; or even that pregnant women have lots of sex with their husbands and resume sexual intercourse shortly after giving birth'.

So what is giving rise to this 1% incidence of HIV, the rate of new infections, during and just after pregnancy? Is it all heterosexual intercourse? If so, all the partners of women who seroconvert must also be HIV positive. Yet HIV rates among men are usually lower than among men; it is highly likely that many of the men are not HIV positive. When African women are found to be infected with HIV, even when their partner is negative, it is assumed that they were infected sexually. But is any effort made to find out if they had other HIV risks, such as unsafe healthcare? Some receive a lot of healthcare, and in some countries women who receive reproductive care are far more likely to be HIV positive.

It may not be a popular view, but the rate of new infections among women taking part in this research is very high, higher than it is in Kenya, Uganda or Tanzania; 1% incidence could result in 8% prevalence or more after only 10 years. In Kenya, Uganda and Tanzania, prevalence has remained static at about 6% for much of the last decade. Why are transmission rates so high in this population in Zimbabwe? Those infected clearly face non-sexual risks, but researchers don't seem to want to ask what those risks are, or to investigate them.

It is inconsistant, indeed futile, to aim to reduce HIV transmission from mothers to their children when it is not even known how the mothers are being infected because reducing infection in mothers is far preferable to waiting until they become pregnant and then offering them PMTCT, and may even be more easily achievable.

[There have been many cases of unexplained and/or unexpected HIV transmission among women, men and children in Zimbabwe and further instances in most other sub-Saharan African countries.]

Keep Using Depo Provera For the Next Five Years; It May Not Be Harmful

The issue of whether use of hormonal contraceptives such as Depo Provera may increase risk of HIV transmission in both directions (from male to female and from female to male) has cropped up on this blog a couple of times and several more times on the Don't Get Stuck With HIV blog. Three months ago, when a paper was published suggesting a possible danger of increased HIV transmission, the WHO, UNAIDS and others recommended doing nothing until they held a 'high level consultation' in January. Apparently that consultation is still on the cards, if this podcast is anything to go by (Podcast 4: Hormonal Contraception and HIV).

The podcast goes through the motions of rubbishing the publication that suggested Depo Provera and similar contraceptives may be dangerous, as various factions of the HIV industry did several months ago. However, their pronouncements on the subject seem somewhat disingenuous; the uncertainty about the safety of Depo Provera, both the pills and the injectible form, runs both ways; things may not be as bad as the research suggests, but it may be a whole lot worse. For those previously advised to keep taking the injections or the pills, they might need to make a decision now. Because trials, we are told, could take four to five years.

It remains to be seen whether people using the product will happily keep using it for four to five years in the hope that the research was wrong and they are in no danger, and that all the evidence produced in the past suggesting that hormonal contraceptives are not safe will turn out to be mistaken, or whether they will stop using the product and wait till they get the all clear, even if that happens to be four to five years from now. I would certainly choose the latter!

Yet again, UNAIDS are advising people who are using Depo Provera, oral or injectible, to also use condoms. Somehow, I don't think people are as moronic as these bureaucrats imagine. Condoms will protect people against HIV and other sexually transmitted infections and they will also prevent unplanned pregnancies. Even if there were no questions about the safety of Depo Provera, many would question the need to use two contraceptive methods. But where there are such important questions it would seem unnecessarily risky as well.

There is a good review of the current evidence about Depo Provera and other issues on the Don't Get Stuck With HIV website, for those who wish to practice safe sex and avoid unplanned pregnancies but don't wish to wait four to five years to find out if their contraceptive method is really safe.

Following Pepin, We Have a Duty to Rethink the HIV Orthodoxy

On page 9 of Pepin's book 'The Origins of AIDS', he writes: "The earliest evidence of HIV in East Africa comes from Nairobi in 1980-1 where 1% of patients with STDs and 5% of sex workers were HIV-1 infected. Just three years later, 82% of Nairobi sex workers were HIV-1 infected." Yet Pepin also spends a lot of effort demonstrating that sexual transmission is too inefficient to start an epidemic. If sexual transmission is inefficient, the percentage of HIV positive sex workers did not go from 5% to 82% in three years as a result of sexual transmission alone. You can't have it both ways and that kind of transmission rate suggests an incredible level of efficiency.

Indeed, Pepin's above two sentences, by their very juxtaposition, could suggest that this is an instance of a HIV epidemic being 'kick-started' through unsafe healthcare. An unrecognized virus has infected a small percentage of people, most of whom are being targeted for STD screening, vaccination and treatment. Nobody at the time had any idea that the process of rounding up sex workers and people with STDs (long-distance truckers, soldiers, etc) to receive healthcare services could at the same time be infecting them with HIV. It would not be inconsistent for Pepin to argue that HIV prevalence doubling every few months could not happen through sexual transmission alone; but he doesn't argue this.

Peter Piot, who spent many years steering UNAIDS away from considering any kind of HIV transmission aside from heterosexual sex in Africa, has piously stated that he agrees with Pepin and, rather outrageously, that he has always been interested in nosocomial infections. But he was the author of the paper published in the 1980s that came up with the above figures about sex workers in Nairobi. While heterosexual HIV transmission was rare in most countries, and that was known when Piot was writing, he seemed convinced that it was the norm in Africa. What should have looked like a massive, though unavoidable, nosocomial outbreak of HIV to someone interested in such outbreaks, became 'evidence' that Africans are not like non-Africans.

Now that Pepin has published his findings and people like Piot have declared themselves to be convinced that non-sexually transmitted HIV must have played a substantial role in creating the most serious epidemics in the world, the least he and the entirely misled HIV industry can do is take another look at how the impossible has happened. Nothing we know about HIV could result in HIV prevalence among sex workers going from 5% to 82% in three years through heterosexual transmission alone. That single paper and that single 'finding' has been cited over and over again. All the more reason for a scientist with integrity to question it in the light of Pepin's findings.

In a way, once it was concluded that HIV was heterosexually transmitted, it was like a self-fulfilling prophecy about African sexual behavior and HIV: those who had been rounded up in the past for their (often assumed) sexual behavior, again became the culprits. All sorts of 'findings' followed, many of which seem questionable now, but continue to be cited; migrants, casual laborers, bar workers, those who spent a lot of time away from home or traveled a lot, partners of all these groups, etc. High HIV prevalence was found in some (but by no means all) of the groups initially thought likely to be infected. But some of those infected would have been infected through earlier unsafe healthcare because they received the very type of healthcare services that Pepin describes, at a time when no one suspected a blood-borne virus had entered the healthcare system.

I follow Dr David Gisselquist, writing on the Don't Get Stuck With HIV blog, in calling for all scientists working with HIV, not just healthcare professionals, to gather up earlier claims (and perhaps more importantly, assumptions) about sexual transmission of HIV and look at them again in the light of Pepin's findings. We no longer need to accept the sort of racist and sexist assumptions about African sexual behavior that have passed as 'knowledge' about HIV. We are now free to rethink the HIV orthodoxy; in fact, we have a duty to do so.

How Many Dictatorial Bureaucrats Can You Fit in a Five Star Luxury Hotel?

It's discomfiting to hear that Uganda's male circumcision program is being described as 'failing' by a journalist. However, what the journalist actually says about the program is that they really haven't a clue how it is going. Of course, the journalist may know something that is not mentioned in the article. But knowing very little about an expensive, highly politicized 'health' campaign, and one that is concerned (ostensibly) with reducing HIV transmission, is certainly a failure of sorts; think of the publicity.

The Ugandans should take a leaf out of the Kenyans' book and just make up the figures. There's nothing a foreign donor likes more than to hear that everything is going well and few things they hate more than to hear that those involved are indiscreet enough to tell the truth, even if it's an admission that they really don't know how many people have been operated on.

The Ugandans could even just adopt their current strategy on reporting numbers of people on HIV drugs; they don't take too much notice of the substantial percentage that is lost to follow-up every year, those who die or those who develop resistance to the 'cheap' drugs, if they even notice the last issue at all. Many of those being counted could have died or could be getting double counted because they are registered for drugs in several places, which is done because Uganda has never been able to get its drug supply capacity quite right.

The article claims that there is a high demand for circumcisions, which is surprising when the same sentence also says it's not known how many men are receiving the operation. Apparently "most of the institutions carrying out circumcision don't share their data with the ministry of Health". So the journalist and those interviewed are, effectively, just guessing. Which is not really a problem, after all, as those publishing 'figures' purporting to show that male circumcision has any appreciable impact on HIV transmission are entirely unable to say why such an operation should work in the way they say it does, nor why it only seems to work as often as it clearly doesn't work. They too are just guessing.

As for various health facilities not sharing data, I guess that's no more horrifying than the admission that data is not always even shared with people taking part in some of these studies. HIV positive people are not always told they are HIV positive, their partners are not always warned, etc. This wouldn't happen in the countries from where the money emanates for this research, but it appears that ethical standards paid for by big donors, such as Gates and whoever he fronts for, don't apply to Africans. Like Tuskegee (which is so often mentioned in these contexts), it may come out in a few decades time, but for now, people who are known by medical professionals to be HIV positive are allowed to leave health facilities and infect their partner or partners, and no parties need be informed.

The commissioner for National Disease Control, Dr Alex Opio, does "not have a single figure on the great work being done": so how does he know how great it is? I'm glad he has spotted that there is a need to "address this immediately", but shouldn't he wait till he knows what is going on before commenting so liberally? Aren't there laws about telling the truth to journalists when there are important international donors involved?

In a sense the commissioner is right: such 'data' is being used for 'evidence-based medicine'; the whole circumcision (for Africans) program is based on such questionable evidence. Despite citing the rather far-fetched figures ("4.2 million adult/adolescent men need to be circumcised in five years to avert 340,000 new HIV infections by 2025"), the commissioner does realize that a lot of foreign money is pulling out. But enthusiasm for circumcision still seems to be as keen as ever. Other figures cited are equally disturbing, such as the 20.3 million Africans that 'need' to be circumcised, which we are assured will 'prevent' several million infections and save 16.5 billion dollars in treatment costs.

In stark contrast to all the rhetoric about democracy, good governance, accountability and the like that we hear from some of the more pompous and sanctimonious representatives of the HIV industry, some of the least accountable and most undemocratic institutions the world has ever known (as for governance, we don't know, they are unaccountable) have developed a framework 'in consultation' with national ministries of health.

Institutions listed include "the World Health Organization, the Joint United National Programme on HIV/AIDS (UNAIDS), the US President's Emergency Plan for AIDS Relief (PEPFAR), the Bill & Melinda Gates Foundation and the World Bank". While we have little idea how many Ugandan men have been circumcised under the current program, we can gain some idea of how much of the HIV industry funding will be spent, given that particular bunch of overpaid bureaucrats.

[For more about non-sexual HIV transmission, such as through unsafe healthcare and cosmetic services, see the Don't Get Stuck With HIV site and blog.]