Pre-Exposure Prophylaxis, Till Death Do Us Part

Pre-exposure prophylaxis (PrEP) involves putting HIV negative people on antiretroviral drugs (ARV) with the aim of protecting them from HIV infection. So far, such a use of ARV does not give 100% protection. However, like male circumcision and the use of topical microbicides, it could be used along with condoms. Or you could just use condoms.

But the ultimate aim is to develop PrEP that allows people to have safe sex without using condoms (otherwise they will tempt very few). Cynics even suggest that the aim is to allow men who have sex with men (MSM) in rich countries to have unprotected sex, but I don't quite buy that.

The fact that a lot of the clinical trials are taking place in developing countries doesn't mean the people there will eventually benefit from PrEP. But to the pharmaceutical companies that sell ARVs, developing countries represent a huge potential market. That's as long as donors can be persuaded to pay for the drugs. Costs are far beyond what people or governments in developing countries can afford.

There are many questions to be raised about how much the use of PrEP could really help reduce HIV transmission. But my question is about who, exactly, would be the targets of a PrEP program in developing countries, taking Uganda as an example (because I happen to have the Ugandan Modes of Transmission Survey handy).

You might think an obvious target for PrEP would be sex workers. But in the 2009 survey, Ugandan sex workers were estimated to contribute 0.91% of HIV incidence. If you add in their clients and the partners of their clients, that still only comes to an estimated 10.5%. PrEP rollout for these groups, assuming you could actually round them all up, would be very expensive. But it doesn't look like it would have much impact on the overall epidemic.

The largest single group, contributing 43% of total incidence, consists of mutually monogamous couples engaging in heterosexual sex. Bizarre as it may sound, most HIV in Uganda, a virus that is difficult to transmit sexually, is transmitted by very low risk sex.

Those engaging in multiple partnerships, along with their partners, make up 45% of incidence, so perhaps they would be good targets. Again, it would be a mammoth task to round up such a large number of people, let alone distribute drugs to them all and ensure that most of them took the drugs most of the time for as long as they continue to be sexually active.

Think of it this way, Kenya has several hundred thousand HIV positive people on ARVs, that's less than 1% of the population. Around 99% of that money comes from donors. And even that few hundred thousand people is beyond what the countries health services can manage, despite all the donor funding.

The sad truth is that, either you 'target' much of the sexually active population of Uganda, which is not really targeting, more scattergunning, or you will not have any sizable impact on the epidemic. But PrEP is simply not the sort of intervention that you can roll out to a large sector of your population.

An article about the costs involved in rolling out PrEP in Australia cites very high costs just for basic, first line drugs. At up to and beyond 10,000 dollars per person, for the rest of their life, this will not even be discussed in developing countries. And while the drugs will be available at far lower cost in places like Uganda, you are talking about millions of potential recipients. Resistance to first line drugs may only amount to 3 or 4% (if they are lucky) but you can multiply that five or ten times to calculate the addition to costs.

The drugs will be available at far lower prices because drug companies have an uncanny way of knowing just how much they can squeeze out of a 'marketing' situation. Rich countries will pay hefty sums for worthless drugs, or drugs worth very little but in huge quantities. Just look at Tamiflu and the stockpiles of it. They will pay less to purchase drugs for developing countries, but the quantities will be mind boggling and Western run institutions will agree to any price once it's in the hundreds of dollars, apparently.

Talking of Tamiflu, one of the main proposed PrEP drugs is Tenofovir, discussed in glowing terms and voluminous quantities during the Vienna Aids Conference. Another is called Truvada, a combination drug. Gilead is involved in all three.

Another name that crops up is Bill Gates and his Foundation, who are never far away if there is money to be made out of intellectual property. But what will the benefits of PrEP be? If Modes of Transmission Surveys like the one for Uganda are correct, almost everyone that has sex in high and medium HIV prevalence countries is at risk. They can't all be put on preventive drugs, even if it were possible to afford such an intervention.

It may sound as if I am claiming that an almost entirely useless HIV prevention strategy is being advocated for by the very pharmaceutical industry that stands to gain billions from it. And that's exactly what I am claiming. Big Pharma expect billions more dollars, on top of the billions they have already received, to flow from persuading donors to pay for up to tens of millions of healthy people to be put on drugs for a large part of their life, with little or no benefit and possibly a lot of damage. In a nutshell: pre-exposure prophylaxis or PrEP. Remember the name.

NB: I have set up a new blog to discuss the subject of pre-exposure prophylaxis or PrEP.

HIV Policy Based on Anecdote and Hearsay

A recent paper entitled “‘‘When I Was Circumcised I Was Taught Certain Things’’: Risk Compensation and Protective Sexual Behavior among Circumcised Men in Kisumu, Kenya” extols the virtues of male circumcision for protection against HIV infection. The paper is authored by a number of prominent circumcision evangelists, some of whose names crop up constantly in the literature. And it’s not just the title that sounds anecdotal.

But there is a much older paper entitled “Soap and water prophylaxis for limiting genital ulcer disease and HIV-1 infection in men in sub-Saharan Africa”. This paper has only been cited six times in the seventeen years since its publication (although others have investigated genital hygiene and its relationships with HIV and other diseases). Pro-circumcision papers, in contrast, are cited hundreds of times, even ones that were only published in the last few years.

Circumcision, the frequently cited papers tell us, can reduce HIV transmission from women to men by up to 60%. They don’t dwell on the fact that male to female transmission could actually be facilitated by male circumcision, or on the fact that circumcised men still need to use condoms after they are circumcised if they want to protect themselves from HIV infection.

After all, ‘up to 60% protection’ means that the risk is only deferred. Proper use of condoms will increase protection to very high levels. But then, proper use of condoms would increase protection just as much for uncircumcised men. Such use of condoms would also increase protection for women, who are far more likely to be infected than men. In some parts of Kenya, there are three HIV positive women for every HIV positive man.

A lot of recent work has gone into demonstrating the efficacy of male circumcision in reducing female to male HIV transmission. Why this work didn’t take place in the early 1990s, when this ‘discovery’ was already widely acknowledged, is a matter for medical historians (or political ones, or both).

But, far more importantly, why has the use of soap and water as a HIV prophylactic not been investigated with the same zeal that we now associate with male circumcision? Not only is it very cheap, socially acceptable, non invasive, harmless and many other things, but it would also play a part in reducing transmission of other sexually transmitted infections (STI). Has it been ruled out by some randomised controlled trials? If it has, I haven’t read about them, ad nauseam.

It's probably no coincidence that mass male circumcision campaigns have attracted the interest of Bill Gates, who regularly demonstrates his non-expertise in public health, agriculture, development and education. Like his attempts to find a vaccine for a handful of trophy diseases, ignoring alternatives to circumcision seems to have little to do with philanthropy or even the reality of HIV transmission. Access to clean water and sanitation would reduce incidence of countless diseases, HIV being yet another possibility to add to the list.

It is estimated that the mass male circumcision campaign currently taking place in Kenya will cost around $50 million. That's nothing compared to what it will cost in all the other countries where circumcision rates are even lower, but it's a lot of money for an intervention that will only significantly affect a relatively small percentage of Kenyan men (albeit with a prevalence of HIV).

Of course, the same amount of money probably couldn't ensure clean water and sanitation for the whole of Kenya. Even Gates, with his millions and his notoriously generous nature, probably would balk at the costs of providing all high HIV prevalence countries with clean water and sanitation. Besides, it would do a lot of damage to the pharmaceutical industry, which provides the Gates Foundation with a fair bit of money.

But why the obsession with circumcision? Given the risks associated with nosocomial transmission of HIV (transmission taking place as a result of medical treatment), one might have expected the HIV mafia to steer clear of further bad publicity. After all, their record for reducing transmission of their one single disease is far from enviable. Another failed attempt and people might suspect them of being incompetent, money grabbing bullshitters. And then where would we be?

The fact is, the HIV industry doesn't have a lot of tricks in the box. They have been furiously waving their magic wand for years, little realizing that they forgot to put the batteries in (which is why the little pink bulb doesn't light up). But the least they could do now is admit that sexual hygiene is a health issue. It requires public health measures for everyone, rather than the railroading of a couple of million men to undergo an  invasive operation. The evidence for the effectiveness of male circumcision in reducing transmission of HIV is not strong enough to justify continuing with this potentially destructive intervention.

Male circumcision is just another intervention that assumes HIV is mainly transmitted sexually in African countries when this has not been demonstrated. On the contrary, there is a lot of evidence that non-sexual transmission plays a significant role in high prevalence epidemics. This program will not reduce HIV transmission and it risks doing a lot of irreversible damage. Concentrate on establishing what exactly is driving HIV epidemics before hitting out at easy targets.

By the way, did you hear about the latest scheme to eradicate conjunctivitis? It involves cutting off people's eyelids and it can be done preemptively. Hello, is that Bill?

Idle Arguments Support Blinkered Policy

I'm developing a tendency to write very long blog posts and this means that I'm less likely to pick up errors. My last post contained a serious error in the second paragraph that probably made the following paragraphs difficult to understand. I have inserted a correction and apologise to anyone who may have found my argument hard to follow as a result.

In future I need to remind myself that if I can't form a conclusion in less than 1000 words, I probably need to do more thinking than writing. Perhaps even 1000 words is too long and I should aim for 500-700? Anyhow, I thank people for their patience and especially those who have taken the trouble to let me know when they have spotted an error.

In a nutshell, I don't disagree with Mr April's conclusion, that opt-out testing is superior to opt-in testing. I just think the argument is idle and should be completely unnecessary in the first place.

People originally advocated for opt-in HIV testing because those found positive risked being stigmatized. They risked being stigmatized because of the mistaken belief that HIV positive people are in some way immoral or bad (although these qualities are usually implied rather than stated). Unfortunately, the risk of being stigmatized is still very real, despite the evidence that HIV infection is not mainly, as the HIV orthodox view claims, a result of unsafe sexual practice.

Arguments like those presented by April presuppose the truth of the behavioral paradigm, this view that HIV is mainly transmitted through unsafe sex. Attempts to test as many people as possible for HIV in high prevalence populations have been thwarted by the resulting stigma and discrimination, which arises from the behavioral paradigm, even though this paradigm is completely unsupported by evidence.

It shouldn’t take a philosopher or medical ethicist to spot policy that has been formulated on the basis of naked prejudice. But as long as the offending paradigm is retained in HIV policy making, people will continue to be stigmatized. The stigma is a consequence of the paradigm.

To the extent that philosophers or ethicists fail to take account of how things actually are on the ground, their arguments will be, as Wittgenstein might say, ‘wheels that are turning but are not themselves turning anything’. Perhaps Mr April even thinks that UNAIDS, the WHO, the Harvard Medical School, the CDC or the Johns Hopkins School of Public Health are able to inform him about how things are on the ground. But he is mistaken. All they can offer is their prejudice, which he seems to have accepted.

It could be argued that, because Mr April’s arguments are not based on anything happening in the real world, they have no consequences. But his arguments are developed in places where HIV policy is also developed. Therefore, people in high HIV prevalence countries suffer the consequences of the stigma and prejudice that arises from current policies. In fact, what is happening in the real world, unlike academic arguments in certain institutions, has little noticeable influence on policy. But policy can have a huge and overwhelmingly destructive influence on the real world.

UNAIDS Can't Put the Shit Back in the Horse

As a result of the historical association between HIV and sexual behavior, especially sexual behavior considered to be unsafe, illicit, immoral, or whatever, HIV testing is unusual among medical tests by being 'opt-in'. People need to request that they be tested or agree to be tested, in theory, anyhow. Michael April discusses the merits of the WHO's recommendation that HIV testing become 'opt-out' rather than 'opt-in', with reference to the greater availability of HIV treatment.

April wishes to argue for opt-out [apologies, earlier I wrote 'opt-in' in error] testing on ethical grounds, in terms of the themes of consequentialism, liberalism and libertarian paternalism. In deference to his expertise in these themes, I shall not comment on them. This is partly because I'm a very deferential person but, more importantly, because they are quite irrelevant to the issue of whether HIV testing should be opt-in or opt-out. (Although I would point out that, despite the precepts of liberalism and libertarianism, epidemics are factors of whole populations of people, people interacting with other people; they are not factors of individuals.)

First, I take issue with April's claim that "Treatment provision is currently the most important benefit of HIV testing." Treatment provision is important, but it is no more important than establishing, not just whether someone is HIV positive or HIV negative, but finding out how infected people became infected. Treatment is not, and April accepts this in his paper, the same as prevention. But HIV would be exceptional in yet another way if preventing further infection was not also a primary aim of HIV testing.

In order to find out how HIV is spreading, we need to go beyond the highly prejudiced assumption that HIV is mainly transmitted through heterosexual sex in African countries. We need to document people's medical histories in a way that helps us to identify the contribution of non-sexual HIV transmission. Once we have done this, we can best advise people on how to avoid infection if they are HIV negative and how to avoid transmitting the virus if they are HIV positive. Testing aims to screen the whole population, not just those who are HIV positive.

The current practice is to follow UNAIDS advice that HIV is almost always sexually transmitted in African countries (though not in other countries, even in contexts where 'unsafe' sex is very widely practiced). 'Counselling' involves all manner of verbal contortion in the attempt to explain to HIV positive people that they had some kind of unsafe sex, whether they ever remember doing so or not. People who have not had any kind of sex or any kind of sex that could be considered unsafe may be puzzled, but their pleas are generally ignored. They are African and everyone in the HIV industry knows what African sexuality is like, don't they?

April surmises that treatment should be an important consideration for someone weighing up the respective consequences of not getting tested or getting tested. They could risk becoming very sick and eventually dying, also transmitting the virus to others, on the one hand. And they could face the almost inevitable stigma if found to be HIV positive on the other hand. Is the promise of being treated, and therefore less likely to become sick and die relatively soon and less likely to transmit the virus to others enough to assuage people's worries about facing HIV related stigma?

You could argue that, given the availability of treatment, people should reasonably be expected to be tested and, if found HIV positive, face the stigma. The benefits could be seen to outweigh the potential stigma. Or you could argue that the stigma would be unbearable and that, under such conditions, a person would be better off to take their chances and possibly suffer terribly and die prematurely from AIDS.

But people should be able to decide whether they want to be tested without the fear of being stigmatized if found to be HIV positive. There should be no fear of being stigmatized, such that a person might refuse to be tested and even treated, and go through the rest of their remaining years suffering as a result of their decision, and possibly not even managing to avoid stigma in the end. And I'm not just saying 'stigma is bad, we shouldn't stigmatize', as UNAIDS and the HIV industry tend to do (though stigma is bad and we shouldn't stigmatize).

I mentioned above the 'historical' association between HIV and sexual behavior, not because HIV is never sexually transmitted. Sometimes it is. But we should have moved on from the knee-jerk reactions of journalists and other commentators in concluding that because HIV is sometimes sexually transmitted, anyone who is infected almost definitely engaged in some kind of unsafe sex. Not only have journalists and other commentators not moved on; a whole UN agency was built around a virus that is known to be transmitted sexually and non-sexually, and it hasn't moved on, either.

Ok, that's a bit inaccurate. UNAIDS does realize that HIV can be transmitted non-sexually and they realize that it can be transmitted non-sexually in African countries. They just don't tell people in Africa. They warn their own employees to avoid medical facilities in African countries but they deny that medical transmission of HIV plays a significant part in the worst HIV epidemics in the world. Most African countries have inadequate medical facilities, unbelievably low numbers of skilled personnel, shortages of equipment and drugs. If medical transmission of a blood-borne pathogen hardly every occurs in African countries, where does it occur? Let’s, at least, investigate.

So, Mr April, if HIV is seen as a disease of whole populations, one that can be prevented as well as treated, testing can benefit everyone. If it is seen as a virus that can be transmitted both sexually and non-sexually, that might help reduce the stigma that has been driven by the HIV industry itself. But more than that needs to happen. The HIV industry, and especially UNAIDS, need to re-examine their adherence to the behavioral paradigm, which says that preventing HIV (in African countries) is just a matter of influencing sexual behavior.

Evidence against the behavioral paradigm is plentiful, certainly too plentiful to rehearse in a brief blog post. But it should be clear now how the 'dilemma' Mr April would 'solve' through ethics has a far more pragmatic solution (or ‘dissolution’). It's not certain that we can ever undo the stigma that UNAIDS and the HIV industry have spread. That will certainly take a lot of work. But we need to start by reforming and, if necessary, dismantling the institutions that are the source of this stigma.

We need to gather evidence of how HIV is being transmitted in order to mount a viable prevention campaign. We should no longer resort to the mathematical models that pander to the industry, the innuendo that panders to the press and the pseudo-morality that panders to politicians. If there is a possibility that medical, cosmetic or any other facilities could be sources of HIV transmission, that needs to be investigated. It's not good enough to carry out investigations in wealthy countries, it's poor countries that have the facilities that are most likely to be transmitting HIV.

HIV is not just a matter of individual responsibility, as it's been painted. In relation to viruses like HIV, people are not mere individuals. It is their interactions with others, many and various interactions, that give rise to epidemic spread. Reuse of unsterile medical and cosmetic equipment provides the perfect conditions for transmission of HIV and other blood-borne viruses. It’s only the prurient association of HIV and illicit sex that allows such a dogmatic and irrelevant notion of individuality to arise in the first place.

Spread of HIV will not be prevented through individual behavior change alone when it was not individual behavior alone that resulted in the virus becoming endemic. But sexual behavior is, par excellence, group behavior. This is not to say that people shouldn't receive sex education and take precautions against infection with all diseases and against unplanned pregnancy. But nor can you accuse every HIV positive person of being promiscuous or careless. Sex, in itself, is not wrong, not even for Africans. There’s no ethical dilemma. But there is a pragmatic problem of how to undo the damage we have done by stigmatizing HIV to the extent that many people would risk suffering and dying rather than be tested and treated accordingly.

If there is any dilemma, it is this: how can the very people who established the extremely racist orthodox view of HIV now replace that view with one that is more appropriate? Personally, I don’t think the same people can take everything back. Why should anyone believe them? So, does the HIV industry hold on to its rather tattered credibility and keep on lying to cover up previous lies? Or does it at least create the possibility of reducing the transmission of HIV and perhaps eventually eradicating the disease? But when you put it that way, there is no real dilemma, is there?

Does the HIV Industry Despise Africans or Just Sex in Africa?

While I commend any activism that opposes the numerous ongoing national and international failures to deal with the HIV pandemic, there is an attitude that treatment for those infected is more important than maintaining the negative status of those who have not been infected. The two are equally vital and they should never be seen as being in opposition. Treatment activists have their legitimate agenda but they sometimes make it clear that they forget that health is a property of whole populations, it is not just a matter of having or not having some disease.

During the recent Vienna Aids Conference, Mark Heywood executive director of Section 27, was widely quoted as saying: "The testing campaign [in South Africa] is only a means to an end...; its intention is to give people access to treatment and to other healthcare services. However, if treatment is not actually provided, then the means cannot be justified."

Mr Heywood is quite wrong. There is talk of testing 15 million South Africans. Are we to believe that this massive number of people is to be tested and no effort made to find out how those who are infected became infected? Is South Africa going to copy the mistake made by most HIV/Aids institutions for nearly thirty years? Will everyone in the HIV industry just continue to assume that HIV is transmitted sexually in African countries, and allow sources of non-sexual infection to continue, unabated?

Testing for HIV is not just the means to one end, that of treating people. Everyone who is infected has the right to treatment, I'm in complete agreement with Heywood there. But people who are not infected have the right to stay that way. And establishing how they can achieve this is another, equally important, justification for mass testing. If we continue to ignore some routes to infection, people will continue to be infected. If campaigns for treatment for all HIV positive people fail to take account of this, the scope for treating everyone infected will start to narrow very rapidly.

Those who advocate treatment for all HIV positive people, and I am one of them, must also advocate for prevention campaigns that are based on the realities of how HIV is transmitted, whether it is transmitted through unsafe sex, unsafe healthcare, unsafe cosmetic practices, intravenous drug use, or any other way. Claiming that mass testing is only justified if those found to be positive are guaranteed treatment is disingenuous and counterproductive.

In the same article, the Nigerian activist Morolake Odetoyinbo said that testing for HIV had been scaled back and was now targeting "people considered to be at high risk, such as sex workers, injecting drug users, truck drivers and people with TB. This stigmatised testing."

Quite, it stigmatizes testing in a very specific way: it assumes the truth of the behavioral paradigm, the assumption that most HIV is transmitted sexually (in African countries) and has the corollary that all (African) people need to do is 'change their sexual behavior' in order to avoid being infected with HIV. Yes, it includes injecting drug users; they also are a stigmatized group. But the majority of people in African countries are not members of any of these groups. Even the majority of HIV positive Africans are not members of any of these groups.

If the Nigerian government wants to follow in the footsteps of other African countries, who have received all their HIV advice and funding from prejudiced Westerners (the HIV industry), all the worse for Nigerians. If you assume that most HIV is transmitted sexually, you will not be looking for non-sexual exposure, nor will you take any measures to avoid it. Nigeria could quite easily pass out South Africa and become the top country in the world for the number of people living with HIV.

Regarding stigma, Odetoyinbo goes on to say “It’s beyond access to medication”. What is the use of life if there is no quality of life? What is the use of life if you just give me pills to stay alive? I don’t want to be alive when there’s such circumstances. I still need my dignity as a human being.”

The HIV industry has set the agenda, the stigmatizing, prejudiced, sexist agenda, that HIV is just a matter of sexual behavior in African countries. With the HIV industry's view of HIV, you will never have dignity. But you can not deplore the stigma without also deploring agenda. And first, it needs to be clear what exactly is being stigmatized. It is sex, simply that. People may say it is unsafe sex or illicit sex or any number of things, but in reality, they object to sex.

Consider that in the early days of development theory, development meant no more and no less than population control. Many institutes haven't gone beyond that development paradigm. And many of the big organizations working towards the aims of that paradigm, to reduce populations in poor countries, are the same organizations claiming that they can reduce HIV transmission by influencing people's sexual behavior.

They were not very successful in reducing birth rates, they are not having much effect on HIV transmission and they will continue to fail, despite receiving the lion's share of funding. Among them are Population Services International, Family Health International, The Futures Group International, the Guttmacher Institute and the Rockefeller Institute, but there are others. A lot of institutions that use terms like 'hygiene' and 'public health' (and various other euphemisms or euphemistic uses of words that sound innocuous enough) have similar histories.

Sex is what people and institutions object to, or say they do. They don't give a damn about diseases, there are plenty of them, sexual and otherwise, but they aren't putting any of their time into reducing their transmission. Sex is what journalists like to write about and what donors like to fund and what politicians make their careers out of condemning and what the public likes to read about. But HIV is a disease, it is not sex, unsafe or otherwise. It is spread in a number of ways, sex being one of them. But the conditions under which people have sex go way beyond mere sexual behavior. Those conditions are part of what makes us human.

Sex is no more wrong than breathing, which transmits TB; drinking water, which transmits water borne diseases; standing too close to someone, which transmits many diseases; eating food, which transmits some of the biggest killers in developing countries; crossing roads, working in mines, playing football or walking home alone on a dark night.

Nor is it sexual abuse, sexual violence, female genital mutilation, male genital mutilation, gender inequality or any other forms of abuse that are responsible for HIV epidemics. They should all be outlawed, but they existed before HIV did and they will continue to exist after HIV ceases to exist, should such a time come.

Some people, who accept that there is nothing wrong with sex, make the objection that if it is recognized that HIV is not always transmitted sexually, that those who are found to have been infected sexually will still be stigmatized. But it is the sex that is being stigmatized, not the HIV. The disease (and people who are infected with it) are stigmatized because of the association with sex. If you think that there will be two tiers of HIV positive people, the sexually infected and the non-sexually infected, you too are moving the target of the stigma!

That people have objections to sex is a complex problem with a long history. It won't be solved by conflating it with something else. HIV, and many other diseases, are being transmitted rapidly when they could all be controlled, to some extent, and many could be prevented or cured. HIV testing needs to ascertain how people become infected, if at all possible, not just whether they are positive or negative. Reading humanity's sexual hang-ups into HIV transmission has allowed the disease to become a pandemic. It could get a lot worse, and it probably will if we don't take our prejudices out of our HIV prevention policies.

Poverty Makes the World Go Round

How do you undermine the rights and autonomy of whole populations and, instead of censure, receive only praise? Simple, you just call it development. A multinational that respects little aside from money, and certainly has no time for democracy, is bad enough. Yet, when it joins forces with an institution with similar qualities, but happens to be an international 'charitable' foundation, there is very little anyone can do to rein in their actions, no matter how exploitative, destructive or manipulative they may be.

The Gates Foundation has been bullying countries into dancing to its tunes for some time now. And Monsanto's monopolistic behavior is legendary. But both these institutions recognise just how far they can go as long as they bleat on about 'helping' people, saving lives, feeding the hungry, etc. How can anyone object to such philanthropic actions, whatever their motivations? They certainly couldn't object to 'donated' food merely on the grounds that it is genetically modified (GM), could they?

Some like to make out that opposition to GM is based on a fear that the foods are damaging to people's health. Perhaps some people do have such fears. And those with an interest in pushing GM do not themselves know what effects the technology could have on health or the environment (or if they do know they have never made their findings public), so they certainly don't want anyone else to know. Because people's fears are based on lack of information, rather than availability of information, the industry can churn out any kind of deceit to defend themselves (or pay pseudo-academics to do it for them).

But others are more worried about the fact that multinationals like Monsanto want to monopolise agricultural production, from the choice of seeds, the varieties of produce, the agricultural inputs, the agricultural practices employed, all the way to what people eat, how much they know about what they eat, how much they pay for it, how food is produced and stored and anything else they can control. They are not just food facists, Monsanto runs the whole gamut of facism.

Couple this with the man who wants to do for food what he succeeded in doing for software and you've got a real threat to democracy, health, the environment, the economy and even global security. If there’s anything about facism Monsanto doesn’t know, Bill Gates and his Foundation will soon fill in the details.

People in developing countries may have been kept in the dark but they are not stupid. They know that there are reasons for high food prices and lack of access to food; they know that the prices are not necessarily high because of shortages and that lack of access to food is not necessarily because of their country's inability to produce it.

There is little secret about the fact that famines, food shortages and food insecurity, including recent instances of these, are not caused by lack of food; many countries experiencing these phenomena have plenty of food. It is obvious to many that it is people with large amounts of money who created prices beyond the means of those living in developing countries. And you don't need to be a genius to know that shortages of (edible) food can be created when most land is used for products destined for the rich; biofuel crops, flowers, luxury fruit and vegetable, tea, coffee, cocoa, rubber, sisal, animal feed (for Western animals) and the like.

One of the financial institutions that did very well out of the recent handouts to the rich, Goldman Sachs, also made a lot out of the food price speculation that created the food crisis a few years ago. They raked in an estimated billion dollars; even by Gates’ standards, that’s a lot. They do very well out of human misery, benefiting from it, as well as causing it. So who would pass up the opportunity to share in their returns? The Gates Foundation certainly wouldn't.

Is it really philanthropy to extract money from people and then give some of it back to them? We don't really know how much the Gates Foundation's ill gotten gains come from the countries that eventually 'benefit' from its 'largesse'. The Foundation, in its great (undemocratic) wisdom, decides who benefits as well as who loses and they are certainly not going to tell members of the public, especially not in developing countries. The Foundation aims to keep its wealth intact, regardless of how it achieves this. Any doubts or worries that arise can be assuaged by some pretty pictures of happy children or mention of names like ‘Kofi Annan’.

It comes as no surprise that the Foundation now has a considerable investment in Monsanto. This multinational has much to gain from developing countries and has shown that it is unscrupulous enough to do whatever is required to maximize its gains. The Foundation's sham 'Alliance for a Green Revolution in Africa' (AGRA) has never denied that it will take advantage of GM if and when it sees the benefits. Gates has been investing in Monsanto for years. Some have probably been wondering when pay day was due.

This diabolical coupling does have one feature that may not be completely negative: it brings into clear focus the intimate connection between the unscrupulous grabbing by some institutions and the equally unscrupulous ‘philanthropy’ of others. Gates and a small handful of other rich people and institutions control the means of production where the products include poverty, disease, starvation, environmental destruction and a whole lot of other ills. And where would we be without all of them?

Who Will Educate the Educators?

After leaving Maker Faire Africa on Friday, inspired by much of what I saw there, I returned to Nakuru, where many of the town's residents stand or sit in the same places every day, staring at passers by, shouting the odd bit of abuse and joining in any commotion that happens to relieve the monotony.

I admit, I was a bit annoyed when I compared how some people do amazing things with their time and others do not. I always have to go through the same thought process; first I get exasperated and then I remember that there can be reasons why some people energetically pursue things that benefit them and others while some people seem condemned to get up every day and stare into the middle distance until it gets dark.

The vast majority of exhibitors that I talked to at Maker Faire were well educated and some were clearly from well off backgrounds. This means nothing on its own. Those with lots of education from well off backgrounds can also end up doing little with their lives. And some from poor families with only a basic education achieve great things.

But some of the exhibitors were also wondering why some of their fellow Africans didn't do what they were doing. And one reason I would suggest is lack of basic education and training in skills that allow people to prosper, or at least to get by better than they do now. When I attempted to demonstrate to people around Nakuru how they could make and use simple technologies, they went through a few phases: they were curious, even surprised; they raised objections; they became silent and sat on their hands.

I admit, they may not have had the best teacher. But I think there is something about education beyond what is imparted by a teacher and embraced by a learner. People didn't sit on their hands because they were unable to cut out shapes using patterns and stick things together with glue. They are well able to do such things and many others. I would guess that most of them could have done much of what the exhibitors at Maker Faire did.

What people gain from education, I hope, is the ability to make what they learn part of their day to day lives, whether this involves various bodies of knowledge or sets of skills. What people with a poor education receive is lists of things to learn off so that they can get the requisite number of ticks in order to graduate to the next class. These ticks are rarely, if ever, of any use to people thereafter. But once people have mastered the pretence of being educated, they have no way of taking their education further.

I'll say it again, people with education and training may not necessarily do much with it. And those with little education and training may spend their lives enhancing what they have got and benefiting themselves and those associated with them. But that seems like leaving things to chance for the majority, while allowing a minority quite an advantage, whether they use it well or not.

Development projects can be very narrowly focused. For example, many education projects focus on a few indicators, often the ones that show the project in a favorable light but give little benefit to the recipients. They might concentrate on enrolment but not attendance, exam results without any evidence of learning or the ability to continue learning after school has finished, gender parity without any change in genuine inequalities, etc. 'Success' in development projects can resemble the 'success' of students who have received a poor education.

HIV projects can involve huge amounts of money and produce amazing statistics about the number of HIV transmissions prevented, the number of deaths averted and the number of condoms distributed. Yet people are suffering from and dying from very ordinary diseases that are easy to prevent and cure. Health is not just a matter of disease or being free of disease and it's even less a matter of one virus (which is still endemic in many countries in the world, despite hundreds of millions having been spent on 'prevention' programs).

There seems to be an emphasis on size and magnitude and the measurement of these development projects, as if there is some great prize to be won on the basis of a few hackneyed quantities. Is the aim of development not to ensure that there are fewer millions of people receiving little or no education, suffering from and dying from preventable and treatable illnesses, unable to afford basic nutrition or water and sanitation? Of course you have to count people, but people are not indicators, nor are health or education.

Many of the projects at Maker Faire were about things that matter to people in their day to day lives, food, water and sanitation, agriculture, communication, income, energy, lighting, raw materials and the like. There was less emphasis on education that I would have expected, unless you count some electronic device that 'helps children learn to read'. But these are all concerns that are raised when you go to villages, slums and isolated areas.

Levels of education, especially among girls and women, can be shockingly bad. Many primary school teachers are said to have a low understanding of the subjects they teach and even those who know more don't manage to impart much. But education is not just a process of 'attaining' a set of facts or skills. It is the preparation that everyone needs in order to ensure the education and health of themselves and their families and to ensure that they grow up to be able to provide for themselves and their families, in turn.

A lot of development is dominated by quantities and measurement, a set of boxes to be ticked, regardless of the irrelevance of such processes to people's lives and livelihoods. The Millennium Development Goals, mentioned several times at Maker Faire, are the epitome of such a lifeless and administrative view of development. People need basic things, education, health, nutrition, income, water and sanitation and infrastructure, but they also need to be able to provide themselves with these and other rights. These are not things you can pack in sacks and send them off in an aid convoy.

Significant feats will not be achieved by hordes of administrators with clipboards (or technological variants of clipboards) recording a handful of indicators as people die prematurely and needlessly, though this is a great way of spending billions of dollars. I suppose development will only achieve anything when it has put people in developing countries in the position where they can do the development. So far, we have not been very good at this (and I include myself, of course).

That development needs to be sustainable, that it needs to give rise to further development, seems clear. But it also seems to matter a great deal who is doing the development, who is able to do it, whether it is outsiders from developed countries or insiders from developing countries. Which is very similar to the conclusion I came up with yesterday! I could go on, but tomorrow is another day.