Items by Simon

HIV in Kenya

• Was the Tenofovir Gel Microbicide Trial Ethical?

  Posted: July 25, 2010, 1:03 am by Simon

  Was the trial ethical and were the results valid? The two questions go hand in hand.
  
  It's quite hard to decide if there was something unethical or invalidating about the Tenofovir Gel Microbicide trial because there could be important details about the trial that have not yet been published. For a start, the trial assumes that most HIV transmission among the participants is sexual. But did the researchers involved actually establish that HIV transmission was all or even mostly sexual? If they did, they haven’t said so in the paper.
  
  The question is important because, during the course of the trial, researchers would have had the opportunity to find out, for each participant who became infected with HIV, how they became infected. One might say they had a duty to find out how they became infected. Were the partners of all the women who seroconverted HIV positive? I don't believe this data was collected. If it was, it should have been published because those who were infected non-sexually should have been excluded from the results. The gel is supposed to protect against heterosexually transmitted HIV, not, for example, HIV transmitted by unsafe medical procedures.
  
  Participants were given the gel as a prophylactic against HIV. They were given to understand that they would be protected against HIV infection. They wouldn't have been told that they were protected against non-sexual HIV transmission. But they don't appear to have been warned about the possibility of non-sexual transmission. If the researchers didn’t exclude the possibility of non-sexual HIV transmission, and they don’t appear to have done so, the results are of questionable validity.
  
  Nearly 900 people were recruited to take part in a trial and it was known that some, perhaps a lot of participants, would become infected with HIV before the end of the trial. It was not known how many would become infected or which participants. Perhaps non-participants in the area may face an even higher risk of becoming infected. But I don't think that excuses those running the trial for failing to ensure the safety of those taking part, or for failing to establish the cause of each HIV infection.
  
  Participants were "provided with comprehensive HIV prevention services (HIV pre- and post-test counseling, HIV risk reduction counseling, condoms, and STI treatment), reproductive health services...". They were made aware of the risk of being infected with HIV sexually, but not non-sexually; this is not comprehensive. But despite this preparation, which surpasses the level of prevention available to most people in most African countries, HIV transmission rates were extremely high.
  
  Why, given all these precautions, including very high condom use, were transmission rates so high? And why did the researchers not make any attempt to find out how people were becoming infected? Did they not have a duty to find out if their gel could even have had any influence on rates of HIV infection, or what level of influence it could have had?
  
  In fact, it is not accurate to say that "All women were counselled on the risk of HIV and encouraged to use condoms at all times..." as one report said. All women were counselled on risks of *sexual* HIV transmission. Condoms wouldn't have been much use if any of the women were infected non-sexually.
  
  A BBC article inadvertently puts its finger on the problem: "A vaginal gel has significantly cut the rate of women contracting HIV from infected partners...". But the trial has not established if partners were infected or uninfected. So we don't know if the vaginal gel has achieved this, or exactly what it has achieved.
  
  The same article goes on: "Such a gel could be a defence for women whose partners refuse to wear condoms." But reported levels of condom use were very high and they increased during the course of the trial. Condoms should be far more effective than they appear to have been during this trial. Condom manufacturers must be asking if it is safe to use the gel when using condoms or if the gel actually weakens them or causes them to burst. I certainly hope they are asking these questions.
  
  The article cites one of the researchers as claiming: "Women who used the gel more consistently were much less likely to be infected…". But women using the gel more consistently also had less sex. And those having more sex tended to use the gel less consistently. It's hard to know exactly how to interpret the results of this trial. If the results were truly valid and significant, how would we know? The research seems to be incomplete in many ways.
  
  Executive director of UNAIDS, Michel Sidibe, is quoted as saying: "For the first time we have seen results for a woman-initiated and controlled HIV prevention option." Well here's another one: Patient Observed Sterile Treatment (POST). In order to protect themselves from non-sexual HIV transmission, people need to be made aware that HIV is not always transmitted sexually and of the precautions they can take. Concentrating on sexual risk alone leads to the sort of travesty that this gel trial appears to have been. If the Executive director of UNAIDS is not aware of this, he should resign.
  
  Can we say clearly that the results of the trial could not have been due to chance? Technically, the result is statistically significant, other things being equal. But we just don't know enough (or are not being told enough). The paper notes that, "Overall, condoms were reportedly used in 80.3% of sex acts; increasing from 78.5% in the first 6 months to 84.3% in months 18-24". This means that as condom use went up, the efficacy of the gel seemed to go down.
  
  The paper goes on "we observed declining HIV incidence rates in the placebo gel arm. This may have been due to their declining coital frequency and increasing condom use." So, are they saying that over time, the efficacy of the placebo gel increased as the efficacy of the Tenofovir gel decreased? That seems like a strange result. If the trial had gone on for five years, would these two trends have continued? Not only is the trial questionable ethically, it is also of questionable validity.
  
  The trial could be unethical because the researchers would have known in advance, or should have known in advance, that at least some HIV is transmitted non-sexually. Yet they made no effort to protect people from this. Nor did they make any effort to inform people that such a risk exists. And the results are of questionable validity because we don't know how people became infected and, therefore, why some people didn't become infected. There could have been many factors that increased the risk of infection and others that decreased the risk. Tenofovir gel may have had some effect, but we don't know what effect it had or why it had an effect.

• How Convinced Were You by the Microbicide Story?

  Posted: July 24, 2010, 2:49 am by Simon

  The six day Vienna Aids Conference has come to an end and the freeloaders will have to finish up their last free drinks until the next junket. The press has excelled itself by repeating, almost word for word, everything they were told to publish. Searches for any of the conference catch phrases, such as 'Treatment 2.0', 'treatment as (or 'is') prevention', 'rights here, right now' or 'Tenofovir gel', etc, will yield thousands of results, all equally uninformative.
  
  Outside the mainstream press, the Huffington Post has an article that questions the big story of the week, the announcement that a vaginal gel, using the antiretroviral drug Tenofovir, has shown some promise in trials. The author, John R Talbott, points out that the results are not really as exciting as they seem and that using this gel will only give a relatively small amount of protection. Over a lifetime, the majority of people in a population like the one in the trial will still eventually become infected, even if they use the gel all the time.
  
  The paper entitled 'Effectiveness and Safety of Tenofovir Gel, an Antiretroviral Microbicide, for the Prevention of HIV Infection in Women' is indeed very unconvincing. Even the authors must feel pretty uncomfortable about the results of their trial and the many unanswered questions thrown up. In the introduction, they mention that in the past three decades "Only five of 37 randomized controlled trials, which tested 39 HIV prevention strategies, have demonstrated protection against sexual transmission of HIV infection". Three of the five are circumcision trials, which were well publicized but not very encouraging. The fourth was a vaccine in Thailand, which was also disappointing.
  
  The fifth was a sexually transmitted infection (STI) treatment trial in Tanzania. Similar trials were carried out in other locations at the same time but they didn't result in any reduction in HIV transmission. The trial in Tanzania seemed to, except that there was an injection safety trial going on at the same time in the same place. It is highly likely that this affected the results of the STI trial. Yet, even though those working on it knew about the injection safety trial, they failed to mention it until many years after publishing their initial results.
  
  The history of HIV prevention is notable not so much for its failures as for the way those failures have been dressed up as successes. The Vienna Conference has pushed the Tenofovir gel trial as a great breakthrough and the press have bounced the story around the world (and the www). The authors of the paper may well be regretting that their work has been chosen to be hyped above all others this time around. They, of all people, are probably painfully aware that we are still a long way from a pharmaceutical product that will have a significant impact on HIV transmission.
  
  The trial itself is quite tentative, involving a small number of people. And the scope of the research was very narrow. One of the most shocking things is how high incidence is, in both the intervention (5.6%) and the control (9.1%) groups. If you had hundreds of people whose sexual behavior you were studying, you might want to investigate their sexual behavior. This trial didn't really do that. They didn't test the participants' partners. They don't even know if those who contracted HIV did so through sexual behavior! Or, if they did check the partners, they don't mention this in the paper.
  
  Another extraordinary thing about the trial is that condom use was high and steady throughout the trial, in both intervention and control groups. Condom manufacturers must be wondering exactly what the participants did with the condoms to have such poor results with them.
  
  Over the trial period, the number of sex acts involved was not particularly high. Even if none of the participants had used condoms, incidence of between 5.6 and 9.1% would be hard to explain. The authors speculate about the women having sex with 'migrant workers' but they don't say if the women did so. The trial selected women that were at low risk of being infected with HIV, so why did so many turn out to be at high risk?
  
  Not only did the women in the trial not have sex particularly often but they had sex less and less often as the trial went on. The number of sex acts per month went from 7.2 to 3.1 per month. The more people were having sex, the less likely they were to use the gel and those who were having sex least frequently were the most likely to use the gel. But frequency of sex doesn't seem to change the risk of becoming infected. It's as if sexual behavior is not especially relevant to the results of the trial.
  
  Talbott touts his own theory of why HIV rates are so high in Africa. He concludes that it is because of the "numerous and informal sexual affairs common in Southern African nations, found both among married and unmarried men, especially with a much smaller highly infected group of very sexually active women who trade sexual favors for material goods and money". There is, in fact, no evidence that 'Southern Africans' have more 'informal sexual affairs' than many people in other continents (or countries). But the Tenofovir trial itself even finds that sexual behavior is not very frequent. Nor does it appear to involve a lot of 'unsafe' sex.
  
  And, like many people who rush to such conclusions, Talbott also doesn't explain how large groups of sexually promiscuous men and small groups of sexually promiscuous women can give rise to far more women being infected than men. Perhaps he would, along with others, say that all these men go home and infect their wives. But about half of the HIV positive married women have HIV negative husbands. His argument suggests, as all arguments do that try to explain high HIV prevalence by reference to sexual behavior alone, that Africans have a lot more unsafe sex than non-Africans and that many of the women are exceptionally promiscuous.
  
  Firstly, we know that Africans don't have a lot more unsafe sex than non-Africans, secondly, we know that African women are not exceptionally promiscuous and thirdly, it has also been shown that even very high rates of unsafe sexual behavior do not explain the levels of HIV prevalence found in some African countries. I applaud Talbott for criticizing the dubious claims being made about the Tenofovir gel trials. But he doesn't do much for his credibility, or that of the Huffington Post, by falling back on the racist and sexist views of the HIV  industry.
  
  Talbott calls for testing. What is needed is investigation. Why are so many women whose lifestyle is not risky becoming infected with a virus that is difficult to transmit? Why were their partners not tested, or if they were, why were the results not published? Who cares whether the gel works or not when we don't even know how the women were becoming infected? Like all the other 'major breakthroughs' discussed at the conference, this gel will only be useful if HIV is mostly sexually transmitted. This is far from evident.

• Sniff it, Lick it, Publish it

  Posted: July 23, 2010, 2:23 am by Simon

  If someone at the Vienna Aids Conference put out a press release saying tests have shown that regular use of bouncy castles cures HIV, would the world's media repeat it, just as they have done with every other improbable press release that has come out over the past few days? Have these journalists ever heard of criticism, originality, judgment, analysis or even writing? They did the same during the World Cup, regurgitating every scrap of rubbish they could find. Was everything washed down with free beer (Fifa approved, of course)? If so, no doubt they are washing things down with good wine in Vienna.
  
  Even Reuters' AlertNet follows the flock with their triumphalist 'MTV drama brings cool to HIV prevention'. Apparently this drama, 'Shuga', was aired some time last year, but where? Perhaps it was aired in Nairobi or in private schools but I don't know anyone who has seen it or even heard of it. "In Kenya, the drama was watched by an astonishing 60 percent of young people – those are amazing figures for any programme," Bill Roedy, CEO of MTV, told IRIN/PlusNews. They're not just amazing, they are not credible. Where's the evidence, Roedy?
  
  Over 80% of Kenyans live in rural areas and about 70% of those who live in urban areas live in slums. Official figures claim that only about 30% of Kenyans do not have access to electricity and that only about 25% don't have regular access to the media (print, radio and TV). But how many people have TVs or regular access to TVs? Most people in the areas I've been working in don't. But in the euphoria at Vienna, with the desperation to churn out feel-good stories, the press will repeat anything they are fed. Haven't they ever heard of evidence?
  
  As for the 'evaluation' of what people learned and think and what that might show, what does that mean? Most people visit the bathroom after watching a few TV shows, does that mean they are good laxatives? Of course young people will be able to repeat what they have heard, especially when treated to a TV show about sex (though I'm still wondering how many have really seen it). Children here, and adults, have been blasted with rubbish about HIV and sex for so long now they know exactly what to say when asked. The problem is, even people who work with HIV have no idea that HIV can be and is transmitted non-sexually, nor any idea how to protect themselves from non-sexual HIV transmission.
  
  This is an extremely dangerous situation. I've sat with people and discussed conditions in hospitals, their experiences with doctors, nurses, dentists and others who might pose a risk of blood-borne infection of some kind. But when the conversation turns to HIV risk reduction, they always talk about sexually transmitted HIV. Of course, Shuga is about sexually transmitted HIV, from what I can glean. What else is there, if you're part of the mainstream media, which MTV most certainly is.
  
  Contradictions are not considered important in the HIV industry but one of the feel-good stories that's been churned around before and during the conference has been about young people 'leading' the drop in the spread of HIV. Yet now, the AlertNet article says "Worldwide, 40 percent of new HIV infections occur among young people between the ages of 15 and 24. Behaviour change campaigns have shown some success...". Behaviour change campaigns have resulted in people being able to answer questions about things they have been taught but they have not resulted in significant levels of behaviour change. And they have had no impact whatsoever on HIV transmission rates.
  
  The 'evaluation' was carried out by the Johns Hopkins Centre for Communication Programs. Johns Hopkins, like the HIV industry, is vehemently opposed to the idea that HIV is commonly transmitted non-sexually in African countries. But just because the HIV industry is completely biased against anything that could threaten their massive levels of funding, that doesn't mean the media should behave as the lapdog of industry, academia and anyone else handing out free booze (or whatever they get out of it).
  
  There's no polite way to say this and politeness would be misplaced anyway: the Vienna Aids Conference is an (expensive) exercise in arse sniffing, a specialty of the press. One can only wonder what they all do to while away the time during those long presentations and seminars. When I tell people in rural areas about things like the HIV industry and conferences, they ask reasonable questions, such as 'what is HIV prevalence like in Vienna?', 'why are they there?', 'how expensive are these conferences?' and 'if the industry gets so much money, why does none of it end up here?' Any chance of a woof, a yelp or even a whimper from the pampered, or they too well bred?

• Whose Rights, Which Rights and Where?

  Posted: July 21, 2010, 2:13 am by Simon

  The punchline for the Vienna Aids Conference that's taking place at the moment is 'Rights Here, Right Now'. But it is only recently that the HIV industry has been making it clear whose rights they are demanding. They are demanding that HIV positive people, all of them, receive treatment. HIV positive people have a right to treatment but the conference rally cry seems to ignore the right that HIV negative people have to stay negative, indeed, the same right that HIV positive people have already been denied. Of course sick people have a right to treatment. But what the industry is claiming is that treatment for HIV positive people will ensure that HIV negative people stay that way; not healthy (not by a long shot), just HIV negative.
  
  Well, in an ideal world, HIV positive people on successful antiretroviral treatment (ART) are less likely to transmit the virus to other people. We actually live in a world where most HIV positive people are not on ART, for a variety of reasons, and that will probably remain the case for the foreseeable future. But UNAIDS and the rest of the HIV industry don't live in this world. They live in a better carpeted world, better paid, where a disaster is having to drink a coffee with full fat milk when they ordered skinny. They themselves have a right to health. Others have a right to (HIV) treatment, and let's be clear, we are talking about people in developing countries here.
  
  The Alma-Ata Declaration defines health as follows:
  

  health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and [...] the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.

  Notice, it is not about treatment, which is for sick people. Telling healthy people who are hoping to stay healthy that treating the sick will also be good for them is not promoting their health. Treatment is not prevention, it is just treatment. But putting as many people as possible on treatment will not have the effect of eradicating HIV. Mass treatment may slow transmission down a bit, but refusing to do anything to reduce transmission aside from treating those known to be HIV positive and willing to be treated with ART, is denying the majority of people their right to health.
  
  There are several manifestations of the industry's desire to see treatment as prevention. In some places, where circumcision rates are low, there are plans to circumcise millions of men. This may or may not protect those circumcised, the evidence is slim. But it is unlikely to protect those with whom they have sex. The difference here is that millions of people, most of whom are not sick, are being told to have an operation that will keep them healthy. It is further implied that their being healthy will ensure the health of others. And this is in countries that have few health facilities, doctors or nurses and chronic shortages of equipment and medication.
  
  Another manifestation is called pre-exposure prophylaxis or PrEP. This involves people who are HIV negative taking ART drugs on the grounds that they will be less likely to become infected. So treatment is not only being offered to those who are HIV positive, it is also being offered to those who 'may' become infected, in the opinion of a bunch of 'experts' who think that HIV treatment is a substitute for health. HIV industry spokespeople like to talk about 'science' and 'evidence', but what about rights, logic and common sense? Is a healthy person just a potential customer to them?
  
  The industry has long insisted (it's a bit tenuous to call it a belief) that HIV is almost always transmitted through heterosexual sex in developing countries. There are two problems with this 'behavioral paradigm': firstly, given that those in developing countries don't engage in more sex, safe or unsafe, than those in rich countries, why do some developing countries have unbelievably high rates of HIV transmission, far beyond what could be reasonably explained by sexual behavior? Secondly, it is clear that a lot of HIV transmission must occur through non-sexual routes, but what exactly are these routes and how much transmission do they account for?
  
  The first problem is vexing because there has never been any evidence for the rampant levels of unsafe sex that would be required for 20 or 30% of any population to become infected with a virus that is difficult to transmit through sexual intercourse. The industry has reacted by insisting that some people really do have the time, the opportunity and the inclination to lead a life that, previously, only existed in porn films. The second problem, the industry simply ignores. Almost everything about the industry assumes the truth of the behavioral paradigm. You could say that they view everybody (in developing countries, of course) as already sick and that they see the treatment as being preemptive (without being preventive).
  
  Until we know why people in developing countries are becoming infected with HIV in such large numbers, it is senseless to keep droning on about sexual behavior. If there is something about sexual behavior in developing countries that results in a difficult to transmit virus being transmitted with ease, we don't know what it is yet. But we do know that there is a lot more non-sexual HIV transmission than the HIV industry are prepared to admit. HIV treatment is for HIV positive people, and I hope everybody who needs it receives it, regardless of their race, religion, sexual status or anything else. But everyone has a right to health; everyone has a right to live free of HIV. Avoidable HIV transmission needs to be prevented.
  
  There is still a need for genuine HIV prevention and if UNAIDS can't come up with anything better than slogans, the agency should be abolished. They have shown a complete unwillingness to drop the behavioral paradigm despite there being no evidence for it and a lot against it. Their calls for rights are just humbug and they seem to be more interested in self-preservation than anything else. As more and more people become infected unnecessarily and many die every day, UNAIDS and the rest of the industry do little but spread stigma and lies about HIV. Those who are HIV positive, many as a result of the industry's failures, have a right to treatment. Others have a right to health, the same right that so many HIV positive people have been denied by this industry.
  
  The Vienna Aids Conference is being used as a platform to make desperate pleas for yet more donor money to be ploughed into an industry that has failed to reduce HIV transmission and will continue to fail, given their present trajectory. They do not have any new ideas; they have just dressed up their old prejudices in new terminology. People have a right to health. Those who are sick have a right to treatment, a right to live lives that are as close to healthy as possible. But enough money has been wasted on political and commercial interests. We know enough about HIV to do things much better.

• Difficult Questions That Won't Be Asked in Vienna

  Posted: July 19, 2010, 12:31 am by Simon

  Press releases say that about 20,000 people are expected to attend the Vienna Aids Conference this year. I don't know if they will all attend for the whole six days but if they do, it is likely that someone or some institution will be paying an average of $200 per day per person. They conference may not cost $24,000,000, perhaps it will only cost $10,000,000. But even so, that could supply 50,000 people in developing countries with antiretroviral treatment (ART), the drugs and other aspects of treatment, for a year. That's assuming that an average of $200 is being spent per person.
  I wouldn't want to suggest that the Vienna Aids Conference is a useless waste of money, it may well have its value. But that much money and that many people in that city? Much of the discussions will be matters that have been both published and well publicized over the last year or two. In fact, a lot of money has already been spent on disseminating the data, reports, presentations, findings, opinions, maunderings, crackpot ideas and things swept up after previous conferences and stuck together with cello tape.
  We know already from pre-conference releases that many of those attending buy into the 'behavioral paradigm', the view that HIV is primarily transmitted by heterosexual sex (in African countries) and that in order to reduce transmission, people need to change their sexual behavior. The behavioral paradigm is divisive, racist and sexist and even its closest adherents know that it is entirely without foundation. Yet, there are unlikely to be many people presenting at this conference, or any other Aids conference, willing to admit that their whole theory of HIV transmission is based on a falsehood.
  We can only speculate about why the HIV industry seems hell bent on allowing HIV to be transmitted through non-sexual means, such as unsafe health care or cosmetic practices. And it is also hard to understand why they will probably continue to allow HIV to be transmitted sexually by failing to implement any effective prevention strategies. Perhaps the industry is concentrating on 'solutions' that make enough money to be attractive to those who hawk those solutions. They do seem to favor technical solutions, ones that involve expensive commodities. But alas, this is only speculation.
  It is unusual to see articles in the mainstream media that even mention non-sexual HIV transmission, especially transmission through unsafe health care. But there was one in Media Global yesterday. This article mentions the WHO's estimate that between 5 and 10% of all HIV infections in Africa occur as a result of unsafe blood transfusions. It also mentions that a WHO researcher estimates that 17% of HIV infection in African countries is due to unsafe injections. Worse still, a substantial proportion of transfusions and the majority of infections are entirely unnecessary!
  Putting these together, over 20% of infections could be coming from unsafe health care, perhaps almost 30%. To put that in perspective, only around 10% of new HIV infections in Uganda are estimated to come from commercial sex workers, their clients and their clients' partners added together. If 20-30% of infections are coming from unsafe health care, the percentage attributable to sexual transmission must be considerably lower than previously thought. Unsafe health care could even be the main route to transmission.
  The HIV industry knows how to make a lot of noise. After all, it's a very well funded industry. It receives billions of dollars of public money every year and the world's media, public and private, hang on to every word that emanates from official HIV industry mouthpieces. They are not shy about trumpeting their successes, their needs, their problems and their highly suspect philosophy. But they are amazingly reticent when it comes to non-sexual HIV transmission. It's as if the very non-sexuality of it is as taboo as the sexuality is in other contexts.
  Another thing the HIV industry is reticent about is prevention, but that's understandable. They have frittered away billions in useless programs and spent years researching others which will never fly. They have come up with tonnes of worthless strategies and now they haven't a clue what to say about HIV prevention any more. So they have come up with the idea of saying that treatment is prevention. And so it is, in a sense. If all HIV positive people were to be aware of their status and everybody at risk of becoming infected were to be tested regularly, perhaps every year, then treatment could play a big part in prevention.
  But we are very far from that position. It's possible that 20% of HIV positive people know their status. But very few people test regularly. And many of the people who are at risk of being infected don't know they are at risk. The reason they don't know they are at risk is because the HIV industry will not speak about non-sexual risk, nor will they allow anyone associated with them to speak about it. So even their 'treatment as prevention' sleight of hand will fail for the very reason that they will not admit that non-sexual HIV transmission could be as common as sexual transmission and may be even more common.
  The HIV industry machinery is concentrating on the usual, money. Some of the biggest sources of funding are being cut or flatlined. I think this is a mistake because the countries with the worst epidemics are most in need of more money, not less. But given how badly the billions of the last 20 years have been spent, is it wise to continue allowing the same people and the same institutions to receive whatever money is being made available? Is it wise to continue spending money on the same failed policies of the past? It's a bad time to knock everything down to the foundations, but which part of the HIV industry is worthy of being allowed to continue? These questions will probably remain unanswered, even unasked, at the Vienna Aids Conference. But if HIV is ever to be eradicated, there will have to be an answer.

• But the Media Doesn't Want to be Free

  Posted: July 18, 2010, 9:38 pm by Simon

  It's odd how countries that have a 'free' press seem content to publish whatever is put in front of them. Coming up to the Vienna Aids Conference, UNAIDS puts out a press release about their new 'platform', called 'Treatment 2.0', with which they are going to conquer the virus that they have, so far, failed to influence in any way since the UN spawned this curious agency. And the world's press simply echoes what UNAIDS says. You can search for any of their expensively honed terminology and you'll find the same thing, repeated like a fart in a whispering gallery, until it's overtaken by their next performance. And the world's busy dung beetles do what their species does best, rolling out articles as indistinguishable as balls of shit. It's not (yet) as if the global media is entirely owned by the likes of that arch dung-heap master, Rupert Murdoch. But out they come, without thought, comment or criticism. Of course they roll, they're spherical!
  
  Before the World Cup, which apparently involved football and sex, the busy creatures were set to work on UNAIDS' predictable offering. This involved making the connection between football supporters away from home drinking a lot and the possibility of their availing of some of the personal services said to be on offer in South Africa. Every news agency did the usual and warned people to avoid having sex with anyone and if they had to have sex, to make sure they used a condom.
  
  Now that the World Cup is over, news agencies can still churn out articles with the popular mixture of football and sex in the form of warnings to those who may have indulged in any kind of unprotected sex while in South Africa, to go for a HIV test. If their pre-World Cup messages had any effect, many football fans probably used condoms and should be ok. For those who were not reading or heeding the articles, it is a good idea to get tested for HIV and all other sexually transmitted infections.
  
  But one thing these guardians of our health and wellbeing never mentioned is that HIV is not only sexually transmitted. In fact, they have been trotting out the sex message for so long, people have probably heard it by now. UNAIDS and therefore the world's press, meanwhile, have kept what they know about non-sexually transmitted HIV to themselves. UNAIDS are quite explicit in the advice they give to their own employees who may be working in African countries: avoid using health facilities that are not approved or provided by the UN. If the risks are high for UN employees, they may be higher for football supporters and even higher still for Africans.
  
  Football fans visiting South Africa probably had a far greater likelihood of contracting HIV, hepatitis B or C, when visiting a clinic, dentist or tattoo parlor. UNAIDS are well aware of this. But they do not tell Africans, who have no option but to use any facilities they can afford. And they didn't bother to tell football fans. And now, when the press are doing their duty by wallowing through the latest releases, they too are neglecting to mention this risk. People who had unsafe sex may go and get tested, but people who had medical or cosmetic treatment are far more likely to transmit HIV or anything else to their partner before discovering, probably some years from now, that they picked up something during the World Cup.
  
  The BBC runs a typical article, mainly targeting men, despite the fact that women who had medical or cosmetic treatment in South Africa could be just as much at risk. The article is about a campaign being run in the UK, which trots out the half-truth about HIV being sexually transmitted, even though it has always been known that HIV can be transmitted in other ways. Although the article mentions holiday makers in general, many of whom may be visiting developing countries, there is still no acknowledgement of the risks people face in health and cosmetic facilities.
  
  One commentator referred to the campaign as "amusing and engaging". It may well be, but what's the point in amusing people and engaging their attention when the message has been mangled, for whatever perverse reason? South Africa is not just the country with the highest number of HIV positive people in the world. In common with most other African countries, South Africa also has appalling health conditions and run down facilities which are barely accessible to most people. Holiday makers may not have to use the facilities that ordinary Africans have to use. But there is as much of a risk to holiday makers from unsafe medical and cosmetic practices as there is from unsafe sex, perhaps more. So why the failure to mention this?
  
  The media seems to need a reminder that they are allowed, they are even encouraged, to analyse, criticize and comment on what they write about. They are even permitted to disagree. If UN agencies like UNAIDS spew out dung, there is no reason why the media should passively roll it up and pass it on to their readers. If every news agency carries the same story, word for word, as they do in the case of HIV and sexual transmission, without ever mentioning non-sexual transmission, there is only need for one news agency. Right now, it almost seems as if there is only one news agency, run entirely by dung beetles.

• HIV Industry Parties As Virus Spreads

  Posted: July 16, 2010, 1:16 am by Simon

  The HIV industry has a very important junket coming up in Vienna and some of the industry's biggest donors are threatening to reduce funds. The World Bank's Global Fund and the US PEPFAR fund (President's Emergency Fund for Aids Relief), which represent a large proportion of global HIV funding, will be reduced over the next few years. Industry representatives are busy writing press releases, lobbying governments and doing everything in their power to fight for their right to party.
  
  That sounds very cynical, but many people will die of Aids during the coming Vienna Aids Conference and during the many expensive junkets the industry treats itself to. The amount of money spent on such events must be astronomical and they are not usually even held in countries with high HIV prevalence. The same amount of money spent on HIV prevention or treatment could save a lot of lives. But HIV policy is mainly written by Westerners in expensive Western offices and when the policy is written, the writers celebrate in Western bars.
  
  With all the hype around the much touted 'Treatment 2.0', it's hard to believe there will be much left to talk about at the conference. Ironically, there is a lot of talk about the use of mobile phones, laptops, wireless and various other technologies in the fields of HIV and global health in general. But you wouldn't think it to see all these people rushing to some expensive city, first class, expenses paid. Treatment 2.0 does involve a lot of technology, but not the sort that reduces costs or carbon emissions or anything like that.
  
  According to PlusNews, one of the five priorities at the conference is 'universal' access to HIV drugs. This, despite what you might expect, involves putting 80% of people who need drugs on ART (antiretroviral therapy). The target was to achieve this by the end of 2010 but this will not be met by most countries. Even the target of putting everyone with a CD4 count (a measure of immune strength) of 200, rather than the WHO recommended 350, will not be reached.
  
  Another technological approach is called 'treatment as prevention', the idea that people who are responding to HIV treatment will be less infectious and so will not be likely to transmit HIV. In ideal conditions, this works well. However, with so many countries still a long way from their targets, it is unlikely to have much impact in high HIV prevalence countries. In most of these countries, a substantial percentage of HIV positive people don't even know their status, so they will not be on ART. Treatment as prevention has been talked up for nearly two years now but no one has dared to admit that it is an ideal and will always remain an ideal. Even the jokers who came up with the 'no sex month' idea don't believe it.
  
  Even nuttier than that is an approach called pre-exposure prophylaxis (PrEP). This involves putting those 'most at risk' of being infected with HIV on ART. If we had any idea who was most at risk we could have prevented a lot of infections by now. But we have been pretty unsuccessful in predicting who was most at risk in the past. And recent Modes of Transmission Surveys have shown that many of the people who are becoming infected are not in at risk groups. In fact, one of the characteristics of high HIV prevalence countries is that many of the people most likely to become infected are at low risk, according to official definitions! Figure that one out.
  
  So there are a lot of technologies available but they are either not being used or they are not proving too effective in the field. It is difficult enough to persuade people to get tested for HIV once, let alone once a year for the rest of the time they are sexually active. Many who are HIV positive are either not taking the drugs, not taking the drugs properly or do not have access to the drugs or some other aspect of treatment (shocking, but no, you can't just hand out pills). Perhaps a lot of people are on treatment, but many of them will, eventually, develop resistance and need to go on to a far more expensive 'second line' drug. Technology is not simple, but conditions in developing countries are basic.
  
  So what are the problems, if all this money has been spent for so long? Well countries need infrastructure, especially health infrastructures. They need education, especially health education. They need adequate levels of nutrition and food security. They need clean water and sanitation and many other goods that are considered to be human rights. You cannot roll out a high tech treatment or prevention program without countries having some level of development. It may seem possible to the HIV industry, donors or the public. But not only is it not possible, we've spent years demonstrating the impossibility.
  
  In addition to these technical problems and the problems relating to our relative lack of understanding about exactly how HIV spreads, there is another problem, which is harder to characterize. This is the problem of the HIV industry's refusal to accept that we cannot explain high prevalence, generalized epidemics (where the majority of those infected are not members of high risk groups, such as intravenous drug users, men who have sex with men or sex workers) by almost exclusive reference to heterosexual sex. If you refuse to accept the racist, sexist explanations of HIV transmission in African countries being due to the fact that Africans have lots of unsafe sex, you will also refuse to accept that HIV prevention programs that target sexual behaviour, and nothing else, will reduce transmission to the extent that HIV will eventually be eradicated. I don't see what there is to celebrate.

• HIV Programs That Never Happened

  Posted: July 15, 2010, 12:44 am by Simon

  A steaming pile with hundreds of flies buzzing around it surely means a fresh press release has been issued. And putting '2.0' after the word 'treatment' has ensured that every big news agency repeats the press release so that if repetition makes something true, there really is a new approach to HIV treatment. And treatment is prevention, that's been repeated a lot too. And young people are leading the prevention revolution, because a press release saying so has been passed in advance of the Vienna Aids Conference, which involves those in the HIV industry meeting up and patting each other on the back. Predictably, the 'free' press has picked up that one as well.
  
  Meanwhile in South Africa, a piece of research gives an idea of what people really think about condoms, which are an important aspect of preventing HIV transmission through sexual contact. In many African countries condoms are used by young people, but only by some young people and only some of the time. A point that has been entirely missed by UNAIDS is that male condoms need to be worn on penises, preferably erect ones, before and during sexual intercourse. They can be removed afterwards. But waving them around conference halls, writing policy papers about them, filling up storage space with them, putting lots of pretty pictures of them on your website and issuing press releases about them has little impact on sexually transmitted HIV.
  
  This paper finds that most women and girls are not in a position of power in a relationship and do not usually get to decide or even discuss whether to use a condom. Also, some people have negative beliefs about condoms, such as that they decrease sexual pleasure. Others feel that if condoms are discussed, there must be a lack of trust in the relationship, although that lack of trust may be quite justified. A lot of people just don't talk about condoms, HIV or risks like pregnancy or infection with a sexually transmitted infection (STI).
  
  But what is probably one of the biggest obstacles to reducing HIV transmission is the association of HIV with sexual promiscuity and casual sex. Many people, under such circumstances, would think twice before buying condoms in a pharmacy where there are lots of other people or even being seen with condoms, even by their most intimate friends. Young people are unlikely to be sold condoms by pharmacists or given them by health workers because of the stigma that HIV has been surrounded with. Given that HIV transmission is not just a matter of sexual behaviour, why all the stigma?
  
  Well, the HIV industry itself plays a big part in fuelling the stigma that surrounds HIV transmission. The big players in the industry (and they are big) maintain that HIV in developing countries is almost always transmitted through heterosexual sex. They deny that there is any significant risk from unsafe healthcare or cosmetic practices, despite many questions about this claim. The fact that there are young children and infants with HIV whose mothers' are HIV negative should set off alarms and give rise to investigations. But in African countries, no such investigations have been carried out. Many women are infected, often after they become pregnant, even though they have only had sex with their HIV negative husband. Again, no investigations.
  
  Colluding with the HIV industry are the many political interests, African and non-African, commercial interests, generally non-African, and the hoards of religious groups, who can't open their mouths without spreading stigma. And the above research uncovers some of the lies that church leaders spread about HIV, about condoms and about sex education. It's not as if church leaders are above reproach themselves and I'm not just talking about the Catholic Church.
  
  You can accept the plethora of 'good news' HIV press releases or not but it would be very surprising if young people were 'leading the way' in HIV reduction when they are surrounded by a complete absence of accurate information about HIV and a whole lot of lies, often contradictory lies. While UNAIDS tells them that 'safe sex' will protect them from HIV, the churches tell them that condoms are not safe. Many young people are told little or nothing by their parents or teachers, who probably know little more than their children do. If HIV transmission among young people is falling, this is unlikely to have much to do with HIV prevention programs.

• Two Point Zero Means We Haven't A Clue

  Posted: July 14, 2010, 1:00 am by Simon

  A prominent UNAIDS spokesperson said "We haven't a clue what to do, really, we have never known. But we have noticed that putting '2.0' after anything will get you mentioned in all the press. And it's true, it works! We haven't had any ideas since we were established but we keep on repackaging tired old ideas that didn't work and the press tell the world what a great job we're all doing".
  
  Sadly, a UNAIDS spokesperson didn't say that or anything else that could be verified. Such top-heavy, high spending bureaucrats with well padded buttocks are not known for making verifiable statements. But they do churn out a lot of photographs and colored diagrams. Their website, which was reasonably easy to find things on before, has succumbed to a late 1990s style splash page and underneath that, another splash page. Where they have put all their content has yet to become clear. Perhaps it's part of their 'treatment 2.0' effort. But some would say, quite cynically in my opinion, that this is no loss.
  
  I was supposed to work for an organization that turned out to be siphoning off money from donors and using it for other purposes, nothing to do with development. But they had a real knack for finding people who would turn the right knobs when potential donors visited. If they were return donors, the same people could push all the right buttons to convince the donors that their money had been well spent and they would be wise to spend more. I think UNAIDS are similar. They have realised that one thing was missing from their attempts to break down in tears at every opportunity and beg for the massive amounts of money going to HIV treatment not to be cut.
  
  They have realised that telling everyone that there are more people becoming newly infected with HIV than being put on treatment was not a good tactic, perhaps because it was too embarrassingly true. Even some of the more foolish people involved were able to think their way through the wet paper bag and see that this would mean the epidemic would just continue to expand. So now they are manufacturing figures to convince us that the childish 'prevention' programs they have wasted so much time on have worked, that you can just wave a magic wand and get people to do what you want and stop doing what you don't want.
  
  On the surface, it looks like things have improved in Kenya a bit since 2000 and somewhat less so between 2003 and 2008. But the year 2000 was just after HIV prevalence peaked and started to drop. It dropped more quickly as death rates increased. Death rates probably peaked around 2003 or 2004 and HIV prevalence has changed little since then. It is claimed that hundreds of thousands of people are now on treatment so prevalence could be expected to have gone up as a result. But it doesn't seem to have done so yet. In fact, death rates are still quite high in Kenya. A few figures have improved between 2003 and 2008, people know the right answers to questions by now, but it is likely that HIV transmission is high enough to keep the epidemic going for some time to come.
  
  If you buy the HIV industry's standard excuse (perhaps there's even an ISO number for it), that HIV is mostly caused by heterosexual sex, then you could easily find the figures seductive. More people now say they are having their first sexual experience later, they are having few partners, they use condoms more often, etc, etc. The behavioral paradigm holds that people (in African countries) have too much unsafe sex and all you have to do is persuade them to have less and HIV transmission will go down. The trend for 'safe' sex indicators has been going up since before HIV was ever heard of so, jumping on that bandwaggon, you could conclude that slight drops in HIV transmission have been a result of 'behavior change'.
  
  If sexual behavior has changed significantly it is possible that some people are less likely to become infected with HIV. It all depends on things like whether they are male or female, urban dwelling or rural dwelling, of childbearing age, married or widowed and various other things. Females and urban dwellers are more likely to be infected. But far more people live in rural areas and out of the 1.5 million HIV positive Kenyans, about one million of them are rural dwellers. Also, the ratio of urban to rural infections is changing, with the percentage of rural infections rising. And while there are more women than men infected, that ratio is also changing. The percentage of men infected is catching up.
  
  I have never seen any clear evidence that you can expect whole populations to say 'Oh, very well, then' when some foreign bureaucrats say 'Ok, you're having too much unsafe sex. Abstain, be faithful and use condoms.' People are more likely to say 'Butt out' or even 'What?'. But even if these 'prevention' efforts have had any effect, HIV is not just transmitted sexually. This is not news, it has been realized since HIV was first identified as the virus that causes Aids. It's just that, somehow, the HIV industry that subsequently developed didn't see non-sexual HIV transmission as worthy of their attention. Perhaps it's not 'treatment 2.0' enough.
  
  So the articles about UNAIDS' non-new new approach are all over the place, bureaucrat-speak for 'We've really screwed up, but hey, that's our job, right?'. UNAIDS need to get clear about where HIV is coming from, who is transmitting it, in which areas and exactly how it is being transmitted. They have got by on 'modeled' figures for too long, figures that depend on too many unwarranted assumptions. Many people have been warning for years now that the behavioral paradigm is a piece of racist, sexist clap trap. They have written articles and books demonstrating how deceitful and misleading it is but UNAIDS and the entire HIV industry still takes this flat-earthist line.
  
  The trouble is that when you set up a cabalistic peer-review system it eventually starts to poke up its own ass. All the 'experts' get together to scratch each other's backs, a sort of mutual delousing, and they agree that their articles are very worthy and must be published at once. Anyone from outside the cabal is ignored. There are millions of people being infected with HIV every year and after 25 years of research, all we can come up with is the same regurgitated nonsense in a new package? Why does UNAIDS still exist, after falling stillborn from the prolific UN? Is this is all they can come up with? People in developing countries, both HIV positive and HIV negative, deserve a lot better.

• Ribbon of Hope Projects

  Posted: July 13, 2010, 12:32 am by Simon

  It's a delicate balance sometimes, when you are trying to support orphans and vulnerable children (OVC) and some other members of their family are even worse off than they are. Several of the guardians of the OVCs Ribbon of Hope Self Help Group are supporting face more immediate threats to their health than the children they are looking after. One mother is suffering from diabetes that appears to be very advanced. She is just recovering from TB and she has been losing her sight for some time. She is in her early twenties and is already having trouble caring for her daughter. If she was HIV positive, she could at least get antiretroviral drugs (ARV) for free. But as it's diabetes, the drugs are prohibitively expensive. Her own mother is on ARVs but she is old to be looking after a daughter and a granddaughter. The father of the child is absent.
  
  Another HIV positive guardian is so sick that she has checked herself into a private hospital. Why she chose a private hospital when she can get the drugs for free is not clear. But she appears to be having trouble accepting that she is HIV positive and refuses to go to the local clinic, where she was diagnosed. You do hear stories of people preferring private hospitals but I doubt if this woman will benefit much from the care she gets there. And her life savings will not go too far, either. Maybe Ribbon of Hope can support one or two of her children but I think she has several others, who will all be vulnerable if anything happens to her. Her husband died some time ago, apparently of Aids.
  
  Thankfully, some of the guardians are well enough to care for their own children, in addition to another child, usually a relative. They are all doing some kind of work but that usually involves long hours, low pay and a good chance that the employer will withhold the wages for as long as possible, months and even years. All the villages we are working in are sisal growing areas. These are vast tracts of land owned by a very small number of extremely rich business people and politicians. The villages are all isolated, several kilometers from the nearest tarred road. For people who live there, the main transport available is bicycle, motorbike, or hired bicycle or motorbike, for those who don't have their own.
  
  We hope that each guardian will come up with some kind of income generation scheme, some way of making a bit of extra money. Ribbon of Hope will assist with loans, advice and perhaps other things. Some of the guardians already have a clear idea of what they would like to do and they have the skills and knowledge to start just as soon as the money is made available. Others are not so sure and are not quite ready. A couple of people seem unprepared to be completely honest or committed, but most had some kind of income generation activity up until the start of 2008. It's unbelievable how many people lost assets and businesses as a result of the civil unrest. Two and a half years later and many have not got back to where they were then and probably will not do so for some time yet. Some will be lucky just to get their land back but most have lost things they will never be compensated for.
  
  After spending a few days visiting two of the villages where some of our clients live, we had to return to our fields, where the maize was in need of harvesting and the other crops, millet and sorghum, were in need of weeding. There has been terrible flooding in the last few months, since the maize was planted. Luckily, much of the maize has survived and the crop is looking good. The beans we planted between the maize plants were almost all washed away. The weeding is being done by some local people and in a few days we should have cleared the backlog and got back to the OVCs in the three other villages we work in.
  
  I was very keen on demonstrating solar cookers and a couple of other simple technologies and I did some demonstrating a while back. But there has not been a lot of interest since. Ribbon of Hope has plenty of core activities to keep us busy and I wanted solar cookers and the like to be an additional activity that wouldn't take up too much time. I mentioned the ideas to the community volunteers whom we work with and they mobilized people. But after a few demonstrations, there were no requests for more. I'd like to do some refresher demonstrations but I'm not sure if it will be possible to drum up enough interest.
  
  I think income generation schemes are good, especially when they work. But they often don't. Not everyone can be a business person. And as we have found from our own projects, mostly growing crops, there are a lot of things that can go wrong; too much rain, too little rain, diseases, pests, lack of market, poor infrastructure and downright dishonesty. That's why I try to persuade people to do some things that can save them money. If they spend a little less on cooking fuel, they will have more for food or other things. And you can save quite a lot, perhaps the equivalent of two or two and a half month's pay over a period of one year. I'd like to understand better why I have not been too successful in selling these technologies, which, by the way, are more or less free! It can be very hard to make money but it's not so hard to spend less.
  
  But most of Ribbon of Hope's projects are going well at the moment. Some of the community based organizations are running themselves and we only visit now and again. One of the organizations that was doing badly at the start of the year, but turned itself around later, is now much stricter, which is a good thing. Too many times the work would be done by two or three people and the others would only turn up when the returns were coming in. A number of projects would have done well if the few workers just got on with it. But no one will work when they think others will help themselves to the results and many community based organizations fail because they are not strict enough about what people have to do in order to collect any of the group's winnings.
  
  I think some people will do a very good job of supporting an extra child while continuing to look after their immediate family. Others may already be too overwhelmed by sickness and poverty. But then maybe we'll find additional ways of supporting them. So far, Ribbon of Hope has done very well keeping things ticking over. There have been challenges, some of which we have met, some of which have been too much. In the long run it's hard to say, but I'm optimistic about a lot of things. I'm just sorry I won't be able to stay here indefinitely to see how everything goes.

• HIV Industry Withholding Vital Evidence

  Posted: July 11, 2010, 12:44 am by Simon

  Some former sex workers in Uganda have set up an organization to represent sex workers , called the Women's Organization Network for Human Rights Advocacy (WONETHA). WONETHA believes that women who are involved in sex work should be supported as sex workers, rather than persuaded to change occupation. Trying to persuade sex workers to find another way of making money may be well intentioned (though it probably isn't). But in addition to not bothering to ask sex workers what they would like, such attempts fail to take into account the economic realities.
  
  If you take a large number of women off the streets and give them other jobs, several things happen. Other women move into sex work, probably attracted by the higher price that sex work receives because there are fewer doing the work. Also, wages in the more conventional job market go down, as a result of more people looking for jobs and employers being able to pay even less than before. There are already lots of people doing some kind of subsistence or low paid work. It's often because they are so badly paid that they get into sex work in the first place.
  
  People here have assured me that it is always possible to get a job or find some way of making money, that it is not necessary to resort to sex work. They don't seem to see that it is the fact that some people are not competing with them for these other jobs that makes it possible for them to find such work. Many other people, too, benefit from sex work, directly and indirectly. Police, security people in bars, clubs and hotels who get money from sex workers to allow them to do their work, other people who 'protect' sex workers or just bribe them, bar, club and hotel owners and various others.
  
  Sex workers very often do look for alternative work, sooner or later. Many that I have spoken to have tried to work in the hospitality industry, to make money buying and selling things or by providing various services. But they often return to sex work, if they are not too old to do so, because there are already too many people trying to make money in these ways. The best thing civil society can do for sex workers is to advocate for better conditions for them, the protection of the law, access to safe medical services and full recognition of their human rights.
  
  The motivation behind some of the efforts to persuade sex workers to give up sex work is the HIV epidemic, to which commercial sex work was said to have contributed greatly. Perhaps it did, though this is not clear. The most recent Modes of Transmission Survey for Uganda finds that sex workers, their clients and the partners of their clients contributed around 10% of new infections in 2008. Compared to this, over 40% of infections were from people in monogamous relationships. In other words, it is safe sex that is giving rise to a lot of HIV transmission, not unsafe sex.
  
  The greatest contribution to HIV prevalence is said to come from people engaging in multiple partnerships and their partners. However, the percentage of people engaging in multiple partnerships is no higher in Uganda than it is in many Western countries and it is lower than in some. Very high rates of HIV transmission in Uganda are not explained by sexual behavior when the same behavior only results in very low transmission rates in other, more developed countries.
  
  In the mid eighties, HIV prevalence among sex workers in Nairobi was found to be 81%. However, HIV rates, along with rates for other sexually transmitted infections (STI), began to fall over the next few years and continued to fall thereafter. And this happened in the absence of any HIV prevention programs. Whether earlier STI prevention vaccination programs had spread HIV among sex workers is debatable but such high rates among sex workers are unusual. In some countries, sex workers are unlikely to be HIV positive unless they are also intravenous drug users. So there is still a problem explaining why HIV rates are so much hither in developing countries than in developed countries.
  
  Sex workers may face high risk of being infected with HIV and other STIs through their work. But they also face other risks that are much easier to avoid than sexual risks. For example, sex workers (and others) often use injectible contraceptives. They also regularly visit clinics for checkups and vaccinations against various STIs. If any of these clinics are reusing needles, syringes or any other equipment, a lot of infections could be transmitted by such unsafe practices. The Modes of Transmission Survey finds that 0.06% of HIV infections are transmitted in this way. But this figure is questionable in a country that has ongoing shortages of medicines, contraceptives, equipment, trained personnel and clinics.
  
  Non-sexual HIV risks could be avoided but no one is going to avoid them if they don't know they exist. Sex workers are constantly being told about the risks they face through unsafe sex. But they are never told about the risks they face in clinics. Yet, they are being sent to these clinics in ever growing numbers. Sex workers have a right to know that HIV is not just transmitted sexually. Telling them about condoms and unsafe practices will not help them avoid non-sexual risks. And people who are not sex workers also need to know about non-sexual risks. They are quite mistaken in their belief that sex workers play a big part in transmitting HIV.
  
  The most disgusting thing about the belief that HIV is almost always transmitted sexually in African countries is that it emanates from the HIV industry, which goes on about reducing stigma. There is no better way to promote stigma than to label people as 'most at risk', especially when they are known not to be most at risk. The HIV industry is well aware that unsafe medical practices can be far more efficient transmitters of HIV than unsafe sexual practices. And while they warn their own employees about these risks when they are visiting developing countries, they tell people who have to live in those countries that they needn't worry about injection safety or anything else that may result in exposure to contaminated blood.
  
  Much of the stigma that sex workers and HIV positive people face is manufactured by the HIV industry, who know that non-sexual HIV transmission plays a part in the epidemic. They just don't want to admit that this phenomenon exists or to carry out any research that could reveal the exact contribution it makes to HIV epidemics in developing countries. Sex workers, HIV positive people, HIV negative people in developing countries and anyone concerned about human rights should be advocating for the right to know about something that represents such a huge threat to people's health and welfare. Until people know, they will not be able to protect themselves.

• Will a New HIV Boss at WHO Make a Difference?

  Posted: July 9, 2010, 1:18 am by Simon

  The World Health Organization (WHO) has a new head of HIV called Gottfried Hirnschall and he gave an interview recently to IRIN. Apparently he feels that, as a prevention message, abstinence is unrealistic. That's good, but not good enough. Abstinence didn't just fail because it's unrealistic. There's no reason why the option of choosing not to have sex under certain circumstances shouldn't be part of a comprehensive sex education program. It's just better if it's not called 'abstinence' and if it isn't the only trick in the box.
  
  There are probably many reasons why HIV prevention programs have failed in African countries but the one reason that WHO, UNAIDS, CDC and all the main HIV institutions refuse to countenance is that not all HIV is transmitted sexually. They go as far as admitting that a small amount is transmitted non-sexualy, but not enough for them to bother spending money or time on. And sure enough, Hirnschall mentions male circumcision and 'treatment as prevention'.
  
  But what does treatment as prevention involve? Because HIV positive people who are responding to antiretroviral treatment (ART) eventually have a low viral load, they are very unlikely to transmit HIV to their partner. If it were possible to test every sexually active member of a population regularly, say once a year, anyone found HIV positive could be put on treatment.
  
  There are just two small flaws. One is that persuading the majority of sexually active people to be tested even once, even to save their lives, has proved elusive. The second is that the majority of people who are currently in need of treatment are not yet receiving it. Much of the funding for HIV treatment that was so fothcoming in recent years has been cut or flatlined. Just as the WHO released new guidelines that would put more people on ART, there isn't even enough money to keep some people already on treatment in drugs.
  
  People on ART need to take the drugs every day for the rest of their lives. If they miss their dose too many times, resistance builds up and they need to move to a different drug regime, a far more expensive one. It is very difficult to get credible figures on what percentage of people in African countries are adhering to ART. But numbers of people dying from Aids is suspiciously high in some countries. It would be one thing if those providing people with the drugs could afford the second or third line drugs for those who develop resistance. But some countries are in the position of not even being able to afford first line drugs.
  
  Hirnschall is asked about the shortage of money and he mentions 'task shifting', things like training nurses to do what doctors have been doing up till now. For people who don't mind being seen by a doctor or who really don't need to see a doctor, that's fine. Most people in developing countries don't get to see doctors anyway, they are too scarce. But even nurses are scarce and they are pretty stretched already. Perhaps more nurses will be trained and these ones will not be poached by rich countries.
  
  So much for treatment, though it's not very much. But will those advocating putting more people on treatment get around to preventing new infections? Ok, they like to say that treatment is also prevention, but from a practical point of view, this will not work. People are becoming infected faster than others can be put on treatment and if money for treatment becomes scarce, where will prevention be then?
  
  First of all, not all HIV is transmitted sexually. It needs to be established how much is coming from non-sexual routes, such as unsafe healthcare and other things. And this needs to be dealt with because it sure as hell won't stop by handing out condoms, circumcising men and telling people how to run their sex lives. Hirnschall thinks that a HIV vaccine would be ideal. But what would be ideal would be to establish where most HIV infections are really coming from so that, even if there were a vaccine, we wouldn't need to waste so much money on it.
  
  Second of all, if Hirnschall is worried about where all the money is going to come from if donors are thinking of pulling out he should get on to the issue of generic drugs. He talks about negotiating with big pharma. What's the point of negotiating with them? They want the highest price they can get, they know people in developing countries can't pay it but they think donors can. They will never reduce their prices to a reasonable level. The only way to ensure that drugs are made available at an affordable price is to open up the market to generic producers.
  
  Of course, big pharma don't want that, they don't want to compete, they want to hide behind the protectionism of intellectual property 'rights'. There are companies well able to produce enough generics to supply everyone who needs ART, to scale up treatment and to continue treating people who go on to need second and third line drugs, as many people eventually will. This has to happen some time. It should have happened a long time ago. Will Hirnschall just drag his heels the way all the others are doing?
  
  Is the WHO's new head of HIV just going to give us more of the same? Or is he going to question the behavioral paradigm that says that most HIV is transmitted sexually? And is he going to stop 'negotiating' with the blood suckers in big pharma and open up the drugs market to competition? If his aims are to reduce HIV transmission and eventually eradicate it, and to treat as many HIV positive people as possible, he will have to take both these steps.

• Don't Just Repeat the Mantra; Follow it!

  Posted: July 7, 2010, 12:28 am by Simon

  One of the people who came up with the idea of a 'no sex month' to reduce HIV transmission by 10-45% (for that month) has published a paper which finds that neither poverty nor wealth drive the HIV epidemic. The no sex month idea suffers from what could be a major flaw: it will only reduce sexually transmitted HIV infection. That may sound obvious but this researcher assumes that most, perhaps even all HIV, is transmitted sexually. So his analysis of the finding that neither poverty nor wealth drive HIV is similarly flawed.
  
  This latest paper may be more comprehensive than previous ones. But the suggestion that wealthy people are often more likely to be HIV positive than poorer people has been made a number of times over quite a few years. It has also been noted that higher levels of education can be correlated with higher rates of HIV. And it has been clear that these trends can change, with the correlation becoming less pronounced and even reversing over time. Whereas earlier in an epidemic, wealth and education may correlate with higher HIV rates, they may correlate with lower rates later on.
  
  It has been clear also that HIV rates differ strongly among men and women, with prevalence among women being far higher than that among men at later stages in epidemics. Correlations between wealth and education are often stronger for women and less pronounced for men. And correlations can be stronger in poorer countries than in wealthier countries. So far, so good, these findings are all interesting and revealing. Before they were established, many pronouncements were made about connections between HIV and poverty and HIV and education which resulted in ineffective strategies.
  
  But the paper's author links all these findings to the unspoken assumption that HIV is mostly transmitted through heterosexual intercourse, that the 'behavioral paradigm' is true. The extent to which HIV is transmitted sexually is not clear because the extent to which it could be transmitted non-sexually has never been properly investigated.
  
  Many poor African countries have high HIV rates. But many richer African countries have even higher rates. Even within Kenya, the highest HIV rates are not found in the poorest areas. North Eastern province is by far the poorest province, with the worst education indicators, yet HIV prevalence is very low. Higher rates are found in Nairobi, whose population is richer and better educated, on the whole. But no matter how you slice up the population, high HIV prevalence does not correlate with wealth, poverty, inequality, education or anything else that is obvious.
  
  If you assume that HIV is mostly transmitted sexually, you wonder why infections among women can be four times as high as those among men. Just who is infecting these women and under what circumstances? You could assuage these doubts somewhat by pointing out that women are more susceptible, for various different reasons. But then you find the richest women with the highest levels of education in Tanzania are far more likely to be infected than the poorest. This changes over time, but the trend certainly doesn't reverse. And the pattern among men is completely different. With the behavioral paradigm, you have to tie yourself in knots to understand just what sort of sexual behavior is going on here.
  
  It helps if you are quite racist, which is lucky for UNAIDS because as an institution, they are racist through and through. It also doesn't do any harm to be sexist and UNAIDS also ticks that box. You then make up various different (and fairly improbable) hypothetical scenarios and you come up with this:
  
  

  Poor people in some settings undertake particular risky practices – e.g. earlier sexual debut or reliance on transactional sex – whereas wealthy individuals may engage in other risky practices, such as participation in broader social and sexual networks or sex with higher numbers of (voluntary) regular partners.

  
  
  It doesn't mean very much but it sounds good, especially as there are some citations in the original article, giving the whole thing a veneer of authenticity. But there is no evidence that Africans, rich or poor, male or female, engage in large enough amounts of the sorts of behavior considered risky enough to explain the devastating epidemics found in Sub-Saharan African countries. Sexual behavior varies from place to place, but not in the way UNAIDS and the author in question would like. Most Africans do not have lots of risky sex, only some do. But some Europeans do, as do some Americans. You just don't find HIV epidemics in Europe and America like the ones in Africa.
  
  The author goes on :
  
  

  Effective action requires unpacking the black box of behaviour by recognizing that HIV infection in poorer groups may arise from certain lifestyles and risky behaviours related to poverty, whereas HIV infection in wealthy groups may be due to different lifestyles and risky behaviours related to their wealth.

  
  
  This may all be true but it is only true of sexually transmitted HIV.
  
  If you don't assume the truth of the behavioral paradigm and you accept that some HIV is transmitted non-sexually, they you can consider less improbable and more testable scenarios. For example, you could look at the different behaviors of males and females relating to health care. Women could be exposed to more of the kinds of medical procedures and cosmetic procedures that might carry a risk of HIV infection. Richer women could be exposed to more of these procedures than poor women. Earlier on in the epidemic, education and wealth may have had little influence on women's attitudes towards health and cosmetic treatments but this could have changed as more became known about the epidemic.
  
  If it is assumed that all or most HIV is transmitted sexually then you will end up with HIV prevention programs that aim to change people's sexual behavior. That's what we have ended up with, even worse, most of the programs don't work. Unless we also target non-sexual transmission, which means establishing its contribution to the HIV pandemic first, we will never 'know our epidemic', in the words of UNAIDS. And if we don't know our epidemic we will never 'know our response', either. The key to a mantra is not just to repeat it, you also have to follow it.

• Individual Behavior Threatens National Security?

  Posted: July 7, 2010, 2:00 am by Simon

  One often hears the term 'national security' being used in discussions about HIV/Aids. The epidemic is said to be threatening in a way that other epidemics are not, despite affecting fewer people than a lot of other diseases and health conditions. HIV/Aids is sometimes talked and written about as if it could topple governments or as if people from high prevalence countries could commit acts of aggression against low prevalence countries that would threaten security. There's a particularly interesting discussion of this phenomenon of the 'securitization' of HIV/Aids in relation to photo-journalism.
  
  But I don't accept that HIV/Aids is an issue of national security. At least, I don't believe it is a threat to US national security, which is what most instances of the phrase seem to refer to. The argument is rarely that HIV/Aids is a threat to South African, Swazi, Kenyan or Botswanan national security, though it sometimes is. Even other rich countries don't seem to obsess so much about a specific national security threat from HIV/Aids. But use of the term seems to equivocate between referring to national and global security, almost as if they are the same thing.
  
  It seems possible that the HIV/Aids pandemic, commonly framed as a threat that needs to be 'fought', becomes confused with the metaphor as used of diseases. Many diseases are said to threaten to attack us, that we need to defend ourselves, to fight back. People with a disease are said to fight it off, sometimes winning, sometimes not. Such metaphors are ubiquitous in talk about diseases of all kinds, whether infectious or not. The metaphor is fine until it starts to be taken a bit too literally.
  
  But another thing that could be going on is that 'national security' is a convenient label, like 'terrorist', that you can slap on anything to support your claim that it is your business and that you have a right to interfere. Much of the funding for HIV/Aids over the past couple of decades seems to have been politically motivated and the fact that much of it was squandered on appeasing political and religious interests doesn't seem to bother the big donors. Health and disease don't seem to have been on the agenda, in reality.
  
  I could understand if health, as a whole, were thought to be a potential matter of national security. But countries with high disease burdens and low standards of health care don't appear to have people fighting on the streets or invading other countries calling for these things to change. If the issue were denial of human rights, health being a human right, this might make it a matter of national security. But the big HIV/Aids donors have not shown much interest in health or in any other human rights. Some of the worst damage that the HIV/Aids pandemic has done has been to other areas of health, which have been almost completely ignored for over two decades. And the association of HIV with sex, sexuality, sex work and illicit drug use have done a lot of harm to decades of sexual, gender and racial equality movements.
  
  If the pandemic were really an issue of national security, why is HIV prevention allocated such a small amount of money compared to HIV treatment and care? And why is HIV transmission seen as a matter of individual behavior, to be influenced, if at all, by an appeal to people to change their sexual habits, to avoid 'unsafe' sex or perhaps to avoid sex altogether? If HIV/Aids were really an issue of national security, surely reducing transmission would go beyond an appeal to individuals to modify their sexual behavior?
  
  I recently mentioned a new fund called the Global Health Initiative, which is unusual in that it is specifically aimed at strengthening health systems in developing countries. Previous funds, such as PEPFAR (President's Emergency Fund for Aids Relief) and the World Bank's Global Fund, took the individual behavior change approach and even claimed that health systems were benefiting as a result of the work they were funding. Few critics believed this, but nor do those behind the Global Health Initiative, apparently.
  
  Whereas the individual behavior change approach to HIV transmission seemed inimical to the 'national security' label, the perceived need to strengthen health systems could signal a renewed focus on HIV/Aids as a potential security threat. But that leaves me at a loss to know what to make of the Global Health Initiative. I think it's a good thing to see HIV transmission as going beyond the sexual behavior of individual people and to develop health systems. Health systems have been ignored for too long and this has clearly contributed to continued high levels of HIV transmission in many countries.
  
  I just don't accept that HIV/Aids is a national security issue, or even a global security issue. I think the determinants of HIV, denial of human rights in the form of widespread poverty, poor living conditions, low levels of education and health care and crumbling infrastructures, could constitute issues of global security.
  
  I don't think the Global Health Initiative is an admission, inadvertent or otherwise, that we have failed in our attempts to reverse the HIV pandemic. But if it reduces dependence on the individual sexual behavior theories of HIV transmission it may get us closer to working out exactly why some countries and some parts of some countries have such high levels of HIV. That should have been the first question that UNAIDS asked. But even if it's not the first, and even if UNAIDS are not asking it, it would still be good if it were taken seriously.

• You've Been Bad: No Sex for a Month

  Posted: July 4, 2010, 12:46 am by Simon

  One of the noticeable characteristics of many HIV researchers is that they seem to have a liking for telling people how to run their sex lives, who to have and not to have sex with, when to have sex, where to have sex and what sorts of sex to have. Crucially, they feel the need to tell people in developing countries these things. They certainly don't tell people in rich countries, unless they are men who have sex with men (MSM) or commercial sex workers.
  
  This is because, typically, HIV researchers toe the line on HIV transmission: that in high prevalence countries, it is almost all transmitted through heterosexual sex but in low prevalence countries, it is mainly transmitted by MSM, intravenous drug users and perhaps commercial sex workers. These researchers seem to see themselves as arbiters of good sexual behaviour and they can even threaten to come along and circumcise anyone who misbehaves, as long as they are not already circumcised, of course. If they are circumcised they are considered to be better behaved than the uncircumcised, anyhow.
  
  So two of these intrepid researchers have come up with a plan to have an official 'no sex month'. The thinking behind this is that HIV positive people are most infectious when they have just been infected. At this stage, they will probably not know they have been infected and even if they test, they will probably not receive a positive result. Anyone going through this stage of HIV infection during a no sex month will avoid transmitting the virus, at least for a while. Once they have gone through to the next stage, they will be far less infectious and, hopefully, they will be tested before they reach the third stage, during which they will be highly infectious again.
  
  There are people to whom this proposal will not appeal, specific groups that these researchers will probably want to include. Commercial sex workers will be unlikely to forgo a month of earnings, for example. (And intravenous drug users could be relatively unaffected by the cunning plan.) But the researchers point to the Muslim month of Ramadan, where Muslims abstain from sex during daylight hours. I wonder if they have done any research into whether this has had any impact on HIV transmission, aside from their assumption that because HIV is often lower among Muslims, Ramadan could the the key. And is daytime sex more likely to result in HIV transmission than nighttime sex? Or perhaps daytime sex is seen as more in need of censure.
  
  Well, because we are talking mainly about African countries, it will probably be seen as perfectly reasonable to 'test their hypothesis' on the people. After all, they clearly have too much sex, of the wrong kind and possibly even during the day. Why these researchers see their proposal as a one off is not clear. But they are wrong in saying that it 'does not create additional stigma'.
  
  The behavioural paradigm, which says that HIV is mainly transmitted heterosexually in developing countries, is what causes the main stigma that attaches to HIV. It is because people in developing countries are being told that they have too much sex, and sex of the wrong kind, that HIV is stigmatized, that people are made to feel that they are bad people, who must be censured and punished, if necessary.
  
  More importantly, the behavioural paradigm is completely unfounded. HIV is not mainly transmitted by heterosexual sex in developing countries. The extent to which HIV is transmitted non-sexually is not clear precisely because researchers like the two in question refuse to consider non-sexual transmission as being important enough to research.
  
  If, as a result of this 'experiment', HIV rates are found to have dropped, this will not necessarily mean that sexual transmission will have been cut. Non-sexual transmission, for example, through unsafe medical practices, could also go down during the no sex month. Sex workers and MSM, if they do give up sex, will have less need to visit sexually transmitted infection clinics to receive jabs and contraceptive injections (very popular among sex workers). These are likely routes to HIV infection through unsafe injections. Will the research take such circumstances into consideration?
  
  Perhaps the researchers would like to carry out another experiment on this obliging and convenient population of human beings: perhaps they would like to have a medical safety month. During this month, it would be ensured, not just that every health care worker takes the utmost care during every procedure, but that there are enough health care workers everywhere and all of them have enough equipment so that they don't need to reuse anything or do anything that could put their patients at risk. During this month, Everyone in the country would have access to safe health care, no one would have to resort to some quack wielding a much reused needle and no one in the health care industry would have to take any risks because of lack of resources.
  
  Apart from seeing how this affects HIV transmission, it would be interesting to see what sort of demand there was for treatment and what levels of diseases and other health conditions would be revealed. But if no sex months provide a 'potential strategy', then so do medical safety months. Indeed, medical safety months would have benefits that go far beyond HIV transmission. Perhaps we could have clean water and sanitation months, where people are provided with enough water and sanitation facilities to reduce some of the biggest killers in the developing world. The possibilities are endless, we could have infrastructure months, electricity and lighting months, connectivity months and many other types of month.
  
  The researchers assure us that a no sex month would produce "easily verifiable data with regards to adherence, evidenced in the number of births occurring nine months after the campaign". And I'm sure all the other types of month would also supply vast quantities of data, such as maternal health figures, infant mortality figures, child mortality health figures, nutrition figures, disease mortality figures, more data than you could shake a circumciser's scalpel at. In fact, I don't think you would need to threaten people at all, I really think they would go for these dedicated months without any incentive. They may even demand that such benefits be granted to them all the time, not just for a month.
  
  Even the researchers themselves warm to their theme and suggest that such months could be adapted for different populations "depending on what is driving the epidemic". So, among miners in South Africa they suggest a 'no commercial sex' month. But how about a no mining month? Then they could have a significant impact on the TB epidemic, which is driven by the mining industry and is said to spread hand in hand with HIV.
  
  The researchers conclude that "In hyper-endemic countries policy-makers, populations and politicians are open to new ideas to address the epidemic". But are these researchers open to new ideas? Are UNAIDS and CDC open to new ideas? The biggest new idea, which is only new in the sense that it has been ignored by those who are best placed to apprehend it, is that HIV is not only transmitted sexually, that the behavioural paradigm is wrong. No new discovery needs to be made: these people and institutions simply need to tell the truth. A 'no lies' month from UNAIDS would do more to reduce HIV transmission than all their HIV 'prevention' programs, past, present or future.

• Even WHO Admits Unsafe Injections are Ubiquitous

  Posted: July 3, 2010, 1:24 am by Simon

  The dental unit of a hospital in Missouri has realised that 1,800 of its clients may have been exposed to diseases such as HIV and hepatitis B and C as a result of poor hygiene. All the people, apparently all war veterans, who may have been exposed, are being contacted and an investigation has been called for to find out how such an incident could occur. A political spokesperson has said that this is unacceptable for veterans. Whether he thinks it would be equally unacceptable for people who have spent no time in military service is unclear.
  
  Still, it’s good to hear that there is a protocol, there is sterilization equipment and that someone is checking to see that the protocol is adhered to. It’s also reassuring that there are people who know that lack of care in using such equipment can give rise to infection risks and that if there is any possibility that clients are at risk, they can be and will be contacted and given a full check-up. Presumably, the staff involved will be retrained and those found to be responsible will be disciplined appropriately.
  
  A similar occurrence in California resulted in 3,400 patients being contacted because they underwent a colonoscopy and it was found that correct hygiene precautions may not have been followed. And in the UK, 519 people have been contacted because a healthcare worker who may have treated them was found to be HIV positive. The worker, who has worked in a number of hospitals, has been moved to a role where there is no risk of blood contact.
  
  The two American incidents are probably more worrying than the UK incident because patients are unlikely to be infected by HIV positive healthcare workers, in practice. But infections from unsafe medical procedures are thought to be common, especially in countries where there are low levels of training, staffing, safety and funding. The World Health Organisation (WHO) estimates that in some regions, up to 70% of the 16 billion injections given in transitional and developing countries are unnecessary. They estimate that up to 40% of injections worldwide are given with syringes or needles reused without sterilization and this could be as high as 70% in some countries.
  
  One doctor in Kenya relates how he has stuck himself with needles on several occasions. He also says this is common among healthcare workers. However, the likelihood of a healthcare worker becoming infected is quite low, in practice. The biggest worry is of patients being infected by contaminated equipment. And this doctor says that they don’t always have enough needles, for children in particular. He describes how they improvise to get around this problem but also admits that this means the patient can be infected with hepatitis. He doesn’t mention HIV but presumably they are at risk from any blood borne disease.
  
  This one medic can see up to 100 patients a day, as can many practicing healthcare workers in other facilities all over Kenya and East Africa. Doctors and other healthcare practitioners receive a lot of training but if they don’t have the equipment, they either need to ‘improvise’ or refuse to treat people. But what of all the other people who give injections and carry out other procedures that involve potential blood exposure? The risks may be lower but some of them only receive a few weeks training. And there are those with no training at all who also give injections, informal practitioners and the like.
  
  UNAIDS ‘estimate’ that unsafe healthcare results in around 0.6% to 2.5% of HIV infections in Kenya. Yet the WHO estimate that globally, 2% of HIV infections are caused by unsafe injections. Is it really credible that countries with high prevalence of blood borne diseases and low levels of safety in healthcare settings could have such low transmission rates through unsafe medical procedures? WHO estimates that up to 9% of HIV infections may come from unsafe injections in South Asia. How could the figure be so much lower in African countries, where healthcare is known to be of a very low standard and prevalence of HIV is so much higher than it is anywhere in Asia?
  
  In the US and the UK, where there is a relatively small risk that people will be infected with HIV as a result of medical procedures, hundreds, even thousands of people are screened to make sure that they were not infected. But in developing countries, where HIV prevalence is high, we are told that most HIV transmission is through heterosexual sex and therefore transmission through unsafe medical procedures cannot be high. Where there is doubt, people are not recalled and screened. Potential nosocomial cases (ones that occurred in healthcare settings) are not investigated. There is overwhelming evidence that heterosexual behaviour in African countries does not explain high levels of HIV, but because they are African countries, it is accepted that they have lots of sex, that they should stop doing so and when they do, everything will be ok.
  
  Health facilities in African countries lack adequate drug supplies, have chronic shortages of trained personnel and do not even have enough condoms at a time when they are faced with rising HIV prevalence. It is not credible that, at the same time, there is a very low risk of HIV infection through unsafe medical practices. Global HIV policy is obsessed with sexual HIV transmission to the extent that non-sexual transmission is being completely ignored, especially in developing countries. Informing people of the non-sexual risks of HIV transmission, and how to avoid them, is just as important as informing them of the sexual risks. People have a right to the information they need to protect themselves.

• Test All, Treat All for HIV: Just Another Shot in the Dark

  Posted: July 1, 2010, 7:52 pm by Simon

  The authors of an article entitled ‘HIV drugs for treatment, and for prevention’ write as if to ask why we would delay using antiretroviral (ARV) drugs for preventing, in addition to for treating HIV, when so much evidence points to the effectiveness of such a strategy. But their rhetoric could be interpreted another way. They and others in the HIV industry seem to be saying, in a tone of mounting desperation, “Look, nothing else has worked so far, let’s try it until something else comes along”. In a list of failed possibilities including condoms, behaviour change of various kinds, circumcision, vaccines, microbicides and treating other sexually transmitted infections (STI), something else probably will come along. Whether that something will also fail remains to be seen.
  
  The authors may object that some of those possibilities have not failed, for example, circumcision. Well, results of circumcision trials and even large scale circumcision rollout are shrouded in controversy but in Kenya, the only place where substantial numbers have been circumcised, the issue is far from resolved. And the biggest worry for some people is that Kenya does not have adequate health facilities to rollout any widespread programme safely. Aside from that, some worry that the program is being rolled out before its effectiveness has been adequately demonstrated. Maybe circumcision can help in areas where levels are currently low but this is by no means clear.
  
  The effectiveness of condoms, also, is not as clear as one might expect. The latest results from the Kenya Demographic and Health Survey, 2008-09, suggests that people using condoms are often more likely to be HIV positive. It’s not certain why this is so and people would be unwise to give up using condoms, but a major problem with condoms and contraception in general in some countries, Uganda, for example, is availability and accessibility. The Kenyan DHS report, along with many other DHS reports, also cast doubt on the value of various behaviour change campaigns. Behaviour often doesn’t change, for various reasons. But even where it does, this doesn’t seem to have much impact on HIV transmission.
  
  Testing everyone for HIV and treating everyone found to be HIV positive, the strategy advocated by the authors in question, may well have its virtues. If it’s possible to test everyone in every country that has high HIV prevalence regularly, perhaps every year, that would be a good start. Then, being able to treat all of them, for the rest of their lives, would also be required. Mathematical models have shown, apparently, that if such massive numbers of people could be tested regularly and then treated for the rest of their lives this would, under optimal conditions, quickly eradicate HIV (although not all models are in agreement). All we have to do is ensure optimal conditions.
  
  Uganda doesn’t currently have optimal conditions for such a strategy, nor does any other high prevalence country. Testing is slow, many have never been tested, others return for testing more than once but most don’t. There is even an unmet demand for testing which may take some time to meet, given the country’s poor infrastructure and health network. Condom distribution is failed by a stop-start supply and contraception more generally suffers from similar problems, despite family planning being pursued in the country for several decades before HIV was recognised.
  
  In fact, the country’s reasonably modest aim, to treat all HIV positive people who have reached a specific stage of disease progression, is not being met either. Drugs often don’t reach their destination or arive too late. Some remain in storage, even until they have expired, because of lack of infrastructure and health systems. Funding for ARV treatment comes exclusively from external donors. And these donors are talking about reducing funding substantially, some have already done so. An important question is not just about whether these conditions will be changed but would it really be possible to successfully implement a strategy like ‘test and treat’? Does the country’s performance over the past 25 years suggest that it would be possible?
  
  The results of trials that show that HIV transmission is very low when people are on ARV treatment seem impressive. But a universal ‘test and treat’ programme would be, presumably, rolled out under the same conditions as previous HIV prevention programmes. Or maybe the latest one will be rolled out under optimal conditions? Maybe health institutions, infrastructures, education and other social services will be improved to the extent that this test and treat programme will work. It seems likely that HIV transmission would reduce somewhat without a test and treat programme under these conditions. At least it would be a possibility, however surplus to requirements it may become.
  
  But there is still the same worry about this and all the failed or failing programmes that went before: shouldn’t we be frank about what we know and don’t know about HIV transmission, especially the extent to which HIV is sexually transmitted? We know HIV is not always transmitted sexually, but the HIV industry is very coy about admitting the extent of non-sexual transmission. And all the programmes listed above presuppose sexual transmission of HIV, whether they involve vaccines, microbicides, condoms, behaviour change, circumcision, STI treatment or a selection of these combined. Maybe test and treat is different, perhaps it will also reduce non-sexual HIV transmission. But it won’t, on its own, alter the circumstances that result in non-sexual transmission. Rolling out a disease prevention programme that is indifferent as to how that disease is spread seems foolhardy.

• HIV Industry Admits They Got it Wrong? Sort of!

  Posted: June 30, 2010, 3:14 am by Simon

  The US has launched a new grant to help developing countries to strengthen their health systems. The term 'health system strengthening' has become quite fashionable recently. But it's usually used by defenders of the likes of PEPFAR (President's Emergency Fund for Aids Relief) and the World Bank's Global fund, who argue that their funds do not target HIV at the expense of other diseases or of health systems strengthening. Remarkably, the article about this new fund, the Global Health Initiative, flatly contradicts these claims and even reads like an admission that mistakes have been made. Such admissions are rare, but vital if serious diseases such as HIV are to be controlled.
  
  In another article, it is noted that the amount of money spent on HIV in Tanzania has risen by over 2000% between 2001 and 2007, from 17 to 381 billion Tanzanian shillings (11.5M to 259M USD). And the author is encouraged that in the same period, prevalence has dropped by 1%, from 6.7% to 5.7%. Is that encouraging? Hard to say, but apparently "Some of the biggest challenges in the fight against HIV/Aids are embezzlement and mismanagement of funds." One wonders where prevalence would stand if the money hadn't been embezzled and mismanaged. In some sectors of the Tanzanian population prevalence has been increasing.
  
  The article ends with the conclusion that HIV was not adequately addressed because the focus was on the health sector, whereas this disease in particular is not simply a health problem. But you could argue that diarrhoeal diseases and intestinal parasites are a matter of water and sanitation, respiratory diseases are a matter of environment and housing and malaria is a combination of all of these factors and perhaps some others. None of them are 'simply' health problems.
  
  Yet, it is true to say that you can't just reduce HIV transmission by sending everyone to a clinic and giving them counselling and drugs if they are infected and lecturing everyone who is not infected about safe sex and perhaps giving them condoms. This has been tried and has failed. Amazing amounts of money have been thrown at HIV and the result has been a continuation of very high levels of transmission and a distinct lack of understanding of why some countries and parts of countries have such profound HIV epidemics and why some do not.
  
  So, like other diseases, HIV epidemics are not just a matter of dealing with a particular pathogen, you must also consider the host and the environment. Looking at it (and other diseases) from this point of view, there are a lot of ways of spending 381 billion Tanzanian shillings aside from on health aspects alone. Many people are said to be more susceptible to HIV infection because they don't have a choice about when, how often or with whom they have sex. Others are susceptible because they have various health conditions that make them so, for example, malnutrition, intestinal parasites, sexually transmitted infections, TB, malaria, etc.
  
  As well as dealing with host factors, then, money could be spent on environmental factors, water and sanitation, infrastructure, gender relations, equality, poverty and many other things. But anyhow, the claim is that the money was spent on the health sector, not on health systems (supply chain management, health worker retention, information management, etc). And it seems fairly clear that money has not been spent on health systems, pace the argument for the Global Health Initiative and contra the unconvincing arguments of Global Fund and PEPFAR proponents.
  
  But here's a thing, you could argue that those tenets of epidemiology leave out something very important, perhaps most important when the epidemic is HIV: nosocomial infections. This is where the disease is spread by medical procedures. The pathogen is clearly being introduced into a host, but artificially so and the environment is a rarefied but highly risky one. Do nosocomial infections, to some extent, elude epidemiologists altogether (or just those who work for UNAIDS, WHO or CDC and a few other institutions that have a lot of influence in the HIV industry)?
  
  Following the pronouncements of those august institutions, you would think that nosocomial infections hardly infect anyone in developing countries, with the rare exception of some of their own employees who happen to be working in those countries and have to use the same medical facilities as the natives. Don't worry, that has probably never happened, though that doesn't stop them from warning their employees.
  
  Ignoring other diseases, health in general, water and sanitation, nutrition, environmental conditions and structural conditions in the fight against HIV has been unbelievably stupid. Equally stupid is the failure to ensure that there were adequate health structures in place to implement various HIV prevention and treatment initiatives, however misguided some of these may have been. In fact, in countries like Kenya, health structures were being dismantled from the 1980s onwards at the instigation of institutions like the World Bank (yes, the one that came up with the Global Fund!).
  
  In admitting that health systems have been ignored, the HIV aristocracy may be getting just a little closer to admitting that their view of HIV transmission in developing countries is in bad need of reconsideration. They still tell us that HIV is almost entirely transmitted through heterosexual intercourse in developing countries. But it would seem very hard to maintain this view when the Global Health Initiative is admitting that health systems have been ignored and this has done a lot of damage and has wasted much of the money that has been poured into HIV so far.
  
  Huge amounts of money have been and still are being spent on trying to get people into medical facilities, to be tested and/or treated for HIV and many other diseases. Pregnant mothers are encouraged to go to clinics and to bring their babies and infants to be vaccinated. Men are being encouraged to go to clinics to be tested and/or treated for HIV and sexually transmitted diseases and even non-communicable diseases. But if health advocates want people to go to health facilities, they would need to make sure those health facilities are safe enough that people do not become infected with something as life-threatening as HIV. People need to be made aware of the risks they face in health facilities and those health facilities had better be improved quickly and thoroughly. I don’t think the admission that grotesque mistakes have been made was intended but it has certainly let the genie out of the bottle, well, one of them.

• Big Pharma Must Think We Are Idiots

  Posted: June 28, 2010, 1:39 am by Simon

  A former British politician called Lynda Chalker who interferes with intellectual property (IP) issues in East Africa, says she is sure that East African IP legislation will not confuse generic and counterfeit drugs on the one hand and fake drugs on the other. But Kenya's Constitutional Court has already ruled that its own Anti-Counterfeit Act, only two years old, does confuse the three phenomena. And the court admits that this could result in people presently receiving affordable antiretroviral (ARV) therapy for HIV being denied the drugs the future. Chalker describes Kenya's decision as a 'drawback' to anti-counterfeiting efforts.
  
  But Chalker herself simply makes the same confusion. She says that 'an anti-counterfeit law is essential in Uganda and east Africa as a whole; one only has to look at the number of deaths arising from counterfeit pharmaceutical products, electronic goods and auto spare parts'. If a drug or produce is causing death or injury, that is a health and safety problem. Branded goods can cause death and injury. Putting a brand name on a product illegally doesn't make it harmful, nor does doing so legally make it safe. The harm comes when the goods are substandard or when drugs are fake, not real drugs at all.
  
  The distinction seems basic enough, but Chalker and the people who put together the original Kenyan bill appear unable to comprehend it. Worse still, Uganda and several other countries seem keen to follow Kenya's lead, despite the Kenyan's change of mind. Chalker and others who follow this tendency to conflate counterfeits, generics and fakes then go on to deny that their stance could jeopardize availability of affordable generic drugs, such as ARVs. But their denial sounds hollow when they go to so much trouble to confuse generics with counterfeits and fakes.
  
  Someone who has been taken in by this deception pontificates about 'fake' drugs (and doctors) in Uganda in another article. Eleven Ugandan 'legislators' are querying the quality of drugs from India, which is the source of most of Uganda's affordable generic drugs. They note that the price of the same drugs from the UK is higher and wonder why. Perhaps that's a question for Chalker. But usually a huge difference in the price of drugs indicates that the expensive ones are branded versions and the cheap ones are generic versions.
  
  Of course, there may also be counterfeit drugs and fake drugs in circulation. When drugs are priced so that no one in developing countries can afford them, in the hope that aid money will be used to purchase them, it's not surprising that some people will try to cash in on the market for cheap drugs. If the pharmaceutical industry is concerned about the fact that it is quite easy to make a good profit from counterfeit and fake drugs, they need to sort out their own pricing policies, perhaps by taking a look at what the 'market' can tolerate. Otherwise they might be accused of depending on subsidies and of rigging the market, which would be quite intolerable.
  
  Chalker expresses her concern at the 'extra burden counterfeiting places on health services in developing countries'. If she is worried about health services being burdened, it is branded goods she should target. If she thinks that health services will be unable to afford the growing need for ARVs, she needs to champion the cause of those producing affordable generic versions of the grossly overpriced branded drugs that her friends in the pharmaceutical industry produce.
  
  Chalker says that IP laws should be 'well-drafted', which, presumably, all laws should. But well-drafted for whom? Intellectual property is for the benefit of industries like big pharma, not for the benefit of poor people who are sick and dying. IP laws are not, as Chalker seems to think, to protect people from harm, and I don't think anyone who knows about IP would claim something so stupid. That's why human rights activists had to fight for international law to protect people from IP laws and allow poor countries access to affordable generics. I don't believe Chalker is stupid, though. She just thinks that everyone else is.

• Facts, Facts, Facts, Just Not That One

  Posted: June 28, 2010, 2:43 am by Simon

  In an article entitled ‘Aids and Evidence: Interrogating Some Ugandan Myths’, Tim Allen concludes something that others have also concluded about HIV, in relation to Uganda, in particular: ‘Much less is known about the epidemic than is asserted’. We don’t know why prevalence and even incidence in Uganda dropped from very high rates in the 1980s to far lower rates in the 2000s. There is a lot of speculation about why this happened, but it remains speculation. It is possible that much of the apparent improvement in Uganda’s epidemic was a result of the disease taking its natural course. And it is fairly clear that many of the things that are said to have contributed to the epidemic’s decline either didn’t occur or didn’t have much effect.
  
  It was established quite early on that HIV could be transmitted through blood and other bodily fluids, not just through sexual contact. This meant that people could be infected through medical procedures such as injections and blood transfusions, intravenous drug users could be infected, HIV positive mothers could pass on the infection to their babies, either in the womb, during delivery or through breastfeeding and people might even be infected by their hairdresser or manicurist, if they didn't take proper precautions. Early on in the epidemic, these considerations probably influenced the measures that countries such as Uganda took to reduce the spread of HIV. But later, as HIV became more dominated by political and religious leaders, it was treated as if it was almost entirely sexually transmitted. According to the official view, this is only true of developing countries, though.
  
  For me, the thing that doesn’t ring true in the many allusions to Uganda’s great success in fighting HIV is that they all assume the truth of the behavioural paradigm. They all assume that because HIV is mainly sexually transmitted, what a country needs to do is tell people everything about ‘safe sex’, give them some condoms and everything will be ok. When Uganda first started putting in place measures to reduce the spread of HIV, they probably didn’t subscribe to what became the enduring fiction that drives HIV policy, national and international. But later, when donors, politicians, religious prognosticators and commercial interests become involved, Uganda said whatever was required to get the money flowing and to keep it flowing.
  
  Because the most prominent people in the industry so much want everyone to believe that HIV is primarily sexually transmitted, they even want to believe it themselves, they have rewritten everything that happened before the fiction was created. They so much want this fiction to be true that they refuse to countenance the possibility that a certain amount of HIV, perhaps a very large amount, comes from non-sexual processes. Even though there are measures that can be taken to prevent non-sexual HIV transmission, these measures are generally not taken in developing countries. Even though we know that it is not possible to significantly influence people’s sexual behaviour just by telling them what they should and shouldn’t do, that’s what most HIV prevention programmes consist of.
  
  Given that those who control the HIV industry and its considerable wealth base all their decisions on a fiction, it’s not surprising that others, who don’t have access to the same levels of data, expertise and other resources, weave their own fictions. A man calling himself ‘Dr’ Ayiko, seems to accept the fiction based on the behavioural paradigm. He therefore also accepts the story about Uganda reducing HIV prevalence by exhorting people to abstain from sex, be faithful to one partner and use condoms. But he feels that this approach no longer works and that one of the main reasons for the continued spread of HIV is ‘intentional’ transmission.
  
  I assume he means the intentional spread of HIV through sexual means. He refers to the bill currently being discussed in the Ugandan parliament that would make it a capital offence to intentionally spread HIV and I think the bill is aimed at sexual transmission, though I’m not sure and I doubt if many Ugandans, including the ‘Dr’ in question, are sure either. Anyhow, Dr Ayiko says that ‘in virtually all the 112 districts [of Uganda], there are people who boast of having successfully lured 20 plus people into unprotected sex knowing they are HIV positive’.
  
  The deluded man goes on to make the ‘modest’ assumption that there are eight such people in each district and that if each of them infects 20 people who all go on to infect two more people, there will be many tens of thousands of people infected (although his calculations go a bit awry here). Even if Dr Ayiko is right in assuming that there are many people who behave this way and that they have many partners who also have many partners, HIV is not transmitted quite so fast. If it was, HIV prevalence would be a lot higher, in every country in the world, not just in Uganda. The partners of HIV positive people can remain HIV negative for many years, even if they are having regular, unprotected sex. HIV just doesn’t spread that quickly through heterosexual sex.
  
  What the doctor needs to do is calculate how many times each of the 8 people per district would have had to have sex with the 20 others and how many times they would have to have sex in order to infect two others each, given the probability of heterosexual HIV transmission per sex act. That’s not a simple calculation and I won’t even attempt it here. But even if the probability is relatively high, each HIV positive person would have to have sex with each HIV negative person several hundred times for HIV to spread at the speed Dr Ayiko suggests. Deliberately spreading HIV is despicable, especially where there may be force or coercion involved. But deliberate spread of HIV through heterosexual intercourse would be a very slow process indeed. However heinous, it is not a major factor in Uganda’s HIV epidemic.
  
  I would suggest to Dr Ayiko and others who support the Ugandan bill that purposely ignoring what could be the main modes of HIV transmission, non-sexual modes, is despicable. Not only is it despicable but some non-sexual modes of transmission, such as certain unsafe medical practices, are very efficient, far more efficient than sexual transmission. Worse still, the same people who have all the data and the epidemiological expertise that Dr Ayiko lacks are the ones who continue to ignore these modes of HIV transmission. UNAIDS, WHO, CDC and the rest of the HIV industry know that they are wrong about non-sexual HIV transmission in developing countries but they don’t admit it, for some reason.
  
  Tim Allen notes the current dependency on large scale rollout of antiretroviral treatment (ART) as a possible remedy for HIV epidemics, despite the fact that we know so little about how these epidemics increase and decline. He warns that such dependence could give rise to widespread resistance, which could result in Uganda’s epidemic taking a serious turn for the worse. And it does seem sensible to find out how the epidemic progressed in the first place before climbing on the latest bandwagon, ART. In a country where it is not even clear how much medical treatment contributed to the epidemic, it seems rash to advocate purely for more medical treatment. There’s something of the black box about the HIV industry.

• Promoting HIV Transmission

  Posted: June 26, 2010, 8:59 pm by Simon

  A recent survey in Chad has shown that a third of sex workers think that mosquito bites or sharing a meal can spread Aids. National HIV prevalence in Chad is 3.3%, only half the prevalence in countries like Kenya, Uganda and Tanzania. But among sex workers in Chad, HIV prevalence is 20%. In Mombasa, it is estimated to be about 31%. Yet in Mombasa, and throughout Kenya, the vast majority of people, male and female, know the right answer to the questions they are regularly asked about Aids and how to protect themselves.
  
  Many years of data on HIV prevalence, HIV knowledge and HIV behaviour show that these three are not very closely connected. People may know all the HIV industry want them to know about HIV but their behaviour is relatively uninfluenced by their knowledge. More to the point, their sexual behaviour is not very closely connected with HIV prevalence. Those who do all the things the HIV industry would like them to do often have higher HIV prevalence than those whose levels of unsafe behaviour would be deemed very high by the industry.
  
  Indeed, sex workers in Kenya have been targeted for a long time. But the shockingly high prevalence found among sex workers in the 1980s, which peaked at 81% in 1986, fell continuously thereafter, falling below 50% in 1997 and remaining below this level. The amazing thing is that behaviour change didn't occur till a long time later. HIV and other sexually transmitted infections (STI) fell even though people didn't change their behaviour significantly. It simply became less likely that people in this group, said to be at high risk of becoming infected, would become infected with HIV or other STIs.
  
  I write 'said to be at high risk' because it is only in some countries that sex workers are at much higher risk of being infected with HIV than other groups. In other countries, sex workers are only really at risk of becoming infected with HIV if they are also intravenous drug users (IDU), which only some sex workers in African cities are. But this kind of data seems to suggest that HIV appears to be a sexually transmitted infection in African countries whereas it is mainly transmitted among men who have sex with men and IDUs in rich countries.
  
  This is not to suggest that HIV is not sexually transmitted, just to remind people that it is not entirely sexually transmitted. But there is a surprising lack of clarity about how much HIV is transmitted sexually and how much non-sexually, especially in African countries with high HIV prevalence. It is clear that HIV can be and is transmitted by unsafe medical and cosmetic practices but it is not clear what percentage of HIV transmission is caused by such practices. The only thing that is clear is that the HIV industry doesn't want to admit that non-sexual HIV transmission is something to worry about in African countries.
  
  Note, they are not saying that no one should worry. Those in the industry worry about their own employees and the risks they face when they visit developing countries. They warn their own employees not to visit clinics unless they are approved, because the industry has its own well funded clinics. They just don't worry about the fact that people who have to live in these countries have no option but to use whatever clinics are available. The even deny that there is a significant risk from medical treatment in these countries while, at the same time, warning their own employees about this risk!
  
  So what is the HIV industry going to teach people, especially sex workers, in Chad? If they approach the problem in the same way that they did in Kenya, prevalence is unlikely to drop. It reached a peak of about 10% in Kenya in the late 1990s and even higher in Uganda some time earlier. But over a decade of 'HIV prevention' later, both countries have prevalence of over 6%. That's nothing to boast about. Will people in Chad be told the truth, rather than a little bit of the truth?
  
  The truth is that people there are at risk of being infected with HIV by medical and cosmetic procedures. How high a risk is not really clear, it depends on how good the hospitals are and how many people have easy access to them. If there are few hospitals and few people go to them, they are probably less likely to be infected with HIV, though they could be more likely to suffer from and die from numerous other preventable and curable conditions. But people need to be warned that sexual behaviour is not the only risk.
  
  I was in Nairobi a few days ago and I talked to several sex workers and, in common with many other people I have talked to in East Africa, they have heard a lot about sexual transmission of HIV. They have heard a little about the risk from intravenous drug use and only brief and infrequent remarks about risks from contaminated blood, such as during blood transfusions. But they are not told that they and their children could be at risk when they go to a clinic or to the hairdresser. Sex workers, especially, go to clinics a lot. They usually go to clinics that specifically target sex workers, where the risk of being infected with an STI would be higher than in clinics not targeting sex workers.
  
  If people in Chad and other African countries are only told how to protect themselves from sexually transmitted HIV, they will not be very well protected. They also need to be told about non-sexual risks, unsafe medical and cosmetic practices. If they don't know about these risks they will not what measures to take to reduce the risks they and their families face. It would also be unsurprising if they continue to believe that they are at risk from mosquito bites and from sharing food.
  
  As long as the HIV industry continues to insist that HIV is primarily transmitted by sexual behaviour in African countries and that other risks are not significant, a lot of preventable HIV infection will continue to occur. If medical facilities are risky for UN employees then they are also risky for Africans. It's hard to believe that the UN can have one story for Africans and another for their employees, but that seems to be the case at the moment.

• UNAIDS: Deadly Omissions

  Posted: June 22, 2010, 1:31 am by Simon

  UNAIDS, a well known publisher of glossy brochures written by highly paid professionals, have come out with one called "Agenda for Accelerated Country Action for Women, Girls, Gender Equality and HIV". It's a worthy sounding name and there's a lot of worthy stuff in it. UNAIDS recognises, to some extent, that more women than men are infected with and probably affected by HIV. The seem to accept that women are, for several reasons, more susceptible to HIV.
  
  But for UNAIDS, the answer to every question about HIV assumes the truth of the 'behavioural paradigm', which holds that the bulk of HIV transmission in African countries occurs through heterosexual sex. Instead of asking why women are being infected with HIV in such high numbers in some places and such low numbers in other places, the document in question assumes that women are becoming infected because they are engaging in unsafe sex. Any action advocated to reduce HIV transmission is based on this assumption.
  
  There were gender inequalities and human rights violations before HIV, and there will be after HIV is eradicated, if that ever happens. The fact that women become more susceptible to HIV as a result of these inequalities and violations is not a reason for objecting to them. The fact that they are gender inequalities and human rights violations is a reason for objecting to them. Equality and human rights are not just instrumentally good, they are good in themselves. Their absence is to be abhorred, regardless of the consequences.
  
  People become infected with HIV by exposure to a virus. One way of becoming infected is by having sex with someone who is infected. Another is by some kind of blood exposure, such as sharing needles when injecting drugs. A third is through unsafe healthcare practices, a fourth is through unsafe cosmetic procedures and a fifth is when a fetus or baby becomes infected by their mother. To prevent HIV transmission, a number of precautions need to be taken, depending on the risks in question.
  
  The UNAIDS 'action framework' focuses on three areas to contribute to HIV prevention: first, countries should 'know their epidemic and know their response' to meet the needs of women and girls. This means that a country should measure the exact contribution of unsafe sex to HIV prevalence. They should also know the extent of non-sexual transmission. But this document simply assumes that non-sexual modes of transmission are irrelevant. There are clearly some inequalities and human rights violations involved here but they are not the ones that are relevant to sexual transmission.
  
  The document goes on to say that they (UNAIDS) and their partners will ensure that countries' strategies, plans, frameworks and budgets will address the rights and needs of women and girls in the context of HIV. But this is not so, they will only address rights and needs that pertain to sexual transmission of HIV. So all their 'Advocacy, capacity strengthening and mobilization of resources to deliver a comprehensive set of measures to address the needs and rights of women and girls in the context of HIV' will also be similarly limited.
  
  There are many women who are mystified as to how they became infected with HIV. If they are not mystified, it's because they have been assured that they must have become infected by their partners. But some have had no partners. And others have partners who are not infected. UNAIDS, in this and other documents, assumes the applicability of the behavioural paradigm and concludes that almost everybody in African countries, male and female, was infected sexually. And then they go to great pains to say to women, who are infected in far greater numbers than men, that it is not their fault.
  
  Women who are infected with HIV do not want to be told that it wasn't their fault that they had unsafe sex, that it's because they suffer from multiple inequalities and violations of their human rights. They don't want to be told how to protect themselves from sexually transmitting HIV when they are not engaging in unsafe sex and will not be in the future. The want to be told how to protect themselves from HIV, whether sexually or non-sexually transmitted. And if they are infected, they need to know how to protect their partner, their children and anyone else around them.
  
  UNAIDS likes to use words such as 'participation', 'engagement' and 'decision-making', but this kind of documentation doesn't appear to have had any time for these concepts. They are not creating an 'enabling environment' or 'empowerment', rather, they are doing the opposite. They are brainwashing the world, and HIV positive women in developing countries in particular, into believing that HIV is mainly spread by heterosexual sex when it is quite clear that some transmission is by non-sexual modes. A genuinely 'evidence informed' and 'ethical' response would be to establish exactly how people are being infected and what contribution each mode of transmission makes in every country.
  
  If UNAIDS are so concerned about gender inequalities and violations of women's human rights, they should do some genuine participative research in the field, rather than publishing pseudo-academic, platitudinous half-truths. HIV is a virus, a disease, it is a subject for epidemiologists, not moralists or politicians. HIV positive people are victims of the disease, not mere 'disease vectors'. If you want HIV to be seen as a disease and HIV positive people to be seen as victims of an epidemic, rather than being stigmatized and reviled, dump the behavioural paradigm. It's not all about sex.

• Institutional Sexism and HIV Transmission

  Posted: June 21, 2010, 7:50 pm by Simon

  There was a time when HIV was thought to affect men far more than women. That may be partly because it was first recognized in rich countries, where people infected were usually male and had sex with men. But it was soon accepted by the health care profession that both men and women could be infected, sexually and non-sexually. In developing countries, the number of women infected soon outnumbered the men. In Kenya, the ratio of HIV positive females went from 1:2.7 in 1986 to 2:1 in 2006 and it's probably about the same now, in 2010.
  
  That makes HIV much more of a woman's disease than many others, even sexually transmitted diseases. The orthodoxy of UNAIDS, the WHO, CDC and others is that women are more susceptible, for various reasons, than men. But these institutions have been trying for years to say what it is that makes women more likely to be infected with HIV in developing countries than women in rich countries. They have come up with a lot of theories about African sexual behaviour, many of which are not borne out by the evidence. These 'theories' are mere prejudices in the absence of evidence, but they have been used to influence most of the HIV prevention activities carried out in high prevalence countries.
  
  It's no wonder that most of these high prevalence countries have only seen small drops in HIV transmission. If there is no evidence for very high rates of unsafe sexual behaviour in high prevalence countries, and plenty of evidence for higher rates of unsafe sexual behaviour in low prevalence countries, the behavioural paradigm, the belief that most HIV transmission is due to high levels of unsafe heterosexual behaviour, is clearly faulty.
  
  The behavioural paradigm was not so evident in the 1980s or even in the early 1990s. It arrived later, probably on the back of large amounts of donor funding from countries who chose, for political or religious reasons of some kind, to see HIV transmission as a moral issue. They chose to see high HIV prevalence as a sign that people in some countries were the victims of immoral behaviour and they switched their attention from non-sexual transmission modes to sexual modes.
  
  The issue of institutional racism on the part of these institutions, UNAIDS, the WHO, CDC and others, has been raised on this blog before. The belief that Africans have higher levels of unsafe sex than non-Africans, when all the evidence says this is not so, lays the charge of institutional racism on their doorsteps. Never mind their posturing about wanting to reduce stigma or improve the lot of women.
  
  But these institutions are also guilty of institutional sexism. Far from reducing stigma, the orthodoxy that says that HIV is mainly transmitted by heterosexual sex in developing countries stigmatizes women more than it stigmatizes men. How are HIV positive women supposed to see themselves in the light of this kind of orthodoxy? What options do they have to defend themselves from the implication that they are promiscuous? And how do they explain their positive HIV status to their husbands when they find that they are infected when their husband is not?
  
  The orthodox view, the racist and sexist orthodox view, says that the majority of people infected, including the 53% of married HIV positive women, were infected by having unsafe sex of some kind. Some HIV positive women with HIV positive husbands are not even infected by their husbands because they are infected with a different genetic strain of the virus. All these women and men are tarred with the same brush, stigmatized by the very institutions that use public money, ostensibly, to reduce stigma, to reduce HIV transmission, to find out why HIV is being transmitted at such high rates in some countries and not in others.
  
  We can offer HIV positive people in developing countries some hope of not being stigmatized. But only if we accept that the behavioural paradigm is wrong, that we don't yet know why people are being infected in such huge numbers. We can offer then a thorough investigation of the non-sexual modes of transmission, because this is clearly relevant. We just don't know the significance of non-sexual transmission yet and that is because we, or at least UNAIDS, the WHO and CDC, have steadfastly refused to investigate properly why HIV transmission is still so high in some countries. We behave like people who don't know anything about HIV transmission. But, in reality, we know the behavioural paradigm is a piece of racist and sexist nonsense.
  
  Are we going to continue to allow people to become infected with a chronic and life threatening illness, even though we know that our policies are based on prejudice rather than on scientific knowledge? How do we face off the charges of institutional racism and sexism that we are so clearly guilty of? Or do we need to go through a process of truth and reconciliation, where the movers and shakers of the HIV industry are allowed to admit their abject failure and promise to eradicate racism and sexism from their institutions? This is not a time for professional, political or religious pride: until we admit we were wrong, we will continue to allow people to suffer and die.

• It’s Not an Emergency, it’s in Kenya

  Posted: June 20, 2010, 8:43 pm by Simon

  If Ireland, my country of birth, had a HIV epidemic like Kenya's, there would be 173,250 HIV positive people there, instead of 5,500. HIV prevalence in Kenya is estimated to stand at 6.3%, in Ireland it's 0.2%. Instead of having one HIV positive person for every 818 HIV negative people, Ireland could have one for every 26. Then it would not be unusual for every person and every family to know or be related to at least one HIV positive person, as is the case in Kenya.
  
  Nyanza province, in the South West of Kenya, has a prevalence of 13.9%, twice that of the next highest prevalence, Nairobi, at 7%. But the Luo tribe, consisting of only around three million people, has the highest prevalence of any tribe in Kenya. At 20.2%, it’s over two and a half times the next highest tribe, the Maasai, at 7.9%. If Ireland had an epidemic like that of the Luo, there would be 555,500 HIV positive Irish people. Think of the dependency ratio and the health care bill.
  
  I like to think that if that number of Irish people were infected with a chronic, life threatening illness, it wouldn't take long before it was established how people were becoming infected and measures were taken to ensure that transmission be reduced to as small a number as possible. I would like to think that the epidemic would be seen as an emergency far more significant than foot and mouth, bird flu, H1N1 and BSE all put together.
  
  555500 is probably similar to the number of World Cup visitors currently in South Africa. The total number of HIV positive people in Kenya is about three times that number, or a third of the population of Ireland. And Kenya doesn't even come close to having the worst HIV epidemic in the world. South Africa itself is estimated to have well over 5 million HIV positive people. And prevalence in some countries, such as Swaziland, is even higher than that found among the Luo tribe.
  
  But imagine if Ireland were to have such an epidemic, what would the government and various international health institutions say and do? Would they say that the epidemic was caused by promiscuity and that Irish people need to have less, or even no, unsafe sex? Would they say or imply that it was due to vague 'cultural' or 'tribal' practices? Or would they say it was due to low levels of circumcision? After all, circumcision levels in Ireland are low, as they are in all European countries.
  
  And if many Irish people, either infected with HIV or affected by it, were to deny that they were promiscuous or careless, would they be believed? Would the government and various international health institutions investigate their claims and try to find out how they could have been infected if they were not infected sexually? If large numbers of infants and young children were HIV positive and their mothers were HIV negative, would that be seen as a possible indication that many of them, perhaps all of them, were infected by unsafe medical procedures or by some other non-sexual route?
  
  A friend pointed out to me that the latest figures show that 53% of married HIV positive women in Kenya have HIV negative husbands. How did they become infected? Would the relevant authorities in Ireland, under similar circumstances, say or imply that these women were promiscuous, give them condoms and drugs and tell them to be careful in case they infect their husbands? Would they circumcise all their husbands as a priority?
  
  Perhaps you would object and say that the scenario I present is futile and that the questions I raise are meaningless. Well, I'm tempted to agree. It seems brutal to ask if the world would be indifferent to the plight of such huge numbers of people, of whole nations, of a whole continent. Could health, economic and political professionals be so inhumane as to humiliate sick people and refuse to protect those who are, as yet, uninfected?
  
  The number of people newly infected with HIV every two years globally is about the same as the population of Ireland. HIV has been recognised for nearly three decades. Since it was first identified, it was clear that it was transmitted, not just sexually, but also through contaminated blood and bodily fluids and by mothers to their infants. After HIV was identified, various measures were taken to reduce transmission, whether transmission was sexual or non-sexual.
  
  But now, people here in Kenya seem almost unaware of any threat aside from that of unsafe sex. Many people, on finding they are HIV positive, assume they must have been infected sexually because that's what they are told, over and over again. They have not been told how to protect themselves from unsafe medical or cosmetic practices, only that they should abstain, be faithful and wear a condom, three things that will never protect them from non-sexually transmitted HIV. It's no wonder people think they must have been infected by mosquitoes or by someone putting a curse on them.
  
  Perhaps the eminent people of UNAIDS, CDC, WHO and other institutions would like to tell the president of the US that many members of his father's extended family and fellow tribespeople are HIV positive and that this is so because most of them are extremely promiscuous and that they need to stop having sex, start using condoms and get circumcised if they are male. Because that’s what they are telling Obama’s father’s people. So perhaps this is what they would say to Irish people under the scenario I mention above.
  
  I would like to think that this would not be their reaction, but what evidence is there that their reaction would be different? Because I don't believe that there has ever been a sexually transmitted disease that has spread like HIV is said to have spread among the Luo people or among the Swazis. I'm not sure if such a sexually transmitted disease is even possible, I certainly hope not. But if HIV prevalence among the Luo and among other populations exceeds our worst nightmares, why is it not considered to be the emergency that it clearly is? I'm not asking why HIV spreads as fast as it does but why it spreads so fast among some people and not among others. And please don't tell me that it's because Luos are 100 times more promiscuous than the Irish.

• There's Plenty of Evidence, Now We Need Investigations

  Posted: June 18, 2010, 7:47 pm by Simon

  Having looked at some of the figures for HIV prevalence in Kenya collected in 2007 and published earlier this year, I was not expecting another set of figures to come out so soon. But the 2008-09 Demographic and Health Survey (DHS) was released recently, so it's worth looking at some of these figures.
  
  Since the 2003 DHS, prevalence has fallen slightly, from 6.7% to 6.3%. The major falls were in Nairobi and Coast provinces, though prevalence also fell in five other provinces. The only province that saw an increase was Western province, which went from 4.9% to 6.6%. This is good news, given that the 2008 Kenya Aids Indicator Survey (figures collected in 2007) found that prevalence had increased overall.
  
  HIV prevalence in Kenya has always been higher in urban than in rural areas. However, the trend is for the share of infections in rural areas to increase. And as the vast majority of Kenyans live in rural areas, the number of people living with HIV in rural areas has long been higher than the number in urban areas.
  
  The ratio of female to male infections overall has remained steady, at about 2 females for every one male. But in most provinces, this ratio has altered considerably. In Eastern province, for example, the ratio went from 4 women to every one man in 2003 to 4 women to every 3 men in 2008.
  
  Despite the epidemic affecting women far more than men, there is still a lot of emphasis on the presumed effectiveness of male circumcision. This is said to give men some protection from HIV, though little or none to women. However, the mass male circumcision campaign in Kenya concentrates on only one of the three tribes in only one of the eight provinces, the Luo tribe of Nyanza. This makes the finding that "Luo men who are circumcised have roughly the same HIV prevalence as Luo men who are uncircumcised (16 percent compared with 17 percent)" rather shocking.
  
  A campaign by CDC (US Center for Disease Control) aims to circumcise in excess of one million Luo men in the next year or so. I wonder how much they have told the men about this sort of finding.
  
  The assumption that HIV is almost entirely transmitted sexually, especially by 'high risk' sex, is as pervasive as ever. That assumption is challenged by some of the findings, without being modified in any noticeable way. For example, in Table 14.7, relating to HIV prevalence by sexual behaviour, females reporting no sexual intercourse in the last 12 months have higher prevalence than those reporting 'higher risk' intercourse.
  
  HIV prevalence was twice as high in females who reported sometimes using a condom (16%) than in those who reported never using a condom (7.8%). It's hard to know what is going on here but one thing is sure: if condoms were so ineffective in Western countries, there would be a thorough investigation. How can people be more likely to be infected if they use condoms? The Catholic and other Christian Churches should be happy as they have long preached against the effectiveness and morality of condoms. But if there is a question mark over both circumcision and condom use, how does Kenya now propose to reduce HIV infections?
  
  It is hard to maintain the assumption that HIV is mainly transmitted sexually in Kenya without at the same time assuming that women must be far more promiscuous than men. There is no independent evidence showing that African women are more promiscuous than African men or that Africans are more promiscuous than non-Africans, for that matter. But over and over again in these figures women and girls, from a young age, are infected in much higher numbers than men. Assuming that these women are infected by men, where are all these men? Unless there is a small number of men who do most of the infecting and most of these women are having sex with them at some time, the HIV epidemic in Kenya is hard to understand.
  
  There are figures that may support the contention that HIV is mainly transmitted sexually. For example, in both men and women, those with a history of having a sexually transmitted infection (STI), or symptoms of one, are twice as likely to be HIV positive as those who have not. But this could also suggest that people attending STI clinics are being infected with HIV through unsafe medical practices.
  
  Indeed, the possibility of unsafe injections as a mode of HIV transmission is mentioned twice in this 455 page report. The fact that some people who are HIV positive reported never having had sex raises this possibility. But it is tempered by the possibility that sexual experience can be underreported, which it can. It can also be overreported. But will this lead to an investigation into why some people who say they have never had sex turn out to be HIV positive? I can't imagine such a finding not being investigated in a Western country.
  
  If there are people who have been infected non-sexually in Kenya, and it's highly unlikely that there are none, this needs to be investigated. Because people who are sexually active can also be infected non-sexually. There has not been a proper investigation in Kenya into what proportion of HIV is transmitted non-sexually. The assumption that HIV is predominantly transmitted sexually has shaped HIV intervention policy and this policy appears to be failing. HIV prevalence has stayed at about the same level ever since the high death rates of the early 2000s have gone down.
  
  Another area for enquiry is the large number of men who are infected whose partners are not and the large number of women who are infected whose partners are not. We can't just assume that they have all been infected because they are promiscuous, especially when they say they are not. Even where both male and female partners are infected it can turn out that they didn't infect each other. People are being infected with HIV and they have no idea why. The authors of the DHS have no idea why, either. HIV transmission will not be eliminated or even reduced substantially until we understand exactly how people are being infected.
  
  There is no shortage of evidence showing that the behavioural paradigm is wrong; we cannot explain high rates of HIV prevalence in Kenya and other African countries on the basis of higher rates of 'risky' sexual behaviour. Research has shown that, on the contrary, high rates of the sort of sexual behaviour thought to be most risky are more likely to be found in Western countries, where HIV prevalence is low. If HIV is not only transmitted sexually, we need to establish how else it is being transmitted, to what extent and how best to eliminate these modes of transmission.

• Fake Aid to be Cut: Recipients May Benefit

  Posted: June 17, 2010, 3:24 pm by Simon

  It isn't often that government departments admit that they got something wrong but it's no less welcome when they do. The two Kenyan departments responsible for health (two because of the power sharing government) agree that they were wrong to pass the anti-counterfeiting bill in a form that failed to distinguish between counterfeit and fake. They accept that this could lead to people being unable to purchase affordable versions of vital drugs, including HIV drugs. India was particularly worried as they supply most of the generic drugs that Kenya and other African countries purchase.
  
  The Kenyan health departments claim that the law in question was pushed by the Ministry for Industry, who didn't realise the implications of the wording of the law. Both these claims sound suspect and the whole issue of a bill which was so stacked in favour of the pharmaceutical industry and against the generic drug industry smelled of industry lobbying and arm twisting. And in practice, even without this law, enormous amounts of money are spent on non-generic, branded products, despite the availability of generics that cost a fraction of the brand price.
  
  Most money spent on health in Sub-Saharan African countries comes from donors. This is one of the reasons that unnecessary amounts of money are spent on overpriced branded drugs. African countries certainly couldn't have afforded them. Some even suspect that a lot of foreign donor money is specifically made available for branded drugs in order to destroy the generic market. After all, branding, intellectual property, is a particularly egregious form of market protection. And there are few who like to protect their markets more than the pharmaceutical industry, regardless of how many people suffer or die from treatable and preventable illnesses as a result.
  
  But this is not the end of the matter. The European Union, that bastion of free market talk and protectionist action, wants India to sign up to a 'Free Trade' Agreement which will effectively restrict the country's ability to produce generics and sell them to poor countries. Médecins Sans Frontières (MSF) is campaigning against this appalling threat to the health and lives of so many people, but most international health institutions are remaining silent.
  
  Many other African countries followed Kenya's unwise decision to pass intellectual property law that only benefited pharmaceutical multinationals, so maybe some of them will reconsider this now. Perhaps they will also get behind MSF and any other organisations involved in campaigning for fair economic conditions for developing countries. Tanzania and others are wondering how they will fare now that so much donor funding has been cut, with the global economic crisis being used as an excuse. They will do a lot better when they exercise their right to purchase generic drugs, rather than wasting the ample HIV funding on extortionately priced brands.
  
  Multinationals and other pushers are constantly bleating about how people in developing are suffering and all rich country governments need to do is pay for their products for things to be ok. But there just isn't enough money to buy branded products, nor is there any necessity to do so. Much of the current HIV transmission in developing countries is preventable, especially transmission from mother to child. But despite the relevant drugs being available for many years, an estimated 43,000 babies were infected by their mothers in Tanzania in 2008 alone. Of the 217,704 new infections, many more would have been the result of lack of proper equipment for ensuring proper levels of medical safety. Tanzania need to find affordable drugs and medical equipment so that they can get by with less money.
  
  The issue of intellectual property protectionism goes far beyond essential drugs and medications. Most household product markets in Kenya and other African countries are dominated by one single brand or a handful of brands, for example, soap, sanitary pads, diapers, cleaning materials, etc. These brands are unnecessarily expensive but one disinfectant soap manufacturer even claims that using their soap makes you and your children 100% healthier. Such claims, leading people to believe that they are harming their families if they don't use these products, are widely advertised. That is where much of the money made by multinationals is spent; it's spent on marketing and advertising, not on research, as they would like us to believe.
  
  Let multinationals do their own dirty work, they should not be entitled to donor money that is supposed to be spent on needy people. If these organisations are bothered by competition from generics, let them put their prices down and learn how to compete, for a change. They love talking about competition but they usually operate in completely protected environments. And if they think those producing fakes are worth fighting, they could just lower their prices enough so that it is no longer worth while producing fakes. Fakes are only economic when the cost of making the goods is low but the price charged is high. Multinationals should start abiding by some of the principles they seem to think are so important. They have priced themselves out of the market that they have worked so hard to rig in their favour.
  
  Countries like Kenya and Tanzania are right to be worried about reduced funding but there are two things that may work in their favour. Firstly, if they are less dependent on donor funding, they may be better able to shop around for affordable drugs and other vital goods. At present, donors usually decide which drugs and goods to purchase and they favour their own markets. That's what being a donor is all about, isn't it! Secondly, they may find ways of achieving even more with less money once they are freed of all the restrictions that foreign loans and donations often carry. This is not an argument for reducing funding, which I think should be increased. But it is an argument for funding to become more transparent, more democratic, more like genuine funding than merely a tool for benefiting the donor far more than the recipient, as it appears now.

• Fake Aid to be Cut: Recipients May Benefit

  Posted: June 17, 2010, 3:24 pm by Simon

  It isn't often that government departments admit that they got something wrong but it's no less welcome when they do. The two Kenyan departments responsible for health (two because of the power sharing government) agree that they were wrong to pass the anti-counterfeiting bill in a form that failed to distinguish between counterfeit and fake. They accept that this could lead to people being unable to purchase affordable versions of vital drugs, including HIV drugs. India was particularly worried as they supply most of the generic drugs that Kenya and other African countries purchase.
  
  The Kenyan health departments claim that the law in question was pushed by the Ministry for Industry, who didn't realise the implications of the wording of the law. Both these claims sound suspect and the whole issue of a bill which was so stacked in favour of the pharmaceutical industry and against the generic drug industry smelled of industry lobbying and arm twisting. And in practice, even without this law, enormous amounts of money are spent on non-generic, branded products, despite the availability of generics that cost a fraction of the brand price.
  
  Most money spent on health in Sub-Saharan African countries comes from donors. This is one of the reasons that unnecessary amounts of money are spent on overpriced branded drugs. African countries certainly couldn't have afforded them. Some even suspect that a lot of foreign donor money is specifically made available for branded drugs in order to destroy the generic market. After all, branding, intellectual property, is a particularly egregious form of market protection. And there are few who like to protect their markets more than the pharmaceutical industry, regardless of how many people suffer or die from treatable and preventable illnesses as a result.
  
  But this is not the end of the matter. The European Union, that bastion of free market talk and protectionist action, wants India to sign up to a 'Free Trade' Agreement which will effectively restrict the country's ability to produce generics and sell them to poor countries. Médecins Sans Frontières (MSF) is campaigning against this appalling threat to the health and lives of so many people, but most international health institutions are remaining silent.
  
  Many other African countries followed Kenya's unwise decision to pass intellectual property law that only benefited pharmaceutical multinationals, so maybe some of them will reconsider this now. Perhaps they will also get behind MSF and any other organisations involved in campaigning for fair economic conditions for developing countries. Tanzania and others are wondering how they will fare now that so much donor funding has been cut, with the global economic crisis being used as an excuse. They will do a lot better when they exercise their right to purchase generic drugs, rather than wasting the ample HIV funding on extortionately priced brands.
  
  Multinationals and other pushers are constantly bleating about how people in developing are suffering and all rich country governments need to do is pay for their products for things to be ok. But there just isn't enough money to buy branded products, nor is there any necessity to do so. Much of the current HIV transmission in developing countries is preventable, especially transmission from mother to child. But despite the relevant drugs being available for many years, an estimated 43,000 babies were infected by their mothers in Tanzania in 2008 alone. Of the 217,704 new infections, many more would have been the result of lack of proper equipment for ensuring proper levels of medical safety. Tanzania need to find affordable drugs and medical equipment so that they can get by with less money.
  
  The issue of intellectual property protectionism goes far beyond essential drugs and medications. Most household product markets in Kenya and other African countries are dominated by one single brand or a handful of brands, for example, soap, sanitary pads, diapers, cleaning materials, etc. These brands are unnecessarily expensive but one disinfectant soap manufacturer even claims that using their soap makes you and your children 100% healthier. Such claims, leading people to believe that they are harming their families if they don't use these products, are widely advertised. That is where much of the money made by multinationals is spent; it's spent on marketing and advertising, not on research, as they would like us to believe.
  
  Let multinationals do their own dirty work, they should not be entitled to donor money that is supposed to be spent on needy people. If these organisations are bothered by competition from generics, let them put their prices down and learn how to compete, for a change. They love talking about competition but they usually operate in completely protected environments. And if they think those producing fakes are worth fighting, they could just lower their prices enough so that it is no longer worth while producing fakes. Fakes are only economic when the cost of making the goods is low but the price charged is high. Multinationals should start abiding by some of the principles they seem to think are so important. They have priced themselves out of the market that they have worked so hard to rig in their favour.
  
  Countries like Kenya and Tanzania are right to be worried about reduced funding but there are two things that may work in their favour. Firstly, if they are less dependent on donor funding, they may be better able to shop around for affordable drugs and other vital goods. At present, donors usually decide which drugs and goods to purchase and they favour their own markets. That's what being a donor is all about, isn't it! Secondly, they may find ways of achieving even more with less money once they are freed of all the restrictions that foreign loans and donations often carry. This is not an argument for reducing funding, which I think should be increased. But it is an argument for funding to become more transparent, more democratic, more like genuine funding than merely a tool for benefiting the donor far more than the recipient, as it appears now.

• Give those Women a Pat on the Head

  Posted: June 15, 2010, 4:03 pm by Simon

  Those in the Aids industry often talk about gender and empowerment in relation to reducing HIV transmission. But what do they mean? Do they mean that women would be able to protect themselves from HIV if only their rights were recognised, such as the right to decide when, where, with whom and under which circumstances to have sex? Well, gender inequality is repulsive in many ways and it has numerous negative consequences. Gender equality is a human right and we should strive for full gender equality everywhere and remove barriers to equality.
  
  But in developing countries like Kenya, people face all sorts of risks that make them vulnerable to diseases, not just HIV. And the risk of sexually transmitted HIV is higher where women don't have rights to negotiate or determine their sexual or reproductive life. The Aids industry seems anxious to inform women about these rights but they don't seem to regard women's rights to safe healthcare as being important, or as having any relevance to their sexual or reproductive life. These issues only merit brief mention every now and again. I read or scan through hundreds of articles every week and rarely come across one that even mentions the non-sexual risks of HIV.
  
  To repeat myself, gender inequality is repulsive and such inequalities are probably involved in transmission of all sorts of disease and exposure to many risk factors, such as lack of access to clean water and sanitation, adequate housing and a clean environment. But gender inequality itself does not transmit HIV. HIV is a virus transmitted from person to person, through sexual intercourse, by HIV mothers giving birth or breastfeeding or through unsafe medical or cosmetic procedures.
  
  It may sound like hair splitting, but people will continue to have sex (I presume) even if gender inequalities are reduced, they will continue to have children and they will continue to avail of medical and cosmetic procedures. Ensuring that women have the right to choose the circumstances under which they do these things is all very well, but what sort of choices are women going to make when, firstly, they don't know anything about unsafe medical and cosmetic practices and secondly, they have no influence on how those practices are carried out or how to make them less risky?
  
  The truth is that the Aids industry is very much in the dark about how HIV is transmitted in most countries. They know that medical and cosmetic transmission occurs but they have not investigated instances of these kinds of transmission. They have chosen to concentrate on sexual risk to the exclusion of all other risks. They have made a choice about the health and welfare of people, especially women (who are exposed to far more healthcare and cosmetic risks than men), that disempowers women in developing countries. By deciding what risks women need to avoid and ignoring others, the Aids industry is doing the opposite to what it says: it is beating the empowerment drum while silently spreading disempowerment.
  
  Incidentally, the HIV 'gender imbalance' in Kenya is quite curious in many ways. North Eastern province has the worst Gender Development Index (GDI) but also the lowest HIV prevalence. This province also has the highest percentage of girls married by the age of 18. The province with the lowest percentage of girls married by age 18 and one of the best GDI figures, Nairobi, has the second highest HIV prevalence.
  
  Looking at it another way, in Central and Eastern provinces there are four HIV positive women for every one HIV positive man. These two provinces have little in common, with Central having the best set of development indicators and Eastern having one of the worst. Central province has only half the HIV prevalence rate of the country as a whole but Eastern has only a third, in other words, very low HIV prevalence. According to the received Aids industry view, somehow, a small group of men manage to infect a very large group of women. What, exactly, is the Aids industry saying about the sexual behaviour of people in these provinces?
  
  Compared to that, there are only two HIV positive women for every one HIV positive man in North Eastern and Rift Valley provinces. As you move to the provinces with 'more equal' HIV epidemics, where there are only 1.5 HIV positive women for every HIV positive man, you find that these three provinces all have relatively good GDI scores but they account for half of the HIV positive people in Kenya. The Aids industry may interpret this as showing that sexual behaviour in these provinces is not as risky as that in some other provinces. Yet this lower level of risk seems to give rise to much higher rates of HIV transmission.
  
  The oddest ratio of all is found in Coast province, where there are only 1.3 HIV positive women for every one HIV positive man. This looks more like a truly sexually transmitted disease, where male and female prevalences are similar enough. But this is also the province where there is likely to be the highest rates of intravenous drug use (mostly men) and sex tourism (which doesn’t seem to result in large numbers of HIV positive tourists). Even men having sex with men is said to be high here but I don't think that is borne out by the evidence. But is this infection ratio really a reflection of sexual practices here being quite different from those in other provinces? It would be difficult to say without investigating, not just sexual practices, but also any other ways in which HIV could be transmitted.
  
  HIV transmission patterns are very complex and vary a lot, even within a country like Kenya. Gender is, of course, relevant. But perhaps it's not relevant for the reasons the Aids industry wants us to believe. There is little to be gained by patronising campaigns that tell women how hard their lives are but that also ignore the very risks that could most easily be avoided. Gender inequalities don’t just relate to people’s sexual behaviour, they relate to people’s access to healthcare, education and other social goods. Gender inequalities also relate to the sorts of information that people have access to. The Aids industry currently ensures that women don’t have access to adequate information that would allow them to protect themselves and their children from HIV and other diseases.
  
  Women can be empowered and stigma can be reduced at the same time by accepting that HIV is not just transmitted sexually. To work out what proportion of HIV is transmitted sexually and non-sexually, the Aids industry needs to stop obsessing with people's sex lives and further humiliating them. The industry needs to investigate the numerous women who are HIV positive when their partners are HIV negative and the numerous children who are HIV positive but who were probably not infected by their mothers. Simply telling people that being HIV positive is not their fault while making it clear that you think it probably is their fault is not going to help people to avoid HIV risks or to reduce stigma.
  
  Bandying about words like 'gender', 'empowerment' and 'stigma' is not going to reduce HIV transmission as long as non-sexual HIV transmission is left out of the picture. At present, the strategy of the Aids industry simply disempowers people and increases stigma. Don't just pat people on the head and tell them it's not their fault, show them how HIV is being transmitted and how they can protect themselves and others.

• Big Media: Double Standards or Negligence?

  Posted: June 13, 2010, 1:07 am by Simon

  I searched in vain for any mention of the risks of non-sexually transmitted HIV before the World Cup. But all the big news sources, CNN, BBC, Al Jazeera, along with lots of newspapers and news sites, covered sexual transmission of HIV, exclusively. They warned people about unprotected sex and using condoms, etc, but none of them warned people that in South Africa, medical and cosmetic treatment can carry huge risks from unsterilized equipment and unsafe procedures.
  
  This is particularly odd because I would put money on it that these same organizations warn their own employees about non-sexual dangers. I could be wrong, perhaps they don't warn their own employees. But many big organizations do, such as the UN, WHO and CDC. Even an MSF Kenya employee I talked to recently said she and her colleagues wouldn't use local medical or dental facilities (though, inexplicably, she didn't seem to think medical transmission posed much of a risk to people who lived in the country). So big media are either guilty of the double standard of warning their own employees of a risk that everyone in African countries face without warning African people; or they are guilty of negligence in not warning their employees about this serious risk.
  
  Of course, they may have been advised by UNAIDS or the like that medical treatment does not pose much of a risk. What they mean by this is that they are currently admitting that in excess of 5% of HIV is transmitted by medical treatment. These thousands of people infected are so insignificant that UNAIDS deems it better to keep talking about sexual transmission and completely ignoring medical transmission because otherwise, people might not have confidence in their medical service providers. So, is there a risk or is there not?
  
  If the risk is so small, only a few tens or perhaps hundreds of thousands of new cases every year, why not warn people about it? Because if the risk is small, they shouldn't be unduly worried about their medical service providers. But then, if the risk is small, why do UN agencies warn their own employees away from using medical services in African countries that are not approved by the UN? And while in excess of 5% of cases may not seem so significant to UNAIDS, that's 8 or 9 times higher than the contribution of medical treatment to HIV prevalence claimed for Kenya, which the same UNAIDS put at about 0.6%.
  
  What is so wrong with saying that people face risk from both sexually transmitted and non-sexually transmitted HIV? Is it so hard to admit that when millions of needles and other sharp objects are stuck into people every day, some diseases may be accidentally transmitted? Because, if UNAIDS had the balls (or do I mean teeth?) to admit this obvious possibility, people living in African countries would be in a position to do something to protect themselves, perhaps even to lobby their governments to change things so that they don't face these dangers.
  
  I think UNAIDS are right, if people found out that they or their children face an appreciable risk of being infected with HIV, they would think twice before having routine medical treatment. But what would UNAIDS prefer? That tens of thousands of preventable HIV infections continue to occur because they think that number is insignificant compared to people suspecting that their medical service providers are not very safe?
  
  Either the danger of medical transmission is insignificant, and then it shouldn't be beyond the capability of UNAIDS and their chums to manage the fallout from telling the truth: that there is some danger. Or medical transmission is anything but insignificant, in which case UNAIDS and all other relevant agencies should lose no more time in warning people of the risks and in mitigating those risks so that people can return to their medical service providers with greater confidence.
  
  I don't accept that it is better to keep people in the dark and allow some of them to become infected with HIV when this is completely avoidable. I don't accept that it is better not to tell people how to protect themselves or to try to cover up the danger on the grounds that people not using medical services is a bigger evil. African people are being treated like idiots, who don't know how to evaluate risks and to take measures to avoid them.
  
  It looks as if people visiting the World Cup are being treated the same way, being told to avoid sex or to use a condom. Some of the more self righteous in the HIV industry like to say that the only way to be 100% sure of not contracting HIV is to abstain from sex. But this is not true. Abstaining from sex has not protected the thousands who have been infected non-sexually and the thousands more who will continue to be infected because UNAIDS, in their great collective wisdom, don't wish to inform people that there are also non-sexual risks that abstaining from sex and wearing a condom won't protect you from.
  
  What is so difficult about telling the whole story, that HIV can be transmitted sexually and non-sexually? And if UNAIDS can't be trusted to do so, why is it so difficult for news agencies to do so? Do they really all care that little about HIV continuing to spread, unnecessarily? Or are they just so obsessed with sexual behaviour that only sexual risks are considered worth reporting?

• Abolishing UNAIDS is a Prerequisite to Fighting HIV Pandemic

  Posted: June 10, 2010, 6:34 pm by Simon

  I'm not just suggesting that UNAIDS have failed to reduce HIV transmission to the extent that the epidemic will be wiped out in the foreseeable future, although they have certainly failed to do this. I'm suggesting that they seem content to allow HIV to spread, especially in developing countries, as long as it is not transmitted sexually.
  
  This is disingenuous because people who are not infected with HIV sexually, for example, if they are infected though medical treatment or cosmetic treatment, can still go on to infect others sexually. It is not possible to significantly reduce sexual HIV transmission without also reducing non-sexual transmission. It is also rather pointless to target sexual transmission and exclude non-sexual transmission completely.
  
  The question is, why does UNAIDS see its mission as relating almost entirely to sex? In the early days of Aids, before the exciting prospect of a UN agency entirely devoted to one disease was even recognised, non-sexual transmission of HIV was still considered important. Warnings about HIV risk included risk of medical transmission and risk from other procedures that involved possible blood borne transmission.
  
  As a result, Western hospitals changed the way they did things, especially relating to any procedures involving possible blood exposure. Blood transfusions represented one of the greatest threats and even developing countries now have policies relating to transfusions that are estimated to have cut this form of HIV transmission considerably, perhaps completely.
  
  But developing countries have not had the resources or the training to improve their health facilities enough to convince the UN, and probably many others, that they are safe. And indeed, they are not safe. Westerners travelling to developing countries, especially in Africa, are often warned about medical and other treatment that could carry the risk of exposure to HIV and other blood borne diseases. But Africans are not warned.
  
  An unusual exception to the practice of warning Westerners (and not bothering about people in developing countries) seems to be occurring at the moment. I don't think people visiting South Africa for the World Cup are being warned about non-sexual risks, although they are hearing plenty about the sexual risks. Some of them will probably feel they have had enough sex by the time they get to South Africa. Others may only feel their appetites whetted.
  
  But South Africans are still, to a large extent, in the dark about non-sexual HIV transmission. A report from a few years ago estimated that the number of new infections per year among those aged between 2 and 14 was about 69,000. About 192,000 people between 15 and 24 were infected. But where are all these infections coming from? What makes a South African more or less likely to be infected?
  
  69,000 children infected in one year! What are the possibilities? That their mothers are all HIV positive (the report authors say it is unlikely that these are linked to mother to child transmission)? But many (not all, unfortunately) HIV positive mothers receive treatment to prevent transmission to their infants. And even among those who don't, HIV transmission is not 100%. There are other possibilities, but certainty is needed. When a country has tens of thousands of HIV positive children, this needs to be investigated, so we can be sure what is going on. If you were the parent of one of those children, would you accept UNAIDS contention that most HIV is transmitted sexually?
  
  Being black in South Africa means you are 9 times more likely to be infected than if you are from any other race. Being from Mpumalanga province means that you are 12 times more likely to be infected than if you are from Northern Cape. And if you are from an urban slum, you are over 5 times more likely to be infected than if you are from an urban non-slum area. If you are from a rural area, you are far less likely to be infected, regardless of whether you are from a slum or a non-slum.
  
  Females between the ages of 20 and 29 are over 6 times more likely to be infected than males of the same age group. Just in case these figures suggest that the predominantly well off male and younger visitors to the World Cup could be at an advantage, they will be mainly in urban areas and if they happen to visit medical or cosmetic outlets, the contaminated blood they are exposed to could have come from a male or female of any age or race and from any location.
  
  Also, rates of new infections among people who reported never having sex or who reported not having sex in the past 12 months stood at 1.5% and 2.4%, respectively. This could represent tens of thousands of people whose HIV infection probably came from a source other than sex. Where did their infection come from? From being African, according to the UNAIDS received view; they have simply underreported their sexual behaviour, in other words, they lied.
  
  So, if you are visiting South Africa and you end up in bed with someone you meet there, you would be crazy not to wear a condom, just as it would be crazy in any other country in the world. You would be better off avoiding sex altogether, if that is your favoured way of reducing the risks you face for HIV, unplanned pregnancy and other sexually transmitted infections.
  
  But you are not protecting yourself adequately if you think that having sex is the only way of becoming infected with HIV. You may well be safe enough if you take the right precautions, no matter who you sleep with. But you will be in far greater danger if you have to go to a hospital, a dental surgery, a tattoo parlour or a hairdresser.
  
  If soccer fans visiting South Africa are lucky enough to be able to choose the health facilities and other service providers they visit, that's great. But South Africans will not be so lucky. As long as UNAIDS insists on playing the sexual card, people will remain in the dark about non-sexual risks. Providers of health and cosmetic services will continue to use unsafe procedures and people will continue to be infected with HIV.
  
  Now that fifa and other commercial interests have their snouts firmly in the trough and journalists have been distracted by one of their favourite subjects, sex, UNAIDS is unlikely to take the only sensible route of warning people about both the sexual and non-sexual risks of HIV. As to why they have so far refused to accept that non-sexual transmission of HIV plays a significant part in the HIV pandemic in Africa, that is anyone's guess. But people are being infected, they are suffering and dying, unnecessarily. Why does UNAIDS receive public money to behave in this way?

• HIV Risk From Lies and Half Truths

  Posted: June 9, 2010, 7:30 pm by Simon

  In the run up to the World Cup in South Africa, the excuse for talking exclusively about sexual behaviour and HIV risk and ignoring any other risks, such as the risks of medical transmission, seems to be that sexual transmission is the most common form of transmission in African countries.
  
  The view that sexual transmission is so common that non-sexual transmission is almost negligible is debatable and the official figures are based on guesswork rather than proper research. But even if the figures were correct, it would be stupid to ignore non-sexual risks just because sexual transmission is more common.
  
  Driver error may be a common cause of road traffic accidents but I wouldn't want to ignore the fact that my breaks are worn out just because it is a less frequent cause of accidents.
  
  We know that the UN worries about medically transmitted HIV enough to warn its own employees about it:
  
  "Use of improperly sterilized syringes and other medical equipment in health-care settings can also result in HIV transmission. We in the UN system are unlikely to become infected this way since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment. Extra precautions should be taken, however, when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere. It is always a good idea to avoid direct exposure to another person’s blood — to avoid not only HIV but also hepatitis and other bloodborne infections."
  
  So why not warn soccer fans and other visitors to South Africa and other African countries? More importantly, why not warn all Africans, most of whom have no option but to use their medical facilities, no matter how inadequate they are?
  
  Sure, international health institutions want people to trust their health facilities enough to get medical treatment when they need it, to get tested for things like HIV and to take the advice of health professionals. But is that a reason to deceive the public?
  
  The public might be afraid that official sources are lying to them or that they are keeping something back. But official sources are lying to them and keeping something back. All over Africa, there have been clear outbreaks of medically transmitted HIV. These have been covered up or just ignored and no investigations have been carried out.
  
  Even if only a handful of HIV infections were caused by medical transmission, people should be made aware that the possibility exists. They should be in a position to protect themselves, to insist on sterilized equipment and other safe practices. If they don't even know that unsafe medical procedures occur, they will not know that they need to protect themselves.
  
  But there is little question about whether medical transmission of HIV is common in African countries. Medical facilities have long been underfunded, understaffed and otherwise inadequate. It would be more surprising if very few transmissions of HIV occurred than if a sizeable number occurred. The only question is about how common medical transmission is compared to sexual transmission.
  
  In the long run, people will have more confidence in public health information and in public health facilities if they are told the truth now. Those trusted to provide people with the information they need to stay healthy are not presently entitled to that trust. Maybe people will question the safety of health facilities once they realise that things have been kept from them. But as things stand, they are right to ask questions.
  
  If it is risky for UN employees to trust medical facilities that are not approved by the UN, it is also risky for soccer fans. And if it's risky for visitors to Africa to mistrust medical facilities, it is also risky for Africans. No amount of abstinence, faithfulness to one partner or condom use will protect people from medically transmitted HIV. HIV can be, and often is, transmitted by medical and dental treatment and by cosmetic treatment such as tattooing, piercing and hairdressing, in African countries. It is not just transmitted by 'unsafe' sex.

• Condoms Won't Protect Fans Against Non-Sexual HIV Risk

  Posted: June 8, 2010, 9:09 pm by Simon

  Since writing about HIV and the World Cup in the last few days, I have looked for news outlets and the like for coverage of non-sexual HIV risks that people visiting or living in South Africa face. I found nothing. A couple of sites mention needle sharing as a potential risk but the tone of the warning suggests that it is aimed at intravenous drug users. There is no mention of the risks of visiting a dentist, a doctor, a nurse, a surgeon, a tattoo artist, a hairdresser or any other non-sexual risks. Can journalists and others trying to squeeze all that they can out of the World Cup not find space for a brief mention of these issues?
  
  The remarkable thing about medical transmission of HIV in African countries is not that it doesn't happen. It's that no investigations have been carried out when medical transmission has clearly occurred or where it may have occurred. Infants, children and even adults who have had no sexual exposure are HIV positive, yet there have been no calls by international health institutions, African governments or HIV donors for investigations. In most African countries, the number of women infected far exceeds the number of men infected. And though women's groups fall over themselves to get their issues heard, they don't seem to be outraged that women seem to comprise the largest number of victims of medically transmitted HIV.
  
  Compare this to a story in Australia. There are fears that thousands of patients at a clinic may have been infected with HIV, hepatitis and other diseases after hygiene standards were found to be seriously deficient. The clinic has been closed while the investigations take place. I don't know of any similar investigation in an African country and I've rarely heard of a hospital or clinic closing merely because patients health and lives may be at risk.
  
  Endoscope and biopsy equipment were found to have been insufficiently sterilized after nine patients became sick. There was also a contaminated anaesthetic involved. These are problems that African hospitals face all the time. They often don't have the equipment to sterilize everything properly, nor even enough trained staff to carry out the work. African hospitals also have the problem of old equipment, shortages of equipment and the need to reuse things that are designed to be disposable. Health workers are not going to do without gloves just because there is a shortage. How many options do they have?
  
  In Australian hospitals, people are far less likely to be infected with HIV, hepatitis or other serious illness. But in African countries, where only the sickest go to hospital and many serious diseases are endemic, the risks are very high. But patients becoming ill after receiving medical treatment in African hospitals is so common that this is unlikely to trigger any kind of investigation, as happened in the Australian instance. And if people die, there are unlikely to be any questions asked. Many people die every day of all sorts of things. Health workers have little enough time to deal with sick people, let alone dead people.
  
  In the UK, children who may have been jabbed with discarded hypodermic needles in a paddling pool are being monitored for HIV and other conditions. The have to wait three months to be sure they have not been infected with HIV, but at least they and their parents were alert to the fact that they may have been contaminated. I have passed through a couple of health facilities in East Africa and seen needles and other sharps in the grass where people walk in rubber sandals and where children play. I wonder if African children running around in bare feet would even notice a pinprick or scratch from a needle.
  
  But I know that the parents of most children here would have no idea that needles and other hospital wastes carry a risk of infection with HIV and other diseases. Some people can tell you that sharing needles and the like carries a risk but most have not been fully warned about the risks associated with medical and cosmetic facilities. Indeed, the official line is that there is only a tiny risk from medical and cosmetic transmission of HIV. Those responsible for the official line, UNAIDS, WHO, CDC and the rest, must be well aware that non-sexual risks are far higher than they admit. But for some reason, they don't want Africans to know that these risks exist and, consequently, how to protect themselves.
  
  And so, as the Western world worries about Westerners going to the World Cup being infected with HIV through some kind of sexual encounter, it's quite amazing that there are no warnings about non-sexual risks. Football supporters don't just like drinking and having sex after matches, they also like fighting, especially when their team loses. And drunk people can be prone to all sorts of accidents. People will end up in accident and emergency wards, dental surgeries and the like. People also may like to get that special football tattoo in South Africa, where it may be cheaper, but also more dangerous.
  
  No doubt, there will be the usual slew of stories after the event about how various efforts and initiatives failed and how things should have been done differently. Journalists will never close the stable door if they can make a story about the bolted horse. So if the media, websites, officials and other sources of information will say nothing about non-sexually transmitted HIV, instead concentrating exclusively on sexual transmission, there will also be stories about how people are let down by health services and how unhygienic tattooists, hairdressers and ear piercers are. But only when it is too late for the victims.
  
  If the Western press is really so worried about the health of Westerners, they should highlight the risks of non-sexually transmitted HIV and other health risks that people receiving medical and cosmetic treatment in South Africa face. They clearly are not worried about the risks that South Africans face and will continue to face after the World Cup has ceased to be front page news. But there is hope that South Africans themselves will one day question the official line, that they have so much sex that this explains why the country has more HIV positive people than any other. South Africans themselves may question the state of the health services that are available to them and ask why they have not been warned about non-sexual HIV risks or how to protect themselves. This is a very good time for them to raise these questions, before the Western press goes back to seeing Africa as a far away place populated by foreigners who have a lot of risky sex.

• Unmixed Messages Could Scupper World Cup ‘Opportunity’

  Posted: June 7, 2010, 9:18 pm by Simon

  It's all about taking part, not winning, right? It’s certainly not about corporate domination, making money or anything so sordid. The World Cup probably means different things to those who care, can afford it or have something to gain from it. But there seems to be a worry that warnings about public safety could detract from people’s enjoyment of the football. According to the British Guardian, Fifa are blocking attempts to distribute condoms at venues. Fifa deny this and say no attempts have been made to set up condom distribution facilities. But even safe sex information has been banned, apparently.
  
  I imagine people from Western countries travelling to South Africa will receive plenty of information about safe sex before they leave their own safe countries. Many will probably have their own supply of condoms or be able to buy them on arrival. They may even receive information on other HIV risks, such as from medical and cosmetic treatment.
  
  They may be told that some health providers have a shortage of equipment and trained personnel, so they have to make sure that needles, syringes, suture needles and other equipment are properly sterilised if they haven’t taken a supply of medical equipment with them. It’s possible that visitors will also be warned to avoid getting tattoos, body or ear piercings or any cosmetic treatment that breaks the skin. (I’ve seen a warning about avoiding tattoos because they may be regretted later but none about the risk of HIV or any other disease.) Condoms are great for preventing sexual transmission, but I think people will need information about more than just basic safe sex.
  
  Some Aids organizations are said to see the World Cup as a good opportunity to give out messages about HIV. But which messages are they trying to give out? That HIV is sexually transmitted? Report after report has shown that most people in African countries already know that. Whether people from Western countries know that or see that as relevant to them is another matter. But when will Aids organizations start to warn people about non-sexual risk of HIV? Non-sexual risks, especially from medical treatment, have been recognised since the early 1980s, almost since HIV was identified as the virus that caused Aids. But since early on in the epidemic, international health institutions have remained relatively silent about this important mode of infection. It is rarely discussed and every year these institutions publish figures purporting to show that medical transmission is very low and hardly worth worrying about.
  
  Hospitals in South Africa are generally in poor condition, places you would not visit for treatment unless you really had to. Most South Africans really have to put up with these conditions, but rich South Africans (and rich visitors) don’t. They can opt for the expensive and hopefully safer hospitals, such as the ones that are looking for health tourists during the World Cup. Even those World Cup fans who need routine accident and emergency treatment will probably opt for something a bit better than the facilities available to poor South Africans. If Aids organisations see the World Cup as an opportunity to get a message across, that message should be relevant to everyone, regardless of their race, economic circumstances or any other criterion.
  
  It is clear that HIV is transmitted by routes other than sexual behaviour. It is also clear than non-sexual transmission is far higher than UNAIDS and others will admit. Just how high non-sexual transmission goes in African countries is unclear because outbreaks of medically transmitted HIV have, so far, been entirely uninvestigated. UNAIDS is happy to warn UN employees to avoid medical treatment in African countries, except in UN approved hospitals. But they don’t seem to want Africans to know about the risks of medically (and cosmetically) transmitted HIV. This is the message that needs to be broadcast during the World Cup. Why the sudden worry that a few Westerners will become infected with HIV when Africans are being infected every day and much of this transmission could be avoided?
  
  A brief article about preparations for medical emergencies during the World Cup mentions the ‘beleaguered health system’ and the huge HIV epidemic, but says nothing about the risk of medical transmission of HIV. The country is not suddenly going to acquire the capacity to provide adequate and safe medical treatment for everyone, no matter how important the World Cup is perceived to be. But that is part of the important message that Aids organizations should be concentrating on: that people should be aware of all the risks and how to protect themselves in order to avoid HIV and other diseases. The warnings should no longer be just about sexual risk but should include non-sexual risks too, especially risks of medical transmission.
  
  The sort of racism that gives rise to UNAIDS and other institutions claiming that HIV is mostly transmitted by heterosexual sex in African countries results in an overemphasis on sexual risk and little or no emphasis on medical transmission. But another instance of racism seems to come out in the run up to the World Cup. There seems to be a lot more concern about non-Africans becoming infected with HIV than about Africans, who face risks, sexual and non-sexual, every day. They have faced these risks for decades and it looks as if they will continue to do so for decades. Apartheid may have ended, nominally. But every African, as well as every non-African, needs to be aware of how to avoid HIV infection and everyone needs access to information and facilities that will protect them. These are not yet available: that is why around 1,400 South Africans become infected with HIV ever day. HIV risk didn’t start with the World Cup and it won’t end with there. But it looks as if the usual Aids organisations will waste the opportunity by talking exclusively about sexual risk, yet again.

• UNAIDS Set to Score Own Goal in South Africa

  Posted: June 3, 2010, 8:00 pm by Simon

  Many people who follow the HIV pandemic will be looking with interest at the soccer in South Africa or rather, reports about possible HIV transmission there. There are claims that tens of thousands of women from around the world are flocking to South Africa to work in the sex industry and that a lot of soccer fans will be availing of these services. Whether these claims are true or not is anyone's guess, I've seen no evidence to back them up.
  
  It seems likely that even if people visiting South Africa don't know how to protect themselves, those working in the sex industry will. One hopes so, after decades of warnings about the dangers of sex and HIV. If these warnings haven't worked by now, perhaps those spending public money on them should rethink their HIV strategy.
  
  But what about the dangers of non-sexual infection with HIV? Neither those in the West coming over to South Africa nor those living in South Africa are likely to have had so many warnings. Tourists may well be aware of non-sexual risks, such as tattoo parlours, cosmetic outlets like barber shops and, perhaps most importantly, medical facilities. Go into a travel shop in many European countries and you will find medical equipment that you can bring with you on your trip, such as needles, syringes and sutures. Some of the well known guide books warn against some of the non-sexual dangers of HIV infection in addition to sexual behaviour.
  
  Africans are not granted the benefits of access to affordable medical equipment or even of information about non-sexual HIV risk and how to protect themselves. It seems they are just not as important as tourists and others visiting the continent.
  
  Perhaps Westerners visiting South Africa have some chance of protecting themselves against these risks, although the media coverage of the issue is (as usual) concentrating on sexual risk. In a typical article covering the soccer, we can read about sporting stars and what they have to say about HIV and sexual violence, especially against women and girls. I assume they are saying what they are told to say, perhaps what they are paid to say, but none of them appear to be talking abut non-sexual transmission of HIV. Or perhaps the press just doesn't bother covering that issue.
  
  My guess is that people's heads, wherever they come from, have been so filled with information about condoms, casual sex, multiple partners and the rest, non-sexual risks will have little impact. And conflating gender based violence with HIV risk is not very helpful either. Gender based violence, whoever the victims, is wrong, it's not just wrong because victims may be infected with HIV. In fact, the majority of victims are not infected with HIV, but gender based violence is none the less abhorrent.
  
  In a similar vein, an article about the singer Annie Lennox becoming a Goodwill Ambassador for UNAIDS also conflates the need to reduce HIV transmission with the need to fight against gender based violence. I admire Annie Lennox and I hope she gets through to people in a way that UNAIDS has completely failed to do. But being supported by UNAIDS would tend to suggest otherwise. Still, Lennox is an intelligent and sincere woman. We may see her shaking off the shackles of UNAIDS patronage and speaking the truth about HIV.
  
  The truth is that the mainstream HIV industry has concentrated on sexual transmission of HIV to the exclusion of medical or cosmetic transmission. This was not so much the case in the early days, before the interference of massive levels of funding, commercial, political and religious interests. But now, the industry is all but silent on anything but sexual HIV transmission.
  
  This is not because UNAIDS, the UN, WHO, CDC and other big players don't know about non-sexual HIV transmission. They have just chosen to ignore it. It's not quite clear why and I'd really like to hear their explanation. However, they simply spew out their guesswork figures, which already presuppose that heterosexual transmission accounts for most HIV transmission in African countries. They assume sexual transmission to be so high that there is not much scope for estimating anything more than a few percent for non-sexual transmission, unless the number of transmissions is higher than 100%, which wouldn't be beyond those clever UNAIDS epidemiologists. They can do anything with figures, it appears, except tell the truth.
  
  Even campaigns about sexual transmission of HIV have been unconvincing, to date. But they are better than the complete silence that non-sexual transmission receives. People just don't realize the number of risks they face in their day to day lives. And people in African countries face more of those risks than those in Western countries. For a start, HIV prevalence is already very high in many Sub-Saharan countries. But medical facilities are often understaffed, underfunded, underequipped and oversubscribed. This is a disasterous combination if you consider how efficient medical transmission of HIV is, compared to sexual transmission.
  
  Whatever happens during the World Cup, there will be little point in investigating what went wrong with the campaigns afterwards. The World Cup itself is irrelevant to the fact that millions of Africans face etremely high risk of contracting HIV every day and this has little or nothing to do with their sexual behaviour. The evidence for that is available now. It's time international health institutions stopped ignoring it.

• Paying Ugandans to Transmit HIV

  Posted: June 2, 2010, 9:44 pm by Simon

  For years, we have been blasted with ‘news’ about how successful Uganda was at controlling its HIV epidemic in the early days of the virus. Even articles about HIV in other countries were almost guaranteed to refer to Uganda’s ‘success’ and this was usually put down to the country’s adoption of ABC (Abstain, Be faithful and use a Condom) programmes. This is despite the fact that ABC campaigns didn’t exist anywhere in the late 1980s and early 1990s, at a time that HIV prevalence rates in Uganda were dropping fast. It wasn’t until many years later that Uganda and other countries were sold this rather spurious set of claims, which went so far as to claim that abstinence alone was responsible for falling HIV prevalence.
  
  But it became rather embarrassing in the early 2000s, when Uganda’s prevalence rates appeared to be flatlining and perhaps even rising. Now that it has become too obvious for even the usual suspects at UNAIDS, CDC, WHO and the journalists who spread their wisdom to continue claiming that all is well in Uganda, people are asking what went wrong and how can the country get back on the right track. The UNAIDS Uganda country co-ordinator, Musa Bungudu, is interviewed and his answers show serious lack of understanding about HIV in general and HIV in Uganda in particular.
  
  He emphasises the ‘behavioural change approach that helped Uganda to reduce HIV prevalence in the past’. Among the many who have echoed the praise for Uganda, there have been a few who have questioned the history of HIV there and especially the reasons given for Uganda’s early success and the country’s subsequent failures to eradicate the virus. In an article entitled ‘How Uganda Reversed Its HIV Epidemic’, a number of authors who worked in Uganda in the 1980s and 1990s (Gary Slutkin, Sam Okware, Warren Naamara, Don Sutherland, Donna Flanagan, Michel Carael, Erik Blas, Paul Delay and Daniel Tarantola) remember things very differently.
  
  The story they give is that a campaign was mounted to inform people about all the modes of transmission and ways to avoid infection. Rather than just being a behaviour change campaign aimed at sexual behaviour, people were informed about medical transmission and other non-sexual modes, research and monitoring were carried out to determine who was at risk and why, etc. And these were, we are told, the usual strategies for an early Aids programme. The epidemic in Uganda was one of the first to peak. Therefore, the country would have benefited a lot more from such a campaign than countries where HIV was peaking later, once the ABC and abstinence only adherents managed to wrest most of the money from genuine health professionals.
  
  In contrast, in Kenya, the epidemic peaked 10 years later, by which time politicians, religious leaders and commercial interests had taken the front seat and all reason and sense was stuck in the boot, where it languishes to this day. Interestingly, a completely coincidental sexually transmitted infection (STI) programme had been rolled out in Nairobi, just before HIV had been identified. During the time this programme was going on, HIV prevalence rose from very low rates (determined through stored blood samples) to prevalence rates of over 80%, only to drop dramatically as the STI programme was phased out. Aside from this remarkable coincidence, Kenya as a whole did as little as possible to reduce the spread of HIV and as much as possible to deny that there was even a serious epidemic in the country.
  
  So, Uganda were successful in the early days of the epidemic and people often ask why, what did they do that other countries could have done and what were they doing that they are not doing now. Well, perhaps it was the adoption of the behavioural paradigm, so beloved by politicians, religious leaders and other bigots, the belief that HIV is mostly transmitted by unsafe heterosexual intercourse in African countries because, as the story goes, Africans have inordinately more sex than everyone else. And even Mr Bungudu, a Ugandan, doesn’t seem to feel the need to question the possibility that this behavioural paradigm is wrong.
  
  He mentions that HIV prevalence was perhaps as high as 20% in the 1980s and that it dropped to about 6% by 2000, which would have been, to a large extent, due to very high death rates in the 1990s. He mentions that prevalence is even increasing but, most importantly, he notes that the rate of new infections is increasing. About half the HIV positive people who need antiretroviral treatment (ART), which means that HIV prevalence, the number of people living with HIV, should be rising. But Uganda continued with the programmes said to reduce HIV transmission, so why are they not working now?
  
  One explanation appears to be that the country did, indeed, start off well, approaching every mode of transmission, not just sexual transmission. But once they embraced ABC, abstinence only and anything else that followed from the behavioural paradigm, transmission by all non-sexual routes started to increase. The country, effectively, abandoned a major part of their earlier campaign. In this pursuit, they were amply supported by their major donors, who didn’t want to hear about anything but sexual transmission and ineffective behaviour change campaigns. In fact, most countries are afraid to run any campaign that doesn’t explicitly mention sexual transmission to the exclusion of all other routes of transmission for fear of losing their funding. They are right to worry about losing their funding. But, as a result, they have lost control of the epidemic.
  
  Bungudu then performs the classic UNAIDS trick of attributing most new HIV infections to low risk sex (entailing the contradiction that a virus that is difficult to transmit sexually is frequently transmitted sexually). Most new infections have been found to be among married people. Worse still, most of those infected are women whose husbands are HIV negative. Does Bungudu want to subscribe to the racist view that, not only do most Africans have a lot of sex, but also that many married women are sleeping with people other than their husbands, perhaps for money? To explain such high rates of sexual HIV transmission among married women whose husbands are HIV positive would require that they sleep with an awful lot of other men. HIV negative people married to HIV positive partners can remain HIV negative for years, even if they have regular unprotected sex.
  
  But yes, Bungudu mentions high levels of unfaithfulness and all the other explanations that UNAIDS cling to, even saying that “a poor woman is likely to go out with a rich man for his money. If he is infected, she may get HIV.” What he doesn’t seem to appreciate is that this would take an awful lot of poor women having an awful lot of sex with a lot of rich people (are there many rich people in Uganda?). But we know that, for a long time, HIV prevalence was higher in richer sectors of the population. And this trend was as true for rich women as for rich men. The problem with everything that Bungudu says is that it all presupposes the truth of the behavioural paradigm. And it all ignores the obvious conclusion, that sexual behaviour does not explain why HIV is so high in some African countries and so low in most other countries.
  
  Continuing the official line, which I suppose he has to do if wants funding to continue, Bungudu reflects on the fact that prevention messages are not getting to remote communities. He completely misses the fact that HIV prevalence in remote areas has always been lower than in urban areas. But once ‘messages’ start reaching these areas, in the form of assumptions about people’s sexual behaviour, HIV transmission tends to rise. This is being experienced in Gulu, now that the area is being ‘developed’. Prevalence has doubled in the last few years despite the fact that roads, hospitals, schools and other social services are being built.
  
  It is a good thing that all these amenities are being built and I’m certainly not arguing otherwise. But if the HIV message continues to be about sexual transmission and excludes non-sexual routes, many more people in Gulu and other areas will continue to be infected. People like Bungudu and others need to open their eyes, to question what is happening and not just to repeat the prejudiced rubbish they have been fed by international health institutions.
  
  The only hopeful thing Bungudu mentions is that Uganda’s HIV efforts are about 90% foreign funded. If the Ugandan government can find a way to provide more of the funding, they may be able to find a way to turn the epidemic around. But only if they also reject the simplistic and highly prejudicial maunderings that make up international HIV policy to date. Otherwise, the fact that most Ugandans are not able to access health services could be the only thing that gives them some protection from HIV. But if Ugandans are not prepared to stand up for other Ugandans in the face of such prejudice, no one else will.

• Why is HIV Policy in Africa Written By Racists?

  Posted: May 30, 2010, 12:31 am by Simon

  Kenya appears to have yet another 'campaign' to reduce HIV transmission. This one purports to target HIV positive people, whom, some 'senior government officials' claim, have been ignored so far. This is an odd claim, considering the largest part of the vast sums of money being spent on HIV for many hears now has gone into treatment for HIV positive people. HIV prevention has received a very small amount of money and much of that has been frittered away on 'behaviour change programmes' widely acknowledged to be useless in Western countries.
  
  Of course, HIV positive people must be part of the equation when trying to reduce HIV transmission. But so must HIV negative people. Concentrating on one group and ignoring the other has been counterproductive. One of the reasons that big funders are questioning the continuation of ever increasing funding for HIV drugs is that this approach hasn't yet had much effect on HIV prevalence. As HIV drugs are rolled out, more and more people continue to become infected. If there was an end in sight, perhaps in the form of significant reductions in transmission in high prevalence countries, funders might be persuaded to hang in for a bit longer.
  
  The article is, in fact, very misleading:
  
  

  "We have focused so much on empowering HIV-negative people to avoid infection. We now need to focus on people who are already infected and empower them to prevent new infections, re-infection, and maintain their own and their partners' good health," said Dr Nicholas Muraguri, head of the National AIDS and Sexually Transmitted Infections Control Programme.

  
  
  I haven't seen much evidence of empowerment of HIV negative people, though I've seen many references to it. Whether the focus of most of the money and attention for the last several years on drugs and treatment has also included any empowerment for HIV positive people is another matter. It probably hasn't because pharmaceutical companies don't make money out of 'empowerment', they make money out of drug sales.
  
  I have searched high and low for the guidelines in question without finding a copy but the article goes on:
  
  

  One of the main aims of the guidelines is to ensure that all HIV-positive Kenyans are aware of their status; government statistics show that 84 percent of HIV-positive people do not know they are infected.

  
  
  I hope this figure is out of date because it is the same as it was back in the 2008 Aids Indicator Survey, the data for which was collected in 2007. Since then, articles have claimed that several million more Kenyans have been tested, one even claiming that about 1.5 million were tested in a six week period near the end of last year.
  
  The more people tested the better, but will any effort ever be made to figure out how people became infected? The assumption is still, despite plenty of evidence to the contrary, that most transmission in Kenya and other high prevalence African countries is due to unsafe sex.
  
  Despite finding medical facilities to be too dangerous for UN employees, UNAIDS claims that medical transmission of HIV in Kenya is around 0.6%. There are children who are HIV positive whose mothers are not and nearly half the married women who are HIV positive are married to men who are HIV negative. Are we supposed to believe that all these women are becoming sexually infected with HIV through some relatively small number of men, to whom they are not married? Well, if you pander to the stereotype of the oversexed African, you may be happy with this explanation. But if you're an economist, no matter how bigoted, you may wonder how a large number women can have anything to gain by having sex with a small number of men to whom they are not married.
  
  Dr Muraguri goes on to say "We want to de-stigmatise the HIV test so that HIV testing becomes a 'kawaida' [usual] thing". What better way could there be to stigmatise HIV than to assume that it is mainly sexually transmitted? Even the possibility that some HIV is transmitted non-sexually is not considered in most of the literature, perhaps from unsafe medical procedures, perhaps from unsafe cosmetic procedures or some other likely candidates. In what way, I wonder, is Dr Muraguri suggesting that this de-stigmatises anything? I see the sexual behavioural paradigm as the very source of HIV related stigma.
  
  The article continues:
  
  

  "At one point, every adult with sexually transmitted HIV was the HIV-negative partner in a discordant relationship," Muraguri said. "Over 44 percent of married HIV infected partners have an HIV-negative partner - if they are aware of their status, they can take steps to protect their partners from infection.

  
  
  Yes, over 44% of married HIV positive people have a HIV-negative partner, and haven't people like the doctor ever wondered why this is? And if they were infected by some route other than sexually, their partners could also be infected non-sexually. Isn't it strange that HIV transmission in concordant relationships is so slow? Doesn't it suggest that sexual transmission of HIV alone may not be enough to explain the very high prevalence of HIV in Kenya and other African countries?
  
  People who are aware of their status can protect their partners or protect themselves, but only if they know what the risks are. People can not protect themselves from medical, cosmetic or other non-sexual transmission by wearing a condom or even by abstaining from sex, especially if they don’t even know about these risks.
  
  Anyone worried about reduced funding for HIV, as many claim to be at the moment, should be wondering why the various campaigns that were mere variations on Abstain, Be faithful and use a Condom (ABC), or even worse, abstinence only, have been so unsuccessful. As well as being intuitively unappealing, perhaps they were just barking up the wrong tree. Africans don't have more sex or more unsafe sex than non-Africans, so why should HIV prevalence be higher in many African countries than in many non-African countries?
  
  In case there is any doubt remaining that the campaign excludes all but sexually transmitted HIV:
  
  

  Prevention with Positives includes encouraging partner disclosure, scaling up prevention of mother-to-child transmission, increased condom use, large-scale male circumcision, and ensuring adherence to antiretroviral (ARV) drugs, which have been shown to significantly reduce the risk of mother-to-child as well as sexual HIV transmission.

  
  
  This is all good advice, especially for sexually transmitted HIV. But for non-sexually transmitted HIV it offers nothing. People must know how they are becoming infected in order to protect themselves. The racist view that Africans are all having unsafe sex at such high rates that non-sexual transmission is almost irrelevant will not help to cut HIV transmission. But this latest Kenyan programme is being funded by some arch racists, it appears. The American President's Emergency Plan for Aids Relief, the Elizabeth Glaser Paediatric AIDS Foundation, and the US Centres for Disease Control are mentioned but apparently there are others.
  
  Yet another stigamatising attitude is expressed by Nelson Otuoma, chairperson of the Network Empowerment of People Living with AIDS in Kenya (NEPHAK). This seems surprising, but he claims that the 18,000 or so members of NEPHAK have a "have a common message - they must not be generous with the virus, giving it away; they want to be mean with it, keeping it to themselves." There may have been rare (but very media friendly) exceptions of people deliberately or carelessly transmitting HIV but most people don't want their friends, partners, family or anyone else to become infected. Do people seriously believe otherwise?
  
  Even nurses and other healthcare workers have been denied the knowledge that many people in Kenya probably became infected with HIV through a non-sexual route. Many people will list non-sexual ways of transmitting the disease, but it is clear that the assumption is that HIV is usually transmitted sexually. There is no reason for healthcare workers to assume that people face other risks because, regardless of how much money has been spent on improving healthcare (and I've seen little evidence of much of that in Kenya), they are bombarded with courses, publicity and literature on sexual transmission.
  
  If I get to see the guidelines I'll link to them here. But I am very disappointed to hear that, yet again, non-sexual transmission of HIV has been ignored and the old stigma has been given more fuel, as if it needed any more. I have spoken to many people (laypeople and professionals) in Kenya, Uganda and Tanzania and most of them are willing to admit that things in health facilities are slack and must be giving rise to a lot of risks, whether for HIV or any other blood-borne diseases.
  
  In addition to being able to access treatment when they are HIV positive, HIV negative Kenyans and other Africans need to be able to ensure that they stay negative. This means being made aware of the risks they face, not just sexual risks but risks they face when receiving medical treatment, cosmetic treatment, traditional medicine and other practices and the like. If they are not made aware of these risks, no matter how embarrassing it is to those in UNAIDS, CDC and other institutions that steadfastly deny that such risks exist, people will continue to become infected.
  
  Unsafe medical practices are known to be common in some African countries, which means that everyone who receives medical treatment is at risk of becoming infected with HIV and other diseases. Continuing to maintain that sexual behavior is responsible for most HIV transmission among Africans, while warning non-Africans about these risks, is not the way to reduce HIV transmission. The belief that Africans have a lot of unsafe sex, and that’s why HIV prevalence is high in some African countries, is a prejudice: it arises despite evidence to the contrary, not because of evidence for the belief. But these two claims are what HIV policy in Africa tends to be based on.

• Face the Problem of Medically Transmitted HIV, Don’t Cover it Up

  Posted: May 27, 2010, 8:02 pm by Simon

  In December of last year, three researchers published a paper in the peer-reviewed journal, the International Journal of STD and Aids (IJSA), concerning HIV infected children with HIV negative mothers in Kenya and Swaziland (entitled 'Horizontally-acquired HIV infection in Kenyan and Swazi children'). The researchers concluded that blood exposures are the most likely routes of transmission in these cases. The researchers also called for greater surveillance and investigation of such phenomena and public education about the risks people face, along with steps they can take to reduce these risks.
  
  The Swazi Observer, the Swazi Times and the English Telegraph all covered the research in question, with the two Swazi papers appearing to refer to the Telegraph article, rather than the original research article. [It should be noted that the Telegraph's figure of 5 million new cases of HIV being created annually by healthcare practices is an error as it's higher than the total number of new infections, which was about 2.5 million in 2007.] These newspaper articles were alarmist and tended to go way beyond anything written in the IJSA article. But they were probably no more or less irresponsible than normal newspaper coverage of medical and other issues.
  
  A member of the public working for or studying with the London School of Hygiene and Tropical Medicine (LSHTM) then wrote to the Swazi papers complaining that this kind of sensationalist reporting is a danger to the health of Swazi people. On balance, the newspaper articles were sensationalist and distorted the findings of a careful and professional study.
  
  But this correspondent goes on to criticize the IJSA article itself. These criticisms may need to be dealt with by the authors and by other professionals involved. However, the correspondent’s criticisms are either irrelevant or they relate to limitations that are made quite clear in the paper. It is true that the authors of the paper don’t ‘prove’ that the children were infected by medical procedures; no investigation was done in Swazi health facilities; and the data on routes of transmission were for Kenyan children, not Swazi children. These matters are all made clear in the methodology and throughout the paper.
  
  The correspondent puts great effort into grasping at straws to defend the health services that are not necessarily being attacked by the IJSA article. And in this way, she seems to imply that there is no need to investigate the very possibility that people face risks when they attend medical facilities (and hairdressers, traditional healers, cosmetic service facilities, etc). Even the WHO and the UN would admit that there are serious risks of blood borne transmission of HIV in African medical facilities. They just don’t bother to do anything about it in African countries. They content themselves with endlessly repeating the discredited mantra that HIV is mostly spread through unprotected sex.
  
  The correspondent goes on to clarify her worry: that people needlessly fear going to clinics for medical procedures that may save their lives, including HIV testing, and that these newspaper articles could confirm people’s fears. The IJSA authors come up with questions about the safety of health procedures in African countries, something even the WHO doubts, estimating that up to 50% of injections could be unsafe, and this correspondent thinks the public are worrying needlessly!
  
  Perhaps this correspondent is afraid that people will think they are being lied to. And to assuage their worries, she advocates lying to them. Or, at least, she advocates keeping the truth from them. Is this the LSHTM take on medical ethics? The correspondent goes on to indulge in a bit of sensationalism herself, about newspaper articles killing people and their babies because members of the public are afraid to seek medical treatment. Her attack on the newspapers ends without further reference to a careful piece of research which shows that many questions need to be raised about medical services in Swaziland (and other countries). It is because these incidents have remained uninvestigated that the public need to be made aware. It is because they have remained unaired that people will fear medical facilities: their fears have already been realised.
  
  The date of the newspaper articles is significant, the 2nd of December, the day after the HIV industry gets together to slap each other on the back for the great work they have done and the successes they have had in reducing HIV transmission over the past year. No doubt, it stung those in the industry to get a wake up call the day after International World Aids Day, especially those working in Swaziland, which has one of the highest prevalence figures in the world. But a sensationalist rant about sensationalist reporting should not be used to deflect attention to what may turn out to be one of the biggest drivers of HIV transmission: non-sexual transmission, either through medical procedures, cosmetic procedures or various other modes.
  
  Anyone studying or working in public health should be concerned if there is evidence that lax procedures may be allowing people to become infected with HIV or other blood borne diseases. Anyone truly concerned with the safety of patients and members of the public would advocate that potential medical transmissions be investigated. And they would not let themselves be distracted by entirely separate issues, such as irresponsible newspaper reporting. To date, the many peer-reviewed articles highlighting possible instances of medical HIV transmission in African countries have been ignored. No investigations have been carried out. But those who are most aware of these matters (WHO, UN, CDC) continue to claim that HIV is primarily transmitted though heterosexual intercourse. If people object to what the newspapers are saying or to what the researchers in the IJSA are saying, they should carry out a thorough investigation.
  
  If the LSHTM student or employee is so concerned about newspapers behaving irresponsibly, she could take to task the ones who always tow the official line on HIV, that it is primarily transmitted by heterosexual sex in African countries. As a result of this official view of HIV, people who find they are HIV positive are stigmatized. HIV is so closely related to illicit or unsafe sexual behaviour in people’s minds that they don’t even know that they could be at risk when they visit the dentist, the doctor or the manicurist. And if they don’t know they are at risk, they will not make any effort to protect themselves. It’s all the other newspaper articles that read like UNAIDS press releases that we should object to, not the few questioning the status quo.
  
  If we don’t want the ‘sensationalist’ press to warn the public of the dangers they and their children may face when they visit medical facilities, we need some credible party to let people know. People need and have a right to know in order to protect themselves. But by refusing to investigate any possible instances of medically transmitted HIV, the WHO, the UN and the CDC show that they are not credible parties. It would not be a desirable outcome for people to avoid medical treatment, but nor would it be a desirable outcome for people to continue getting treatment that may be transmitting HIV. This is a dilemma that those working with HIV need to face, not cover up.

• Big HIV Funding and Blatant Racism

  Posted: May 25, 2010, 8:27 pm by Simon

  Many people and organizations in the HIV world, especially those involved in HIV treatment, as opposed to prevention, are worried about the effects of global financial belt tightening on HIV budgets. They are right to worry. A lot of big funders are capping funding or reducing it. And the global financial situation may not be the only reason for this austerity.
  
  For many years, HIV prevention has taken a back seat to HIV treatment. Those in favour of treating as many people as possible and ignoring the fact that more people are becoming infected than going on treatment, assure us that mass roll out of treatment also plays a part in 'health systems strengthening'. This is supposed to make those concerned about a high rate of new infections feel better, as if new infections are being taken care of because those infected for some time are being treated in great numbers.
  
  Indeed, defenders of the status quo that involves treating those who are infected and almost completely ignoring new infections, explicitly argue that HIV treatment also prevents new infections. To an extent that is difficult to quantify, this is true. HIV positive people who are responding to treatment (which means they also need adequate levels of nutrition and general health, etc) tend to have a lower viral load. They are less infectious and, therefore, less likely to infect others.
  
  But this still leaves others vulnerable to infection. If many were not currently vulnerable to infection, the rate of new infections would be negatively correlated with the number of people who are responding to treatment. Those in favour of treatment at the expense of prevention claim to be averting infections, but only by using a circular argument; that the number of new infections must be lower than it would have been if treatment hadn't been rolled out because treatment reduces the incidence of new infections. The fact is, widespread treatment hasn't yet reduced new infections very much.
  
  Well, if these treatment fundamentalists are really concerned about the effect that cuts in funding will have on the lives and health of people in developing countries, there are a number of alternatives they could consider. For a start, they will have to make some effort to reduce new infections at some stage. No person or organization would be wise to keep spending money on outrageously expensive drugs for treatment when the numbers of infections continues to rise, more or less unabated.
  
  So these concerned and worried parties (Michel Kazatchkine, Michel Sidibe and others) can start campaigning for the sole use of generic versions of antireteroviral drugs (ARV), at least in poor countries. At present, expensive, branded versions are used almost universally. There has been a lot of pleading about how much pharmaceutical companies have dropped their prices but these reductions are nothing compared to the savings that use of generics could bring. To argue for more or continued funding for overpriced medicine is stupid and downright deceitful.
  
  With the money saved by switching to generics, some money could be spent on prevention. And I don't mean the ABC (abstain, be faithful, use a condom) rubbish that has been churned out for more than ten years. This 'behaviour change communication' and any prevention programmes based on the idea that Africans have lots more sex than anyone else, has never worked and it never will work. More money has probably gone into publicity to show how successful this disgraceful waste of money has been than into programmes that really do work.
  
  Plenty of research has shown that most of the 'prevention' programmes that have been carried out so far have achieved little, especially as far as reducing HIV transmission is concerned. But there is also research that receives a lot less attention which shows that HIV transmission can be reduced significantly, but also cheaply. Larry Sawers and Eileen Stillwaggon have argued for this in several publications, including in an article entitled 'Understanding the Southern African 'Anomaly'; Poverty, Endemic Disease and HIV'.
  
  In this article, Sawers and Stillwaggon demonstrate that HIV transmission can be influenced by inexpensive measures such as providing people with deworming, sanitation, STI (sexually transmitted infection) treatment, mosquito control and safe water. These, they argue, are all essential in controlling HIV. In addition, these measures all have benefits that go beyond their effects on HIV and will improve the lives and health of tens of millions, perhaps hundreds of millions, of people in developing countries.
  
  There is a lot of good money to be made in the HIV industry, especially where expensive drugs are involved. Attention to these drugs has been far higher than the success of ARV rollout could explain. Yes, many people are alive now who would not be alive without the drugs. But this has been achieved at a cost that is far higher than necessary. And as a result, preventing new infections has been given short shrift, even though this can be effected at relatively low cost. One might almost think that HIV has been seen as an opportunity to sell vast amounts of drugs that have a very small market outside of developing countries.
  
  To make it clear, in case people may think I'm advocating against spending money on drugs for people who are HIV positive: I believe everyone who is in need of HIV drugs should receive them, but I believe they should be purchased at the lowest cost possible. This is not currently the case. Costs are kept artificially high by intellectual property laws (In other words, market protectionism) that favour rich countries and multinationals, by behind the scenes deals, by lobbying and by fancy marketing and publicity. The big HIV funders are being robbed blind, or perhaps they are being robbed and happen to be blind as well. I also believe that HIV positive people should have all their other health needs attended to and that they should have access to an adequate diet without which the drugs and treatment they receive are useless.
  
  Once the cost of treating HIV positive people has been set at a level that poor countries and poor people can afford, there should be a lot more money available for preventing new infections. The approaches mentioned by Sawer and Stillwaggon, above, are all vital. And they are compatible with others, such as identifying instances of HIV being transmitted non-sexually, whether by unsafe medical practices, cosmetic practices, unsafe traditional medical practices or whatever.
  
  As long as the big earners in the HIV industry continue to spend billions on overpriced medicine when cheaper alternatives are available, their wailing about rights and justice are so much hypocrisy. They are long enough in the business now to know what is going on, a lot better than laypeople do. And it must be as clear to them as it is to anyone who bothers to check that HIV prevention has to accompany HIV treatment if the disease is to be eradicated. Equally, these big earners cannot continue to ignore the evidence that they are wrong about sexual behaviour in African countries. Levels of risky sexual behaviour are higher in America and Europe than they are in Africa (and Sawers and Stillwaggon are particularly clear on this point in all their publications). Claiming otherwise is blatant racism.

• UNAIDS: Mythmakers or Liars?

  Posted: May 23, 2010, 7:46 pm by Simon

  We have spent the last few days in Bukoba, talking to people about their memories and perceptions of HIV. Unfortunately, after decades of being told that HIV is primarily spread sexually, most people firmly believe that this is the case. They believe that HIV came from ‘somewhere else’ (Uganda, America, Europe, truck drivers, sex workers, men who have sex with men, etc), a widespread belief. In Bukoba, they believe (mostly) that it came from Uganda and this may be true. Alternatively, HIV may have spread from Tanzania to Uganda at the same time as it was spreading from Uganda to Tanzania. It seems likely that HIV spread in waves at various different times and its impact in a particular place depended on many of the conditions extant in that place at the time.
  
  The problem with ignoring non-sexual transmission of HIV, through unsafe medical practices or through cosmetic or other practices where blood or bodily fluids may be involved, is that people end up not looking out for such risks. Even where they recognise their existence, they don't know how to protect themselves. For instance, people know that hairdressers should sterilize their equipment between clients but their neither the hairdressers nor the clients know what is required for equipment to be properly sterilized.
  
  Contrary to widespread belief, HIV does not die after seconds or minutes of being separated from the host. It can live for hours or even days on instruments that dry out. And it can live for weeks if it remains wet. If a hair trimmer is used on a person with a disease that is transmissible through blood contact, it needs to be boiled. Just cleaning it in water is not enough, nor is wiping it with methylated spirits or bleach. Yet, people are convinced that this is enough. They even admit that they don't know one way or another what is done with the instruments. Manicurists just turn up with a bucket of instruments and do their work before going on to another client. They don't have the equipment necessary to sterilize their tools, nor do their clients seem to be aware that this is very dangerous.
  
  One person we talked to said that she uses a hair relaxant that burns the skin and makes it liable to break. Hair relaxants are popular here, to produce straight hair. So combs and anything else used would need to be carefully sterilized, but the facilities for doing this are often not available. As a hairdresser, she was unaware that it is not just blood that can transmit infection. Pus is even more dangerous. She was under the impression that if people had sores on their head, this was not risky unless there was also blood. Decades of warnings about the risk of HIV infection have concentrated almost exclusively on sexual behaviour and sexual risk. So people are not adequately prepared for non-sexual risks.
  
  Similarly, risks from unsafe medical procedures could be much more of a threat than sexual risks. People's perception of medical risks is that they will be taken care of by health professionals. This may be true in some cases, but not all medical procedures are carried out by health professionals or in ideal conditions. You can get injections, and possibly other services, from people who run 'pharmacies', often just stalls that have a few medicines. Needles may well be changed between patients. One certainly hopes so. But are syringes always changed? Many people say they don't know and they don't feel they are in a position to question doctors and other health professionals. And many injectible products are sold in multi-dose vials. But it has long been known that vials can become contaminated. This can easily lead to HIV and other diseases being transmitted to many people.
  
  People may face threats that they don't even realise are there. And they may face threats that they have never been told how to deal with. There are ways to take precautions against non-sexual transmission of HIV (and other blood borne diseases) but HIV education campaigns concentrate almost exclusively on sexual risk. Although some people can trot out a list of other HIV threats, including shared razors, toothbrushes, cosmetic equipment and medical equipment, these are considered to be relatively unimportant compared to the risk of sexually transmitted HIV.
  
  UNAIDS publishes a list of recent HIV related publications, along with the abstracts and some editorial comments. This list very rarely includes papers that discuss non-sexual HIV transmission, concentrating instead on the many articles that look at sexual risk or what is perceived as sexual risk. So, for example, there's an article about sex work and the 2010 World Cup in South Africa. There are warnings about the risk of becoming infected with HIV and other sexually transmitted infections, but none about the risk people may face if they have to go to a medical facility for treatment or if they visit a tattoo parlour or if they get their hair cut. And South Africa is a country with very high HIV prevalence.
  
  Another article that UNAIDS highlights is about sexual behaviour trends in France from 1970 to 2006. Sexual behaviour became more 'risky', especially for women, during the period. The same trends in a high HIV prevalence country would have been blamed for high levels of HIV transmission. But because this is a low HIV prevalence country and European, no such pronouncements are made. Non-penetrative sex also appeared to become more often practiced, which, of course, is less of a risk when it comes to HIV or sexually transmitted infection risk. But in some African countries, sexual risk behaviours are low but HIV prevalence is high.
  
  When the survey takes place in a country like France, people's responses tend to be believed. Similar surveys in African countries can elicit similar results, but the responses tend not to be believed if they don't correspond with the data collected on HIV. When, as is often the case, people in African countries say they have not had sex, they have not had risky sex or that they took precautions against risk, and they turn out to be HIV positive, it is assumed that they are lying, mistaken or forgetful. Yet, many of them are likely to be telling the truth but they were infected by some non-sexual route, medical, cosmetic or the like.
  
  Similarly, women have often been infected with HIV while they are pregnant. They are tested early on in their pregnancy and initially found to be negative. But they are subsequently found to be positive when they are retested later. The earliest period of HIV infection is the most virulent. If a woman becomes infected while she is pregnant, the chances of HIV being transmitted to the infant is far higher than if she seroconverted some time before becoming pregnant. The conclusion of this paper is that couple counselling may reduce unprotected sex during pregnancy. But have the authors considered the possibility that some of the women were infected non-sexually? Did they even test the husbands to see if they were also HIV positive? Of course, if the husbands were HIV negative, the belief that HIV is usually transmitted sexually leads to the conclusion that the woman must have had sex with someone other than her husband. This is one of the reasons HIV has become so stigmatized. Husbands often accept the received view about HIV being mainly sexually transmitted. They believe the ‘experts’, not their wives.
  
  There are many hints that a good deal of HIV is not sexually transmitted in African countries. So it's surprising that UNAIDS, WHO and others still hold on to the view that non-sexual transmission accounts for a very small proportion of all incidence. In most African countries, various prevention programmes have been run, some for many years. But these programmes are almost all aimed at influencing sexual behaviour. Very few are aimed at medical transmission and even fewer at cosmetic transmission. And these programmes have been quite unsuccessful. A number of papers have asked questions about which prevention interventions work and, on finding that none of them make much difference to HIV transmission, they keep looking for new ways of preventing sexual transmission. They don't seem to consider the possibility that at least some transmission is not sexual, though they admit that conditions in medical facilities are too dangerous to allow UN employees to risk using them! These papers are right to conclude that gender, poverty and alcohol consumption are important when it comes to sexual transmission of HIV but they are probably not so relevant when it comes to non-sexual transmission. Or, at least, they would be relevant for quite different reasons.
  
  Similarly, a lot of research has shown that behavioural differences don't explain variations in HIV prevalence among young people in African countries. High levels of sexual risk behaviour can be found in places with low HIV prevalence and low levels of sexual risk behaviour can be found in places with high HIV prevalence.
  
  How much evidence does it take for the 'experts' at UNAIDS to conclude that their long held view is wrong, that most HIV is not transmitted by heterosexual sex? How much evidence do they need to find it worth their effort to investigate places where many young children are found to be HIV positive when their mothers are not? If UNAIDS recognises the dangers of allowing its own employees to use medical facilities in African countries, when will they admit that Africans living in those countries also face risks?
  
  
  It’s very disturbing to hear people saying that they think HIV was created in a laboratory in America and spread deliberately, for whatever reason this might have been done. But it’s hard to shake people’s beliefs in conspiracies when they are constantly being told things that don’t make sense. Many people here know that Africans are not so different from people in other countries that their sexual habits could be almost wholly responsible for the very high rates of HIV transmission you see in some countries. But those who feel they know most about the disease assure them that this is, indeed, the case.
  
  Those who feel they are HIV experts continue to assert the racist view that some Africans have so much more risky sex than people in other countries, it’s no wonder that HIV prevalence is very high in some places. Africans are being lied to, just not in the ways they think. The people who are tasked with eradicating HIV know that the risk of non-sexual transmission of HIV is so high that they need to protect their own employees. They just don’t tell Africans that. As a result, Africans continue to take risks that they could and should avoid. When people know about the risks they face and they know how to take steps to avoid them, HIV transmission rates will go down. But as long as the sexual behaviour paradigm clouds all HIV prevention activities, several more people will be infected with HIV for every one who receives treatment.

• We in the UN Have Been Lying About HIV and Now...

  Posted: May 20, 2010, 4:50 pm by Simon

  Myself and a friend are taking a trip around Lake Victoria to visit some of the places where HIV prevalence is exceptionally high. Countries around the lake, Kenya, Tanzania and Uganda, all have similar HIV prevalence of between 6 and 8%. But in many places on or close to the lake shores, prevalence is (or was) often well over 20%. Bukoba in Tanzania, Suba and Homa Bay in Kenya are examples, as is Rakai in Uganda.
  
  Our first stop was in Shirati, Tanzania, where there is a Mennonite run hospital. We were made very welcome there and visited several people who have worked for a long time with HIV and health in general. Most people were happy to talk about their experiences and concerns and we were introduced to people who work in various positions in areas around Shirati.
  
  However, even people who work closely with HIV, as well as lay people, seem to regard HIV as being mainly sexually transmitted. This is not surprising because most public education campaigns and most money are concentrated on sexual transmission. People have been listening, to a greater or lesser extent, to all sorts of advice about using condoms, having fewer partners, testing for HIV and other sexually transmitted infections and various other measures thought to reduce transmission of HIV.
  
  But these HIV prevention interventions have had very limited success, despite exaggerated claims by some of the people behind the emphasis on sexual transmission. Perhaps, as a lot of data shows, people in these three countries already take precautions to avoid HIV, but without success. Research has shown that sexual behaviour in African countries differs greatly from place to place, just as it does in non-African countries. In fact, there is no evidence that sexual behaviour thought to be unsafe is that much higher in African countries where HIV prevalence is high. On the contrary, often, areas that have high HIV prevalence also have low levels of unsafe sexual behaviour.
  
  So, if levels of sexual behaviour do not explain differences in prevalence within and between various African countries and non-African countries, it is possible that HIV is also being transmitted in various non-sexual ways. Two prominent examples of this are transmission through unsafe medical procedures and through cosmetic procedures. In the former group, there could be reuse of disposable equipment or failure to sterilize equipment. In the latter, again, use of equipment that is not properly sterilized.
  
  People we talked to showed high levels of awareness of possible exposure to HIV through sexual behaviour and this is corroborated by various research that has taken place over many years. For a long time, people have been able to list all sorts of things about sexual transmission of HIV but this has had little or no effect on HIV prevalence rates in those countries. But few mention non-sexual transmission and even when they do, they don't appear to know of ways to avoid non-sexual transmission.
  
  Some of the people we talked to confirmed that they and their children had their hair cut by a machine that breaks the skin, especially where there are sores or new scars. But they were unaware that it is necessary to sterilize the equipment properly to avoid transmitting infection to the next person who uses the same equipment. They said that hairdressers sterilize equipment using methylated spirits or water. But they didn't know that this is not enough to ensure that all possible infection has been eliminated. They also thought that HIV infection only lives on instruments for a very short period, which is a common belief, though wrong. [There are abstracts to a couple of articles on this subject on PubMed.com, here and here.]
  
  There is remarkably little interest in non-sexual transmission of HIV among the mainstream, UNAIDS, WHO, CDC, UN and others. There seems to be a reluctance to take on board the considerable amounts of research that suggests that a significant amount of HIV transmission occurs through non-sexual means, whether in cosmetic or medical contexts. This is surprising because non-sexual transmission has been recognised by these bodies since the mid 1980s, when HIV had only recently been identified as the virus that causes Aids.
  
  For example, regarding medical conditions in developing countries, the UN has this advice for its employees:
  
  "Use of improperly sterilized syringes and other medical equipment in health-care settings can also result in HIV transmission. We in the UN system are unlikely to become infected this way since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment. Extra precautions should be taken, however, when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere. It is always a good idea to avoid direct exposure to another person’s blood — to avoid not only HIV but also hepatitis and other bloodborne infections."
  
  This suggests that the UN is perfectly well aware that unsafe medical practices are widespread enough to be a threat to their employees. But they and other institutions don't seem to extend the same advice to people who live in those countries and would be likely to visit available facilities more frequently. Maybe the UN is even in conflict with UNAIDS in some instances because the latter claim that medical transmission of HIV in Kenya is around 0.6% of all transmission, meaning that they think health facilities in Kenya are very safe.
  
  The UN goes on to say:
  
  "In several regions, unsafe blood collection and transfusion practices and the use of contaminated syringes account for a notable share of new infections. Because we are UN employees, we and our families are able to receive medical services in safe healthcare settings, where only sterile syringes and medical equipment are used, eliminating any risk to you of HIV transmission as a result of health care."
  
  Am I being oversensitive here in detecting a total disregard for the health and safety of people who happen to live in 'several regions', while paying a lot of attention to people who generally don't have to avail of the services that the general populace have to put up with? Perhaps the UN would like to reveal what this 'notable share of new infections' is and inform UNAIDS, WHO, CDC and others. In particular, perhaps they would like to inform people who live in any of the countries they are worried about. After all, 'we' are not all privileged with being UN employees.
  
  The UN certainly knows how to avoid medical transmission when it comes to its own employees:
  
  "None of us should ever share with another person a needle, syringe or equipment used for injection. If we receive medical care from the UN system medical services or from a UN-affiliated health-care provider, we can be confident that every effort has been made to ensure that injecting devices used to administer a shot are sterile and will not expose us to HIV. If we need to give ourselves a shot outside a UN health-care setting, we should only use disposable needles and syringes and we should use them only once. Because safe injection practices are not followed in all healthcare settings and it may not always be possible to purchase sterile injection devices, the WHO medical kit that is made available to all UN agencies includes disposable syringes and needles."
  
  This means that we have all the information and know-how necessary to reduce non-sexual HIV transmission. Now that we know all this, it's time we went out to tell all the people the truth. We have been telling them lies for a long time now. We have spent years telling people that HIV transmission in Africa is mainly sexual and arguing that this is because Africans have so much more unsafe sex than non-Africans. We can no longer shore up this argument, nor should we. We have the means to cut HIV transmission significantly straight away, we don't need to wait for expensive vaccines or other programmes that will take years to be effective, if they ever are effective. We just need to admit that we have been lying and make amends before more people become infected and die.

• Technology is the Preserve of the Rich

  Posted: May 15, 2010, 10:40 pm by Simon

  Every time I see an article talking up technology in Kenya and in Africa in general, I wonder which aspect of people's lives will be transformed. Over the last few weeks myself and my colleagues from Ribbon of Hope Self Help Group have been visiting families who never complain about having little access to technology. They have very little money and little access to loans. They are often surrounded by mud roads, living a long way from the sealed roads, which are often in bad repair. There is little or no affordable public transport.
  
  Their children sometimes have very little food, no access to clean water or improved sanitation, decent clothing, books and other basic things that they need just to be able to attend school. If children become sick, their parents have to decide between taking them out of school and treating them or leaving them in school and hoping for the best. Hospitals are a long way off, they are expensive and they are poorly equipped and staffed.
  
  Distance education would be great for children who had basic education. But only about three quarters of children even enroll for primary school, let alone finish. And just over 40% enroll for secondary school. Even at university or tertiary level, something few ever reach (despite some great official figures), elearning cannot replace teachers, books and indeed, access. Those who have got to university are already a small percentage of Kenyans who have not been denied any of the many things that poorer children will always be denied.
  
  One of these idiotic sites that produces lots of puff about technology says "Kenyan Universities are increasingly turning to e-learning as tool to facilitate improved education". Will this improve education? It may be a new medium for some educational content but I'd like to see research that shows that education is in any way better for being delivered by electronic means. Computers are also in short supply and skills can be non-existent, especially among those who rarely have access to a computer.
  
  Young children, especially in rural areas, where about 80% of Kenyans live, often don't have electricity or a private place to study, or even their own personal copy of the necessary text books. Some, especially girls, have to do chores around the house and farm when they should be studying. And many have to do work in the fields and in other jobs when the need arises. These are not technology related problems.
  
  Technologies, I suspect, work when other infrastructures are in place. A farmer can, as these fatuous articles often claim, find out the market price of a commodity by mobile phone. But if there is no road, or if the road is impassible, or transport unaffordable, what's the point? Another claim is that medical stocks and medicines can be monitored electronically. The biggest problem in a lot of hospitals is the shortage or staff and medicines. Who is going to do the stocktaking and what stock are they going to monitor if there is not an adequate supply of drugs?
  
  If the problems that most people experience can be relieved by various technologies, great. If everyone has access to these technologies and things in Kenya can change radically, wonderful. But if all these articles want to show is that some people use and like and even profit from technology, they are pointless articles, only useful to people who are already convinced that technology will pull everyone out of every problem them currently face. Technology will not solve problems of inequalities between rich and poor, between males and females, between rural and urban dwellers. Technology seems, at present, to be the preserve of the rich. And if their past behaviour is anything to go by, it will stay that way.

• Some Adverse Circumstances, Some Healthy Projects

  Posted: May 14, 2010, 11:08 pm by Simon

  The weather in the Kenyan Rift Valley has not changed much in several months. The rainy season that was expected to end earlier in the year has not let up yet. Many people waited for the rain to ease before planting crops, trying to avoid losing them to flooding. Others took a chance and some crops are growing, some are not. But some crops will eventually need hot dry weather to ripen and dry out for harvesting. And until it dries out enough, we will not be able to finish preparing another field which has had nothing growing in it for over a month.
  
  A lot of areas around the country have had severe flooding recently. There have been 70 or 80 deaths (there is a lot of disagreement about exact numbers) since the beginning of the year and many tens of thousands of people have been displaced. In Mogotio also, over 60 families were displaced in the December/January floods. They have since been living in UNHCR tents, partly because the areas they were in are still prone to flooding and partly because they were squatters and are not allowed to return to where they were. There is a lot of land in the area, unused and underused. But it is 'owned' by a Greek sisal farmer and a handful of other rich people. They are not known for handing over even very small amounts of land. Some of them don't even bother paying their employees most of the time.
  
  We at Ribbon of Hope Self Help Group have had mixed luck during the prolonged rains. We planted an acre of maize and beans. The maize is doing fine, the beans not so good. We plan to harvest some of the beans while they are still green and use them straight away. It's unlikely that they will dry out enough to be harvested, dried and stored, so we have to cut our losses. The maize should be fine, especially if the rain stops, as expected, some time in June. But if the weather continues warm and wet, we could lose everything yet again. Other crops that we planted on smaller patches of ground may be threatened as well.
  
  When it's too dry, at least we can irrigate. But when it's too wet, there's not much we can do. Instead of working on the crops in the last few days, we went to some more villages to assess orphans for the orphan and vulnerable children (OVC) programme that we are starting. But even then we were thwarted by the rain. We had walked quite a long way from the main road through Mogotio to an area called Sarambei when the rain started. We just had to sit for a couple of hours because the dirt tracks had turned to rivers of muddy water. Luckily, we were with some very hospitable people when the rain started, who plied us with tea until it cleared a bit.
  
  All of the children we have seen, without exception, are in bad need of support. Almost all of their guardians seem to be able and willing to care for the children. But when a child is with someone who seems unsuitable, this creates quite a dilemma. When a guardian has a drink problem and seems totally oblivious to a young child's needs, that child is a lot more vulnerable than the ones who are with good carers, no matter how poor their carers are. We have almost reached our target of 20 or 21 children and we'll then have to decide how to approach each family. They will certainly all require different approaches, being dissimilar in many ways.
  
  But some of our projects have been doing especially well. A small group of people started a rabbit breeding project with three rabbits less than two months ago. They now have 15 as two have given birth. In a few months, they should have a fine project and it will probably be split up so that each group member has their own small project. It's expensive to start off with, rabbits need good housing and other things, but it's not so expensive once it gets going. My only worry is that I have still not met a Kenyan who has eaten rabbit or who intends eating one. Apparently there is a market for rabbits but I've heard about markets before that just dried up as soon as you start trying to sell something. Perhaps I'm just too skeptical. Perhaps they will eat the rabbits if they can't sell them, they could do with the protein.
  
  The same group also started a chicken project that was very slow to get going. I've mentioned the group before because they had a leader who seemed hell bent on making sure they never got anywhere. They got rid of him and since, the chicken project has picked up and most people in the group now have enough chickens to eat some eggs and sell the surplus. In fact, even the uncooperative former leader himself has a good flock of hens, thanks to the project. Bad weather conditions and disruptive people cause the most problems with the various projects we are involved in. But despite everything, some of the projects still produce good results, thankfully. Others will probably just take time. Many things take longer than expected here.

• The Rising Tide that Floats all Goats

  Posted: May 13, 2010, 1:28 am by Simon

  On a big wide plain, surrounded by hills, lived the finest herd of goats ever seen. The greatest of them were immensely hairy and roamed around, eating too much and proclaiming themselves to be the hairiest in creation. They kept the best pastures for themselves and spent a lot of time at the top of the hills, from where they could survey their minions. Anything they didn’t want would roll down the hills and on to the plain, and they considered this to be a very good thing.
  
  Their minions were not so hairy and lived all their lives tethered to posts. All day, every day, they grazed the little that grew in the small disk around their posts. And many had to share their disk of grass with others because the posts were so close together. Sometimes, the free goats would even come and steal grass from the tethered goats, although they had plenty of their own and were free to graze anywhere.
  
  The free goats would often discuss the conditions that the tethered goats had to live in. They would ask if the tethered goats shouldn’t have longer ropes, or even shorter ropes. They would ask if the rope should be made of different materials, perhaps cheaper ones. Once, they even tethered some of the goats with bungees, which meant that they would struggle to a little green grass only to be pulled back just as they started to eat it. This caused the tethered goats a lot of suffering but the free goats found it amusing, especially when the tethered goats hit their posts.
  
  Every now and again, a free goat would have the temerity to suggest that all goats should be free, that none should be tethered and that the plains are subject to floods and eventually everyone will suffer, tethered or free. On such occasions, the biggest and hairiest free goat would be summoned, because he was considered to be the wisest. At least, he had the most impressive set of dried dingleberries that rattled as he walked around, a quality much prized among free goats.
  
  This hairy goat would remonstrate with the outspoken goat and point out that great wisdom does not lie in giving the best answers to questions, or even in asking the best questions. Great wisdom lies in recognising who is the wisest and doing exactly as they do. If the wisest has long shaggy hair and a profusion of dingleberries, this is what one must emulate. As for flooding, he pronounced, the rising tide will float all goats.
  
  And he was right, the tide rose and the goats all floated, for a while. The tethered goats were quickly submerged and the free ones ran for the hills. The water kept rising and food supplies dwindled, but the few free goats that were left ate more than ever. The one with the great dingleberries drowned because wet dingleberries don’t float. And the remaining free goats continue to live in isolated groups at the very tops of the highest hills, wondering what to do now that their hairy leader has gone.
  
  Dingleberries are a lot less fashionable now, and even hairiness is no longer much sought after. But the ability to balance on all four feet on a very small patch of ground is considered to be a sign of great wisdom among free goats.

• Health Minister Takes Aim at Own Foot

  Posted: May 12, 2010, 1:23 am by Simon

  In addition to proposing a draconian law to make certain sex related crimes capital offences, the Ugandan government is also considering a law to criminalize ‘deliberate’ transmission of HIV. The ‘State Minister for Health in charge of General Duties’ (is that the same as ‘Minister of Health’?), Richard Nduhura says he is now behind the law, having previously had some reservations. President Museveni also supports the law, which never bodes well.
  
  Naturally, human rights activists and people who have some feelings of humanity are opposed to these laws. Some of them have spent three decades trying to reduce stigma against HIV positive people, whereas laws like these will increase it. People will think twice before having a HIV test, or even going to hospital, if they think they may be HIV positive. Uganda needs more people to test for HIV, not fewer. With these laws, anyone who is at risk of being HIV positive, or even anyone who may be suspected of being at risk, also risks discrimination by neighbours, police and other professionals.
  
  This is particularly serious in a country like Uganda because UNAIDS maintains the contested claim that most HIV is transmitted by heterosexual sex. That means that all pregnant women, their partners and those suspected of having had sex in the past could be HIV positive. After all, the majority of new infections are occurring inside marriages and steady relationships. Therefore, these are the people, along with men who have sex with men, intravenous drug users and commercial sex workers (or anyone believed to belong to these groups) who are most likely to become infected and to be spreading HIV.
  
  But there is a rather more troubling aspect to making ‘deliberate’ transmission an offence. The law is clearly aimed at people who are already discriminated against, along with a lot of other people who will soon be discriminated against. But will it also apply to providers working in medical facilities and those working places where people receive cosmetic treatment? It has long been established that medical and cosmetic transmission of HIV is far more common than the mainstream HIV industry people will admit. But if it ever gets out that people working in these sectors are ‘deliberately’ transmitting HIV, they too will become victims of the law.
  What about the esteemed State Minister for Health in charge of General Duties, himself? Healthcare personnel, I am sure, are not ‘deliberately’ infecting people. But what about the ones who reuse a needle or a syringe or fail to sterilize equipment properly? They would be well aware that this carries a big risk of transmitting HIV and other diseases. Perhaps there is a shortage of equipment, perhaps people haven’t received adequate training or perhaps someone is making money on the side by selling reused medical equipment or stealing it and selling it on the black market (I’m not necessarily talking about frontline healthcare personnel, by the way). Isn’t the State Minister for Health in charge of General Duties responsible for the conditions of medical facilities currently extant in Uganda?
  
  Ok, the word ‘deliberately’ is in inverted commas for a reason. How can you tell that transmission is deliberate? I think the answer is simple enough: in many cases, you can’t. Some people may transmit HIV because they didn’t take adequate precautions, others may just be unlucky. Others still may not know they are HIV positive. But this applies to non-sexual transmission as much as it applies to sexual transmission. Healthcare personnel and people providing cosmetic services may not know that the last person on which a piece of equipment was used was HIV positive, before going on to use it on someone else without ensuring that it is properly sterilized.
  
  Will people who use razors and other sharp instruments for hairdressing or other cosmetic treatments be liable for ‘deliberate’ transmission of HIV, if they and their clients happen to be so unlucky? Right now, the word on the street about HIV is that medical transmission is so low as to be almost irrelevant and cosmetic transmission is pretty much irrelevant. But once the hunt is on for people to blame, there will surely be questions about the most efficient means of transmitting HIV, that is, through blood contact.
  
  The aim of HIV prevention policies should be to identify the people who are at risk and to deal with the sources of risk. The aim should not be to group people according to how likely they are to transmit HIV or to be infected with HIV and then to create a law which will end up discriminating against them. But by threatening to punish all ‘deliberate’ transmission of HIV, this law could also punish those who are not currently thought of as transmitting the disease at all, health professionals and those in other service sectors where blood transmission may occur.
  
  In a country where most health spending comes out of the pockets of poor Ugandans and from donors, and very little comes from the government, things are not as neat and tidy as this proposed law may assume. If the aim is to identify all the ways in which people are becoming infected and prevent further infections and also to treat those who are already infected, the health minister and his colleagues are going the wrong way about it. They have, rather predictably, failed to control people’s behaviour as a means of reducing transmission of HIV. They will also fail to reduce transmission by threatening people in ways that result in them being very unlikely to get tested or to declare their status if they are HIV positive. The last thing Uganda needs now is more failure.

• Good News for UNAIDS: We Know How to Turn Off the Tap

  Posted: May 12, 2010, 3:01 am by Simon

  An article in the New York Times suggests that the "war on global Aids" is falling apart. Although drug prices have fallen dramatically and the number of people on antiretroviral drugs has risen, this effort to give HIV drugs to everyone that needs them has proved to be unsustainable. In countries like Kenya and Uganda, most of the funding was provided by donors who are now reducing funding, partly, they say, because of the global financial crisis.
  
  But the article suggests that the financial crisis is not the only reason. Big donors are disillusioned at their lack of success, despite spending huge amounts of money on the problem. "For every 100 people put on treatment, 250 are newly infected"; prevention programmes have either been too expensive or almost completely ineffective or both. Donors are now going to turn their attention to cheaper diseases.
  
  Using an often used metaphor, Dr David Kihumuro Apuuli, DG of the Uganda Aids Commission says that "You cannot mop the floor when the tap is still running on it". The executive director of the Global Fund to Fight Aids, TB and Malaria is "frustrated", a researcher from the National Institute of Health is "pessimistic", Obama's Aids Ambassador is "worried", the executive director of UNAIDS is "scared" and the former executive director "has seen optimism soar and then fade".
  
  Well, David, Michel K, Anthony, Eric, Michel S, and Peter, there is a way to reduce the flow from the tap, even if we don't know how to turn it off completely. This may eventually reduce the flow to a trickle and the number of new HIV cases every year could become so small that there is no longer an epidemic. Yes, a new direction is required, but this new direction has already been researched carefully and described by a number of experienced researchers.
  
  Here's what we need to do: we need to re-evaluate the considerable evidence that unsafe medical practices are contributing a lot more to HIV transmission than is currently estimated by UNAIDS. We also need to include in this re-evaluation unsafe cosmetic practices, especially those that, either accidentally or on purpose, draw blood and thereby contaminate instruments.
  
  Aids spending has concentrated overwhelmingly on treatment for much of the last three decades. And much of the money spent on preventing new infections went on mother to child transmission and some rather hopeless exhortations to abstain from sex, reduce numbers of partners and use condoms. Safe sex and increasing condom use are very important for reducing sexually transmitted HIV but they are completely useless when it comes to non-sexually transmitted HIV.
  
  To continue the rather tired metaphor, UNAIDS and many other concerned parties have been turning the tap the wrong way, because anyone infected non-sexually can go on to infect others through sexual contact. Those who are now disillusioned because the number of people becoming newly infected every year still exceeds the number receiving treatment may be inspired when they see this trend slowing down. They may be persuaded to continue paying for more treatment if they think that the numbers of new infections will go down every year from now on.
  
  It has been obvious for a long time that the small number of countries in the world where the vast majority of HIV positive people live are not inhabited by people who have unbelievable numbers of sexual experiences with incalculable numbers of sexual partners. Indeed, only a very dedicated adherent to some long discredited and rather racist views of African people could even countenance such an explanation.
  
  So, HIV prevention is not so intractable as some would have us believe. Yes, it's hard to influence sexual behaviour to any great extent. But if less HIV transmission can be put down to sexual transmission then a lot of money currently being spent on the programmes that are not working can be saved for something worthwhile. And money spent on health services now will result in immediate savings. Ensuring safer medical and cosmetic practices will prevent both direct infections and the indirect infections caused by those infected directly, either sexually or non-sexually.
  
  I call on UNAIDS and all those working in the field to take the official advice, to 'Know your epidemic (or pandemic), know your response'. To understand why HIV has been spreading the way it has in high prevalence countries, we need to look at the most efficient ways of spreading the disease: blood contact. A combination of unsafe medical practices and unsafe cosmetic practices is continuing to spread HIV simply because the official view is that HIV is predominantly spread by unsafe heterosexual sex in high prevalence countries and that blood exposures are so rare as to be insignificant. You know your response has failed, therefore, how well do you know your epidemic?

• More Assessments and a Visit to a Clinic

  Posted: May 11, 2010, 2:06 am by Simon

  My trip today with Ribbon of Hope Self Help Group took us to Lomolo, about 40 minutes cycle from Mogotio and the main road. The conditions were not too bad, despite heavy rains recently. We visited three families, one of which has two orphans. As with the other villages, everyone seemed equally deserving and, no doubt, there are many other deserving families and orphans in all the places we visited.
  
  There was a woman with twelve of her own children (two of whom are grown up) to take care of, yet she is also taking care of a teenage orphan who is doing very well at school. I really don't know how she makes her meagre income go so far! There was also a woman with no children of her own who is taking care of two orphans (who are not siblings). One of them is HIV positive, the other may be, but has not been tested. And there is a young mother who is so sick herself that she is finding it difficult to look after her one daughter.
  
  Once we have done the assessments we can get a better idea of how we can help, especially in ways that will support the whole family. We need to find income generation activities that will give the family extra money and some of that money needs to be forthcoming very soon. Everyone we have spoken to has arrears of some kind, along with bills that soon have to be paid. People do a combination of borrowing and begging sometimes, but most very poor people don't have easy access to microfinance.
  
  On the way to the village, we passed a man who had to make the difficult and expensive trip to Mogotio to see the area chief. Apparently, the microcredit organisation he went to insisted on him getting a letter from the chief. In addition to the time and money (including lost earnings), the chief will require some money, too. Asking someone in a position of authority just to do their job doesn't come cheap.
  
  After the assessments, we went to see a client who is in a local clinic. He's very sick, either not responding to his antiretroviral (ARV) drugs or just not taking them. Neighbours say he was drinking a lot, which often results in people not adhering well to their drug regime, for whatever reason. The drugs are hard to hold down when you don't have enough food but also, probably, when you have a hangover.
  
  Anyhow, we didn't get to the bottom of it because he had such a bad bout of meningitis that he looks like he is recovering from a stroke. He is finding it hard to talk and is difficult to understand. My colleague says he probably has other impairments in addition to his speech. He is emaciated and weak, which is not surprising. We can only hope that his current condition improves and he gets back to his ARV regime. But it's not a foregone conclusion.
  
  On the subject of medical facilities, there was an article in the paper recently about an assistant health minister who visited a hospital in Bungoma, unannounced. I don't see the point in letting a hospital know you are coming as many things can be done to make conditions look better than they are. Anyhow, the man got many shocks. He saw how long people had to wait, some even dying as they waited, the arrogance with which people are treated, the conditions in the hospital and the tendency of people working there to try to cover up things. There were even the bodies of some children that had been left on a bed and he was told they were sleeping.
  
  The man must have a fair idea of what things are like in public hospitals. If he doesn't, he should look for another job. Hospitals are underfunded, understaffed and cannot deal with the number of patients they get. The staff are often not very well trained, they don't get paid too well and they are underequipped. Drugs and other things are in scarce supply and buildings are old and crumbling. These are the conditions in which, UNAIDS claims, only 0.6% of HIV transmission comes from unsafe medical practices. Just how much evidence do they need that this claim should be reconsidered?

• Education in a Box, Or Not

  Posted: May 10, 2010, 2:31 am by Simon

  I recently mentioned the One Laptop Per Child project (OLPC), which aims to provide every child in developing countries with a low spec laptop. These laptops will cost between $190 and $200, which is a lot of money when you consider that government health spending per capita is a lot less than this (though figures vary a lot). I don't seriously believe that a project like this will have much benefit if teachers are left out of the picture. But according to a more recent article "Basic computers skills to enable children use the computers can be learnt in a day".
  
  Having spent some time trying to help people who had never used computers before learn basic things, I would question any claim that you can teach teachers how to teach with these computers in a day. Perhaps it's just a reflection on my teaching skills, but I think people need a long time to get used to complex equipment and to go on to teach others.
  
  But I especially wonder how these computers will "help to get children to learn how to think critically and analytically to become problem solvers." I agree wholeheartedly that children need to learn these things, so do most adults. But how till the introduction of the computers achieve this? Yet again, teachers will need time to learn how to impart critical thinking and analytical skills and to include them in the current curriculum. Laptops are neither necessary nor sufficient for this, they seem quite irrelevant, in fact.
  
  I guess I'm repeating myself but if this project "aims to change the way children are taught" it will need to change the way teachers teach. This is not going to happen over night. Sure, some children will take on laptops quickly and perhaps put them to good use, but many children here lack the most basic skills, such as reading and writing. And they lack them because of other basic needs not being catered for. They don't learn to write properly because they don't have proper desks or three people are sharing a desk made for two. And they don't get much reading practice because they have no books or because there is no electricity at home. Many children don't attend school very often, for various reasons, many have far too many other things to do and neglect their study.
  
  It is quite true that current classroom practice involves getting children to memorize a lot of things, but have people become more critical in their thinking since the advent of cheap laptops and computers? I don't believe so. And is the alternative to memorizing things just bearing in mind that everything they need to know is somewhere there in the laptop? If it is, then it is in danger of staying in the laptop. I think we are being conned into thinking that education in East Africa is suddenly going to improve because children are given cheap laptops.
  
  Also, apparently the laptops are designed for 6-12 year olds. This is something I hadn't realized before. What people over the age of 12 are going to do is anyone's guess. Perhaps they are expected to still have the skills they acquire when they have access to a computer many years later. I sound like a Luddite, which I'm certainly not. But it's just one more piece of technology being thrown at a problem that is not technological. Children need good basic education, they need good basic materials and they need well trained teachers. If the OLPC project proposes providing these, great. Otherwise it will have little benefit.

• Development and Sustainability

  Posted: May 8, 2010, 1:57 am by Simon

  Back in Mogotio today with Ribbon of Hope Self Help Group. We have to go to five villages and identify four especially needy orphans so that we can support their adoptive families to care for them. Not that it's a difficult job to identify four, we ended up with five today and pleas for several others. Yesterday, also, we had several pleas from mothers who heard there were people assessing orphans in the area. It doesn't take long for the word to get around but it's hard to have to tell people that we only have the funding for a very limited number right now.
  
  Today we went to Alfega (a corruption of Alpha and Omega, reflecting the Greek 'ownership' of most of the land in the area), which is about one hour of difficult cycling from Mogotio. I was given one of the very heavy but resilient Indian 'Avon' bikes and told the brakes were not too good. I would have been surprised if I had been told they were good and I've never cycled on a bike that had two brakes here. But by the time I was on a steep hill trying to check my speed, the one brake had failed. I made various attempts to slow down before preparing myself for a crash landing, which I found in a bank of clay that happened to be at just the right angle to stop me without resurfacing my face.
  
  Without further incident, we took the least muddy route through the kilometres of sisal. It was very hot and there were several places where we struggled to push the bikes through the wet mud, but all in all, it was an enjoyable journey. The area is particularly beautiful in the present, rainy season, just a bit wet sometimes. And in the midst of all the sisal, we spotted some industrial greenhouses and some bright green fields of something other than sisal. I hoped to see food crops but, alas, there was mostly flowers (for the European market) and coffee grown there. The area is owned by one of the sons of the former president, Moi, who was quite acquisitive in his time.
  
  Like Majani Mingi, where we went yesterday, Alfega is pretty isolated. The best roads that surround it are mud roads and impassable during and just after the rain. And it's expensive to make the journey if you really need to. So most people don't leave the village much. In spite of being surrounded by such greenery and wealth, the village is as poor as Majani Mingi and far more populous. The latter has a population of only three or four thousand, Alfega is closer to eight thousand. Of course, I never know whether the population figures we are given count the children or just the adults.
  
  We visited four houses, assessing five orphans in all. They were all in need of assistance and the worst thing is seeing the problems that their families have to cope with. It's amazing that families that are so overstretched will still take on another child to care for, but it does seem to happen a lot. And Ribbon of Hope is fortunate enough to have members who are from the area because otherwise, it would be impossible to tell who is genuine and who is not. Even people who are clearly in need sometimes tell a few white lies to try and have one of their children assessed, which is not really surprising.
  
  And that's another way in which we are fortunate, we have limited funding, so we have to be very careful. I've seen and heard of organisations that have large amounts of funding but they end up using it rather indiscriminately and even losing it to people who are not really in need. Organisations shouldn't have any more cash than they know how to administrate. Our biggest asset right now is the closeness of some of our members to the local community we hope to assist.
  
  Just as it seems unfair to help people who are HIV positive when other people are suffering from all sorts of treatable and curable illnesses, it sometimes seems unfair to single out orphaned and vulnerable children for special assistance when there are others who are in equal need. And this is a dilemma that we face every time we visit such villages. Today and yesterday, we saw people, adults and children, who were suffering, but they probably won't attract the attention of NGOs. We try to do things that benefit communities as a whole as well, but we are small right now. Hopefully, things will change over time.
  
  Incidentally, it's worth pointing out that in this area that is mostly owned by Gideon Moi, there are a lot of public toilets being built. As the houses there don't have good sanitation, this sort of intervention will have major benefits for everyone in the village. Water and sanitation related illnesses give rise to a huge share of the disease burden and deaths in developing countries. The Greek owned area around Majani Mingi didn't have any public toilets that I could see and it is likely that the overall health in Alfega in the near future will be far better as a result. I hope to see more of this kind of public intervention, despite the dominance of private (and highly exploitative) enterprise in the area.
  
  Ideally, Ribbon of Hope Self Help Group won't get much bigger because the things we are doing now will be done by other self help groups. To some extent this is already happening. But there is a certain futility to NGOs and community based organisations (CBO) continually setting up and targeting the people and things they most want to benefit, only to be replaced by more NGOs and CBOs, without an end in sight. It would be nice to think that communities like Alfega and Majani Mingi will one day be able to support themselves, perhaps because of the support they received in the past from various parties.
  
  In fact, if that is not what happens, if the development that we are involved in now is not sustainable, if it doesn't give rise to further development that is greater than what came before, I think it may have failed. But the possibility that what we are doing now may only have a short term benefit and that others may have to come and do the same again and again in the future is no reason to stop doing what we are doing. Unless we are doing some harm, and I hope we are not doing that.

• A New Orphan Project (and Another Grumble About Pills)

  Posted: May 7, 2010, 9:19 pm by Simon

  I recently blogged about the tendency to medicalise problems that have very simple and cheap solutions. For example, if people are suffering from nutritional deficiencies, they need a good balanced diet and therefore access to adequate food. So many companies, especially multinationals, are weighing in with their very expensive food supplements and 'biofortified' versions of various seeds. If people don't have the money for even their meager diet, they certainly can't afford these overpriced supplements and fortified seeds.
  
  But as myself and my colleagues from Ribbon of Hope Self Help Group sat in a restaurant having a meeting yesterday, a woman came up to us to sell us some nutritional supplements which had all manner of stuff in them, according to the colourful label. But they were to be taken three a day for seven days to relieve just about any ailment that could possibly relate to nutritional deficiency. And the course cost as much as more than two weeks of staple food for four or five people.
  
  If people had this sort of money, they could just buy good food. They would be ill advised to spend it on pills that some woman who approached them in a restaurant tried to sell them. But people do buy all sorts of rubbish that promises to sort out all their children's or their own problems. This is a terrible form of exploitation and the stuff being sold is often produced by very big, powerful, wealthy companies. We tried to persuade her that what she was saying couldn't be true. But you can't blame her for trying to make a living in a country where most people don't have jobs. After all, she's been conned too.
  
  Anyhow, today we went to a small village called Majani Mingi to assess some orphans so their families can be supported to send the orphans to school and look after them, along with the rest of their family. Majani Mingi is near Mogotio, about 50 kilometres North of Nakuru. In fact, you can't get to Majani Mingi most of the time and the best way to get there is by motor bike. It's about 10 kilometres from the main road but, despite this, you never leave the massive sisal estate that is 'owned' by a Greek man who can't even be bothered to pay his employees and suppliers most of the time.
  
  With this in mind, we visited four households, taking in 5 orphans in all. All of them had lost both of their parents and all were being cared for by families that were already stretched for the means to keep providing themselves with the basics. Most people in the village have some connection, direct or indirect, with the sisal factory, either as employees or people who are dependent on employees. I think it is safe to say that pretty much all the people living in these sisal dominated villages are very needy, so it's hard to assess children and families when your finances will only stretch to four children.
  
  We can put together the information we have received, along with similar information for four other villages and then make a decision. I suspect that families themselves will have to decide how to use any support they get because when money is in short supply, so is everything else. You can't very well ask a family of thirteen to give food, clothes and schooling to the one orphan and leave the others without. I really don't know how these decisions are made at the family level. I hope to gain some insight into this over the next few months.
  
  There can be a tendency to associate orphans and other vulnerable children with orphanages. But thankfully, Ribbon of Hope is not interested in such institutions, they are beyond our scope. They cost so much money to run and the children do not get the sort of care they could get in a family. And so many orphanages have been hotbeds of corruption and deceit, where often children get very little and those running the orphanages make a very comfortable living. Of course, they are not all like that, but finding out which are genuine and which are not is just too time and resource consuming. As the orphan and vulnerable children project gets up and running, I'll report progress here.

• Why Do Some Discount Altruism That Isn't 'Pure'?

  Posted: May 6, 2010, 1:17 am by Simon

  A journalist writing in the Irish Herald ends an article on 'charity gurus' by saying "charity work is best done when it is done quietly". I assume that charity work that is done quietly is that which doesn't attract the attention of the mainstream media, press, TV, glossy magazines, the works. Because this journalist may be relieved to know that most charity work is done quietly, most people doing volunteer work or any other kind of development work, attract little or no attention. I find that gurus of all kinds are created by the very media that so loves to then condemn them once they are no longer able to control them.
  
  This journalist, apparently, made a film about a woman who started a charity in Asia and 'hands out wads of cash to the poor'. The woman enjoys giving money to the poor and the journalist interprets this as meaning that the woman enjoys their gratitude and adoration.
  
  Again, the journalist need not worry so much. I have never seen or heard of someone working in development who hands out wads of cash. Nor is everyone particularly grateful, nor do most people who do voluntary work expect people to be grateful. At least, that's my experience. People who receive charity may sometimes be grateful, perhaps very grateful, but their reaction may be embarrassment, shyness, contempt or perhaps a combination of things, often contradictory things.
  
  I'm not saying this journalist is wrong or that she is misinterpreting things. I'm just saying that she is perhaps underanalysing what appears to be a rather unusual phenomenon. And I don't think she is cynical in interpreting the charity woman's enjoyment the way she does. I'm sure that among all the emotions and sensations people who work in development feel, it wouldn't be unusual to feel some enjoyment of any gratitude and adoration, if they receive such.
  
  But supposing you were to do a survey of lots of people who worked, in any job, to find out what they enjoy about their work, or even why they work at all. I think you would find that many people work for money. They may or may not enjoy their work but the majority will do the job they do because they have to do something to pay their way. But I don't think your analysis of the survey would be very interesting or insightful if it was your main conclusion that people work for money.
  
  Some people working in development earn money, some earn quite a lot. But most of the people I have known working in the field earn very little. Some volunteers earn a local wage and have all their expenses paid. But again, most of the volunteers I know do not earn regular wages, nor do they receive much in the way of expenses. Most of them volunteer for some of the week and do other things the rest of the time, so that they can feed themselves and perhaps their families.
  
  I haven't surveyed the people I know who give some, often a lot, of their time for free. But one, who works as a volunteer for part of almost ever day has even pointed out to me that often when you do a lot for someone, they don't want to know you once they are better. Those were his words. This man has a sense of public spiritedness that you rarely find even among volunteers. Another volunteer, a woman, has never really discussed the subject. But she gives her time and sympathy and even some of the little money she has. And she also knows that people who receive her care can treat her with scorn later.
  
  In fact, most of the volunteers I know don't even give out money most of the time because they don't have very much. They do work, take time, donate their skills and reach out to people who have no one. I don't know if they go home at night and bask in the glory of doing something that they may never even receive thanks for, let alone money. Nor do I care, I don't believe that altruism needs to be 'pure' in order to be altruism. People's motives for anything can be mixed, contradictory and even hidden to them.
  
  By all means, Ms Journalist, condemn the thieves, the bullies, the smug, the sanctimonious, the extortionists and whoever else you like in the world of development, charity and the voluntary sector. But please recognise that they are probably the ones who were unusual enough to be picked out by you and your rather undiscerning and unanalytical media friends. They were picked out because they were unusual, not because they were the low key, modest people who often do things for other people without first thinking what there might be in it for them.

• UNAIDS To Reconsider Evidence on Non-Sexual HIV Transmission: Only Joking!

  Posted: May 5, 2010, 1:01 am by Simon

  My post was getting a bit long yesterday but it is also important to remember other blood related risks that may transmit HIV, hepatitis B and C and other blood borne diseases. For example, sharing a razor or perhaps certain cosmetic instruments, tattooing equipment and body piercing equipment that haven't been sterilized, can all be risky. Yet, UNAIDS don't mention any of these possibilities in their 2009 Aids Epidemic Update.
  
  It seems extraordinary that, given the efficiency of transmission of blood contaminated instruments and the relative inefficiency of sexual transmission, UNAIDS should be happy to dismiss medical transmission as very small and to fail completely to mention cosmetic or other modes of transmission. Have they even checked, and can we see the data collected? We just don't know how much these phenomena could have contributed to HIV epidemics in countries with very high prevalence.
  
  In Kenya and Tanzania, haircutting and other cosmetic processes don't just take place in hairdressers and salons. Women go to each other's homes for such things and you even see people doing their grooming in public. In Dar es Salaam, several times, I saw men shaving the head of another man with a hand held, two sided razor. They would then swap over and both would end up with a lot of cuts on their heads. It's impossible to estimate how much this could contribute unless it is properly investigated.
  
  Yet UNAIDS can happily report the various modes of transmission and say that sexual transmission can even account for 94% of all transmission in Swaziland. That means that the extremely risky (male to male and male to female) anal sex that must take place accounts for only a few percent, at the most. Hospitals and clinics in Swaziland must be so well run that they also account for a few percent. Barbershops, tattoo parlours and hairdressers hardly ever contaminate anyone, perhaps never. And this is in a country with over 25% HIV prevalence! Come on, UNAIDS, this is just not credible.
  
  But UNAIDS and many others just keep to the behavioural paradigm which says that in African countries, HIV is mostly transmitted by sexual intercourse whereas in non-African countries it is mainly transmitted by intravenous drug use, men having sex with men, commercial sex work and a few other things. This behavioural paradigm is one of the main sources of stigma and, despite deploring stigma, UNAIDS will not admit that the paradigm is based on a lot of guesswork and a lot of effort to ignore anything that may contradict them.
  
  What UNAIDS need to do is admit that they are wrong, that research does not show that HIV is mostly transmitted by heterosexual sex in African countries. On the contrary, there is plenty of evidence that most people in African countries do not indulge in the levels of unsafe sex, or any kind of sex, that would be required for the behavioural paradigm to be credible. In addition, there is plenty of evidence that medical and cosmetic procedures often take place in unsterile conditions. It is simply not possible for non-sexual modes to account for as small a percentage of HIV transmission as they would have us believe.

• HIV Stigma and Institutional Racism

  Posted: May 5, 2010, 2:15 am by Simon

  The received view about HIV these days is that unless you are a gay man, a sex worker or an injecting drug user, you are unlikely to be infected. At least, that’s the received view in rich countries. In fact, in their 2009 Aids Epidemic Update, UNAIDS don’t even mention sex workers for North America and Western and Central Europe. They say “[i]n North America and in Western and Central Europe, national epidemics are concentrated among key populations at higher risk, especially men who have sex with men, injecting drug users and immigrants”. Despite this though, heterosexual sex appears to account for about 30% of transmission.
  
  But in poorer countries, especially in Africa, the received view is somewhat different. Here, it is claimed that the most common way of spreading HIV is through heterosexual (vaginal) sex. UNAIDS say “[h]eterosexual intercourse remains the primary mode of HIV transmission in sub-Saharan Africa, with extensive ongoing transmission to newborns and breastfed babies.” They even claim that 94% of transmission is by heterosexual sex in Swaziland.
  
  But the report goes on to suggest, effectively, that low risk sex is high risk sex in Lesotho and Kenya because it accounts for most transmission. “In Lesotho, between 35% and 62% of incident HIV infections in 2008 occurred among people who had a single sexual partner. Heterosexual sex within a union or regular partnership accounted for an estimated 44% of incident HIV infections in Kenya in 2006, while casual heterosexual sex accounted for an additional 20% of new infections”. However, if low risk sex is high risk, this just begs the question of how sexual behaviour could account for so much transmission in some countries but not others. Most people in every country have low risk sex but most countries don't have high HIV prevalence. UNAIDS accept that gay men and drug users are also at high risk, but that they contribute far less to the epidemic.
  
  According to this received view, sex workers in African countries would be particularly at risk, along with their clients and their clients’ other sexual partners. So it’s easy to see how stigma creeps in. If you become infected with HIV, you are probably a prostitute, someone who frequents prostitutes or, even worse, a gay man or an injecting drug user. Because of the stigma attaching to HIV, people are often less quick to see that there are many who could have been infected unwittingly. And the issue of infants being infected by their mother can also be an inconvenience when painting a picture of rampant illicit sex and drug taking.
  
  A former UNAIDS employee, Elizabeth Pisani, says “HIV is mostly about people doing stupid things in the pursuit of pleasure or money”. She also says “In Africa, people are contracting the virus through heterosexual, non-commercial sex”. Pisani is someone who certainly knows how to reinforce stigmatizing views. I’m surprised she ever left UNAIDS.
  
  Of course, heterosexual sex would account for a substantial proportion of HIV transmission. But how substantial is anyone’s guess. Because, holders of the received view claim that HIV infection through accidental blood exposure in poor countries is low or negligible. Back to UNAIDS again: “A small percentage of prevalent HIV infections in sub-Saharan Africa is estimated to stem from unsafe injections in medical settings.” Also: “In an analysis of data from Kenya, medical injections were estimated to be the source of 0.6% of all HIV infections”. Though strangely enough, they admit that medical transmission is far more significant in Uganda.
  
  They even find that in Eastern Europe and Central Asia “[i]n addition to new infections associated with injecting drug use and unprotected sex, key informants and scattered media reports suggest that a notable number of new infections may be occurring as a result of unsafe injections in health-care settings.” However, what they mean by ‘key informants’ etc., actually refers to a whole body of evidence about unsafe injections that UNAIDS are unwilling to countenance, so they ignore it.
  
  In hospitals and clinics in developing countries, instruments that are contaminated with blood and various blood-borne diseases may be reused or inadequately sterilized. Health services are underfunded, understaffed and short of resources. There is no lack of evidence that they are risky places. So how can UNAIDS come up with these figures for medical transmission of HIV? Well, by being selective about what evidence they cite and by ignoring anything they don’t like the look of. High rates of medical transmission, and consequently, lower rates of sexual transmission, doesn’t fit with the view that, in Africa, people have a lot of unsafe sex. And institutions, politicians, churches and funders are interested in supporting sexual behaviour change programmes.
  
  These same people are probably not interested in accepting that some of the problem may arise from unhygienic practices in the very health facilities where they are urging people to go for testing and treatment. The mainstream doesn’t want to see itself as being a significant part of the problem. So UN and WHO personnel, diplomats and other high ranking officers are issued with their own needles and syringes when they are visiting African countries. They are also given instructions to avoid treatment if at all possible.
  
  But Africans themselves are supposed to visit whatever health facility is available to them without even a warning about the risks they face or the precautions they can take. And if they are infected with HIV, they will probably unknowingly go on to infect others.
  
  It seems to me that racist attitudes allow members of institutions such as UNAIDS to assume that Africans have lots of unsafe sex, but that most non-Africans don’t. And racist attitudes allow these institutions to recommend that their employees avoid medical facilities in developing countries, without doing the same for people who have to live in those countries.
  
  In Western countries, people travelling to African countries are likely to be made aware of some of the potential risks of visiting medical facilities there. They can buy information about medical safety and even kits containing syringes, needles and the like, so they can reduce the risks they face further. If it is so important for Westerners visiting African countries to take care when visiting medical facilities, or even to avoid visiting them altogether, why is it not equally important to protect Africans from being infected in these facilities?

• The Ups and Downs of April for Ribbon of Hope

  Posted: May 3, 2010, 1:11 am by Simon

  It's nice to get to the end of another month and find that, despite all the problems and minor disasters, there are also things that are going well. Ribbon of Hope Self Help Group has quite a number of projects that are steady, and should produce good results soon. And there are other projects that are going just as we would like them to go. One project that didn't go so well was our acre of watermelons. Due to a combination of problems, we didn't sell a single one. Torrential rains and humid weather meant that they rotted and split just when we should have been harvesting them.
  
  But on to the good projects. Some of the people we work with recently started a rabbit project and the rabbits have been doing what they are well known for. These same people have a chicken project which was a slow burner for some time but now is producing very good results. Near the watermelon field, on the Equator near Mogotio, we have an acre and a half of maize and beans and they are doing well, despite continuing heavy rains. And all is not lost in the watermelon field. We're only a third of the way into the one year lease, we'll grow more things there. And this is only a few of the projects that Ribbon of Hope is involved in. You can read the monthly report on their Facebook page.
  
  I have been working with several community based organisations for some time now and I always worried about how they would keep managing to implement income generation activities that would really generate income. Sooner or later, if you keep starting chicken, goat and cow projects, there will be too many eggs and hens and new projects will undermine existing ones. Yet, chicken projects and growing maize and the like are good projects for several reasons. They are relatively cheap to start, the products sell well and they can be used by the producer or sold locally.
  
  I started to look for other income generation activities and, although I compiled quite a list, I realized that there was another way to help achieve poverty reduction. There are various ways of cutting down on day to day household expenses and I have discussed them many times on this blog. The best examples are solar cookers and cooking baskets. These and other intermediate technologies can help people to reduce the amount of money they spend on cooking fuel considerably and use the money for something else.
  
  These techniques have many advantages, including the fact that they cost little or nothing but can save quite a lot of money over a year, especially in a big family. Ribbon of Hope doesn't have a huge amount of funding and they would like to use what they have for projects that generate money. So projects that don't generate money, that save people money, are all the more welcome if they don't cost much. And income generation activities are well complemented by techniques for cutting everyday expenditure.
  
  I have mentioned that two support groups we work with benefit greatly from having a very active and dedicated leader. But another support group had the opposite kind of leader, one who really undermined members of the group and, as a result, all their projects flatlined or failed. Recently, the members gave him the boot and elected a new and somewhat reluctant leader. But since then, the group has gone from strength to strength. I was ready to dismiss this group at one time. But luckily my colleague persevered and helped to turn everything around.
  
  As for some groups, we never really had to worry about their leadership. In Mogotio, we have very fine group leaders who are constantly busy with community affairs. They are trained health volunteers and they spend so much time doing voluntary work, I still haven't figured out how they ever find time to make enough money to care for their own families. Yet they do care for their families and they each care for a local orphan as well. I'd really like to know how they do it.
  
  It's a bit of a struggle for people sometimes because, even when things go well, they can end up with other problems. If you get a good maize crop, it's probably because the whole area is producing a surplus. But if conditions are bad, you are as likely to fail as everyone else. I'd like to see people diversify away from producing maize to the exclusion of almost everything else. Also, I'd like to see people concentrating on food crops until they have enough food and spare land to start growing cash crops. Too many lose everything because a cash crop gave good yields but had to be dumped because or a lack of market or something like that.
  
  For me, the ideal crops are food, food that is eaten locally, food the grower can use themselves, food that can be stored, food that has a good, local market, and crops that are indigenous and therefore resilient when it comes to drought, flooding and all the other common adverse conditions you get here. Crops that require expensive inputs should be left to those who can afford them. Growing a crop that is secured against hazards is far better, to my mind, than one that could make you a very good profit, if it works. Sadly, watermelons fall into the latter category.

• One Laptop Per Child: But What About the Teacher?

  Posted: April 30, 2010, 1:50 am by Simon

  It's quite a few years now since someone came up with the idea of giving a cheap laptop to every child in developing countries. The price mentioned was $100 and the laptop would have a device for winding it up for when there was no power, it would be robust against harsh treatment, dust, heat, humidity, etc. It would be simple but attractive and have everything that a child could want in a computer.
  
  Well, such a laptop has been available for some time, but those who came up with the idea have not been able to persuade funders or governments of developing countries to order the things. They were hoping for orders of about one million at a time but they haven't even offloaded 2 million of them yet. The laptops come with Linux and Windows preloaded but they are selling for over $200. I'm not sure how much more than $200.
  
  Some will remember, it's only a few months ago, that both Britain and the US governments decided to withold funding earmarked for education in Kenya. It was a paltry amount, less than $40 million in all. But many people here are having problems paying for school fees and costs because the so called free primary and subsidized secondary education still cost more than a lot of people earn.
  
  There are about 9 million school children in Kenya at the moment. The figure should be a lot higher because some are not attending, though how many is anyone's guess. The money being witheld sounds like only a few dollars a head. But most schools are underequipped and understaffed. Infrastructures that the schools need are crumbling or non-existent, for example, electricity, water and sanitation. Even roads are appalling and transport to and from school is one of the biggest hurdles children have to face, to say nothing of the costs to their parents.
  
  But the one laptop per child scheme, OLPC, that's a substantial amount of money. And they are hoping to raise the money for 30 million of them for the whole of the East African Community. Two hundred and something dollars could pay all the costs that are levied but not considered to be school fees, along with quite a number of other items. Books, for example, are in very short supply. Kids often come to school without having done their homework because they have no book (or because there is no lighting at home).
  
  It's not that I don't think children (or adults) in developing countries should not have such a valuable tool as a laptop, it would be great if everyone had one. But I wonder if it's such a priority. So many infants and under fives are dying of preventable and curable diseases because of conditions such as poor sanitation. Malnutrition is rife and causes growth stunting and retarded intellectual development. And the list is endless.
  
  Not only are there many things children need that would put laptops quite low on the list of priorities, but a lot of the things they need are quite cheap. For the sort of billions that are being proposed for OLPC, a lot of childhood health conditions could be prevented or cured. Children could go to school with things like books and other tools. Girls wouldn't have to stay at home several days a month because they are having their period. And pupils could have enough food to prevent them from falling asleep during classes or just not going to school at all.
  
  Children have a lot of things to grasp when they are young, reading, writing, languages, mathematics, sciences, etc. It's easy enough to see how laptops could be used to help with this. But I have a suggestion: give free laptops to teachers in teacher training schools (who also lack the books they need, sometimes); teach them how to use laptops and how to teach with them. Then roll them out that way. Instead of spending the $6 billion dollars or more on giving tens of millions of children laptops, make sure the educational system is ready for the laptops.
  
  There is no point in just spilling out a few more million to give a laptop to teachers as well. They have to be taughted how to use them and how to teach with them. When I was doing an MA at a London University college just a few years ago, an institute of education, no less, some of the academic staff there had no idea how to use computers to teach, so why should people who have never had the opportunity to even use them? In fact, teaching with computers comes with some huge pedagogical hurdles.
  
  Frankly, I think the project stinks. But it could be turned around, it hasn't even started yet, to make African countries among the first in the world to use a laptop as their main teaching tool in primary and secondary education. Ok, training the teachers may not iron out all the problems of trying to do without books and other everyday teaching materials. But it sure as hell won't work if the teachers get no training (and no laptop). If you can raise that much money, OLPC, don't blow it on the laptops alone. It's not as if the laptops can be recycled if the project goes pear shaped.

• Pills For Poverty

  Posted: April 28, 2010, 1:45 am by Simon

  An article in SciDev.net entitled Don't Medicalize Micronutrient Deficiency argues that biofortifying foods or handing out food supplements is not a sustainable solution to malnutrition problems. Countries that have high levels of malnutrition have food and agriculture problems that pills or fortified foods will not solve.
  
  This is a timely reminder, when so many 'solutions' come in the form of technical fixes that are often expensive, short term, inappropriate, unsustainable and often don't even work. I recently mentioned Bill Gates efforts to eradicate water borne diseases like polio, malaria and cholera by developing vaccines when the best strategy would be to improve water and sanitation. Water borne diseases can not be eradicated in areas where people don't have access to clean water and adequate sanitation.
  
  Another problem with certain biofortified foods is that they have intellectual property rights associated with them, which adds a lot to their cost. Why should poor people suffering from nutritional deficiencies, instead of being enabled to produce enough high quality food, be offered something that is expensive and is just impoverishing their country further?
  
  Some of the manufacturers of genetically modified organisms (GMO) have even got in on the micronutrient method of screwing yet more money out of developing countries. The vitamin A fortified rice, which was claimed to reduce blindness caused by vitamin A deficiency, springs to mind. Unfortunately, it contained vitamin A in a form that could not be absorbed and so it was a useless technology.
  
  Poverty is the real problem when people can't afford a balanced diet for their family. If they are poor, they are certainly not going to be able to afford with the sort of premium price that intellectual property brings. And we have seen enough instances of poverty, disease and malnutrition being used as vehicles to sell expensive Western technologies, especially dangerous technologies that impoverish people further and that could even damage their health.
  
  The attitude of multinationals, and that of certain people, seems to be to let people become sick and then come running with the pills or the GMOs or the technical solution. People need adequate economic means, food, food security, education, health services, water, sanitation, housing and the rest. In the absence of these human rights, they will suffer and die prematurely.
  
  It may be the prerogative of multinationals and others to allow people to live in inhuman conditions as long as they can sell plenty of their goods. But it is not the prerogative of those who work in development or those who work to keep in check the excesses of multinationals. As the article in question points out, many of the people in the world suffering from malnutrition are farmers. They should be allowed to produce food that can provide themselves, their families and their countrypeople with a balanced diet. This would also improve economic circumstances and therefore health, education and other things, too.
  
  If someone prescribes pills as a substitute for clean water or good food, they are probably a multinational.

• Philanthropic Tokenism

  Posted: April 27, 2010, 2:38 am by Simon

  Apparently Zanzibar succeeded in eradicating malaria in the 1970s, but it returned. Now they are about to eradicate it again, or at least, rates are far lower than they have been for a long time. However, there seems little chance that they will succeed in keeping malaria down for good.
  
  Zanzibar, like many places in Africa, has problems with garbage disposal, sewage disposal, water, hygiene, infrastructure, especially roads and electricity, education, housing, poverty, health and many other things. These are the conditions in which a disease like malaria thrives. It is fairly certain that unless Zanzibar tackles these problems, malaria and other deadly (though preventable and curable) diseases will continue to be endemic.
  
  The world was told that polio had been all but eradicated in the last few years and in a short time there would be no further cases. But polio has returned, partly because of a boycott on vaccinations in Nigeria due to rumours about their safety. As a result, there is talk of changing the polio eradication campaign from its present 'vertical' strategy to a more 'horizontal' strategy.
  
  A vertical approach takes one disease and aims to vaccinate everyone who may be infected and, if possible, treat those who are already infected. A horizontal approach aims to provide health services for everyone and sees all diseases as being in need of prevention and/or treatment.
  
  Realization that vertical approaches are not working and that horizontal approaches don't carry the kudos of being able to eradicate a whole disease gave rise to talk about health system strengthening and even 'diagonal' approaches, that would combine the horizontal and the vertical. Unfortunately, much of this has remained just talk.
  
  There is even talk of Bill Gates taking a less vertical approach to polio eradication or risk seeing hundreds of millions go to waste. But I find that hard to believe. I don't think Gates lacks understanding of why polio (and other diseases) elude single disease approaches that involve some kind of expensive, technical fix. All he has to ask himself is why people are being infected by a disease that is spread through human feces. To put it another way, why are people drinking contaminated water?
  
  Gates is fond of talking about water and sanitation but most of his money goes into things like vaccines. Indeed, much of it goes into US institutions and US citizens working on vaccines. Very few broad-based water and sanitation programmes, aimed at preventing all water borne diseases, are being financed by Gates.
  
  Gates can spend his money and fail to eradicate polio or cholera or malaria or any of the diseases that he wants to be associated with eradicating. But as long as the water is contaminated, all his programmes will fail. As for his ideas on how to make the polio programme more 'diagonal', all that's mentioned is "training for health workers on topics such as hygiene and sanitation". Hygiene and sanitation are not just things people need to know about, they are things people need access to. It's no use health workers telling people to wash their hands and dispose of their faecal waste properly when they don't have clean, running water and adequate sewage disposal systems.
  
  Maybe Gates will get involved in genuine 'health system strengthening', but just paying a few professionals more to work in his funded institutions is not going to help. That has just increased the brain drain from indigenous health institutions and taken attention away from health in general to concentrate on his favourites. But it seems more likely that he will continue to do what he is doing and put even more money into spin. After all, he has his agenda and evidence from the field has never affected that.
  
  Diseases are not trophies and global health is not a matter of having a wall covered in certificates for attempting to eradicate a small number, or even a large number. Health depends on other crucial rights, such as food food and food security, water and sanitation, adequate living conditions and good education. Without these, throwing money at a handful of diseases will have little impact. Maybe some disease will be wiped out, or as good as, but people will continue to die of other preventable and curable diseases. Gates should work for human rights, any human rights or even all human rights. Instead, he's just wasting his money on philanthropic tokenism.

• Why is HIV Stigmatized and How Can We Reduce Stigma?

  Posted: April 25, 2010, 6:30 pm by Simon

  When HIV was first identified as the virus that causes the syndrome now known as Aids, it was quickly established that it could be transmitted through exchange of bodily fluids, blood, semen, breast milk and through other routes. This means that it can be transmitted through sexual contact, through blood contact (during medical and cosmetic procedures, also by intravenous drug users) and from mother to child (also called vertical transmission).
  
  Nearly thirty years later, sexual transmission is still the mode of transmission that gets the most attention. The received view, supported by organisations such as UNAIDS, the WHO and others, is that the vast majority of HIV positive people in African countries were infected through some form of sexual contact. Of course, many probably were. But heterosexual transmission is not the most efficient mode of transmission. In fact, it is a relatively inefficient mode of transmission.
  
  Mother to child transmission is an efficient mode of transmission without medical intervention. But with medical intervention, transmission is low, even in developing countries. Now, in countries like Kenya, an increasing number of pregnant women are being tested for HIV as soon as they start attending ante-natal clinics. They are usually monitored and treated if they are found to be HIV positive in order to prevent transmission of HIV from mother to child.
  
  However, exchange of contaminated blood is a very efficient mode of transmission, whether it occurs through intravenous drug use, a visit to the doctor or even a visit to the beautician. One hopes that all the public information and education there have been about the risk of contracting or transmitting HIV through exchange of blood would make people aware of these risks, whether they are drug users, health care workers, patients or clients of hairdressers.
  
  But as I have said, sexual transmission is the mode that has received the most attention. It has and continues to dominate HIV prevention programmes with any other modes of transmission receiving far less attention, if any.
  
  So what is the meaning of the received view of HIV, that 80-85% of it is transmitted sexually? In particular, why would HIV prevalence in Greece be .008% when prevalence in Kenya is 8% and prevalence in Lesotho is 28%? Does this mean that Greeks have orders of magnitude less sex than people in Kenya and Lesotho?
  
  Well, for a start, UNAIDS distinguishes between generalised and concentrated epidemics. Countries with generalised epidemics usually, but not always, have high HIV prevalence, above 1%, and affecting people who are not in groups thought to be at especially high risk. Those at high risk include men who have sex with men, intravenous drug users and commercial sex workers. Greece has a low level, concentrated epidemic. Those infected in Greece are almost all in one of those high risk groups.
  
  In contrast, Lesotho and Kenya have generalized epidemics. According to UNAIDS, the WHO and others, sexual behaviour explains high prevalence of HIV in these two countries, but not in Greece. They say that risky sexual behaviour such as unprotected sex, high numbers of lifetime partners, high levels of concurrency (having sexual relationships with several different people where those relationships overlap to a significant extent) and others are responsible for the terrible HIV epidemics of the sort found almost exclusively in Sub-Saharan African countries.
  
  The claim, then, is that people in these countries indulge in more risky sexual behaviour, but how much more? It would need to be a great deal more but there is little or no evidence to show that this is the case. Rather, when people are diagnosed as HIV positive in African countries, it is assumed that they were infected sexually, either by their main partner or by some other sexual contact. If their partner turns out to be HIV negative it is assumed that they had sexual contact with someone else.
  
  Many people have been diagnosed as HIV positive and it has turned out that their partner is HIV negative. It is then assumed that the HIV positive partner, often the woman, had an affair with someone else. If she denies this, it is assumed that she is lying. Although that’s the case in Kenya and Lesotho, it’s unlikely to be the case in Greece or any other Western country. The assumption that people are just lying partly stems from the received view: that 80-85% of HIV is transmitted sexually in countries with generalized epidemics. Some may lie, but some may lie in Greece too. So how many instances like this have been investigated? In African countries, precisely zero.
  
  Consider another phenomenon: infants and children who have been found to be HIV positive when their mother is not. It’s harder to claim that so many infants and children have been, one, sexually assaulted, two, sexually assaulted by someone who is HIV positive and three, that they were infected as a result of this sexual assault. South Africa recently found quite a worrying number of HIV infections among children who were not sexually active and whose mothers were not HIV positive. Further research was called for, into the possibility of sexual assault and the possibility of medical transmission. Neither, as far as I know, has yet been carried out.
  
  Accepting that HIV is mostly transmitted by heterosexual intercourse means accepting that a lot of people are having a lot of unsafe sex with a lot of other people over a long period of time. It involves accepting that this happens in Sub-Saharan African countries to an extent not found in most other countries, indeed, to an extent that is just not credible.
  
  If unbelievably high rates of risky sex are a figment of the imagination of those who work for or who follow the pronouncements of UNAIDS and WHO, what could account for all the generalized epidemics in Africa?
  
  A number of suggestions have been made (by those who dare to diverge from the received view). Some have suggested that low levels of health care and education and high rates of poverty in many African countries make people more susceptible to HIV infection. But, while it is true that these circumstances are found in many African countries, they are also found in countries where HIV prevalence is far lower. And even in African countries, HIV prevalence has often been higher among the rich and well educated.
  
  A better suggestion is that high rates of disease and low levels of nutrition make people more susceptible. Many preventable and treatable conditions, such as TB, malaria, human parasites and certain sexually transmitted infections have been shown to significantly increase the risk of HIV transmission, especially sexually, though also through blood contact and through vertical transmission.
  
  But then this doesn’t really explain why well off and well educated people were infected in greater numbers than poor and badly educated people, especially in the early stages of the epidemic. Well off and well educated people would be less likely to suffer from these conditions and would have had better access to healthcare.
  
  It’s time for people to question the idea that inordinately high levels of unsafe sex in certain African countries can fully explain the high prevalence of HIV found there. We need to re-examine all other modes of transmission, especially where blood exposure could be involved. Barbers’ and beauticians’ shops don’t always look too sterile. But nor do hospitals and clinics. Putting it a different way, it must be wondered how the sort of badly equipped, understaffed, overcrowded facilities found in African countries can avoid transmitting HIV and other diseases, at least sometimes. Questions about the safety of health and other facilities urgently need to be raised.
  
  The received view, that 80-85% of HIV transmission in Sub-Saharan African countries has been through sexual contact, can not be correct. How much can truly be put down to sexual transmission is unclear because a lot of the research has just not been carried out. What research has been done has been ignored because it contradicts the received view. But we owe it to people who are HIV positive, despite never having engaged in unsafe or illicit sex, to do this research. We owe it to everyone who is HIV positive because we don’t know how they became infected. They may not even know themselves. The stigma comes from an assumption that we are not entitled to make.
  
  If, as some people would argue, a substantial amount of HIV was transmitted by non-sexual means, perhaps a lot by medical transmission, this could explain why HIV reached levels where even sexual transmission started to become far more significant than in other countries, where prevalence remained low. Most children and pregnant women, especially, receive a lot of injections and other medical treatment and a very common form of contraception is given by injection. And many other people in African countries also receive a lot of injections, for example, commercial sex workers and men who have sex with men. The highly efficient transmission of HIV that would occur through blood exposure could quickly spread an infection to many people. There is no evidence that the same rates of transmission could occur through sexual transmission alone, even if risky sex was as common as claimed by the received view.
  
  Reducing stigma is always going to be a difficult task, whatever its target. But it should be easier to reduce stigma once it is clearer how HIV really reached such high levels of prevalence in some countries and not others. Sexually transmitted HIV could only have infected large numbers of people once a high prevalence of HIV had already been reached through some other mode. Research to establish how HIV reached present levels is urgently needed, starting with medical and cosmetic transmission.
  
  HIV is stigmatized because of the received view that it is mostly transmitted by heterosexual sex in Sub-Saharan Africa. However, rates of unsafe sex would need to reach incredible levels for this received view to be correct. Though stigmatizing sick people should always be avoided, there must be other reasons than sexual behaviour to explain why HIV prevalence is so high in some African countries, reasons which would show that this stigma is misplaced. Those who are infected through non-sexual routes, of course, can also go on to transmit HIV sexually. Therefore, a large amount of sexual transmission, which can occur once HIV infects a critical percentage of the population, can also be partly attributed to non-sexual transmission. Some, perhaps most, of this non-sexual transmission may come from unsafe medical and cosmetic practices.

• Unnatural Disasters: GM and Biofuels

  Posted: April 21, 2010, 1:37 am by Simon

  In an article about the highly suspect arrival of 40,000 tonnes of genetically modified (GM) maize in Kenya's Mombasa port, the BBC concludes "Many African countries are under increasing pressure to grow GM crops to tackle hunger and malnutrition, and drought in recent years has caused food shortages in Kenya."
  
  This is very misleading, in several ways. Multinationals like Monsanto, which are having a lot of trouble persuading most countries to trust their attempts to take over world food production, want people to think that GM crops provide a solution to hunger and malnutrition. They want people to believe that their crops are resistant to drought, flooding, pests and whatever else. But none of these things are true. They have not developed crops that have any of these qualities.
  
  Further, it has taken more than just drought to cause Kenya's food shortages. Much of Kenya's productive land is taken up with non-food or non-staple crops, such as sisal, flowers, tea, coffee, sugar and luxury fruit and vegetables. Most of these crops are for the export market. People cannot afford to buy food because they are poor. Because they lack empowerment, they do not have much choice as to what crops the country grows. And most people don't own large amounts of land, producing just enough to get by, if they are lucky. On the other hand, most of the industrial scale farms are owned by very few, well connected people, many of them foreigners.
  
  The BBC article seems to take it as given that GM crops could play any part in reducing hunger and malnutrition. This couldn't be further from the truth. Most Kenyan farmers are subsistence farmers. GM crops were developed for rich farmers, mainly in the US. Some South Africans have fallen into the trap of accepting 'free' GM seeds and other inputs from the likes of Monsanto. Now they are stuck with contaminated land, crops they can't sell, rising input costs, shrinking profits and increased poverty and dependency levels. That's great if you're Monsanto but not so good if you're a small farmer.
  
  This is probably the reason that the unwanted GM maize has ended up in Mombasa in the first place, but many Kenyans are wondering what it is doing there. Well, unless South Africans and some of the other poor fools who have been duped can now dupe others to take GM crops off their hands, they will have trouble shifting it. They have a surplus of maize in South Africa, which is bad enough, but a surplus of contaminated maize could prove to be a very hard sell.
  
  High food prices, which are the real cause of hunger and malnutrition in Kenya and other countries, have a lot more to do with international speculation in staple food commodities. This speculation has recently been spurred by attempts by biofuel producers to buy up land cheaply in developing countries to produce yet more non-food crops or food crops that are destined for the petrol tanks of rich people. [Reuters have an interesting article about potential dangers of biofuels that the EU commissioned but subsequently 'forgot' to publish.]
  
  Drought, flooding, pests and other phenomena can destroy crops and cause widespread poverty and starvation. But rich countries treating developing countries as mere inputs for the production of cheap raw materials, using cheap labour, is the real culprit in many of the famines and food shortages that are labeled 'natural' disasters. The real disasters are far from natural. They are artificially created for the benefit of the world's multinationals, the rich, the powerful and even those who just happen to live in the more fortunate countries.

• Mining, Biofuels and Other Forms of Abuse

  Posted: April 20, 2010, 12:42 am by Simon

  I'd like to follow on from yesterday's theme about developing countries being used to provide wealthy countries with cheap raw materials and labour. These developing countries are never helped to or even allowed to produce their own higher value goods so that they can improve their economies. On the contrary, wealthy countries go out of their way to ensure that poor countries stay that way. Several recent articles discuss other ways in which developing countries are held back from developing.
  
  The European Community (EC) has set a target to source 10% of its energy from renewable sources. Rather than look for genuinely renewable source, the EC has latched on to biofuels as a means of achieving this target. Warnings were raised about the dangers of biofuels as long ago as 2004 but no one was listening then and few are listening now. Biofuel prospecting has gone on, as predicted, to destroy vast tracts of land, increase the prices of fuel, dispossess people of their land and livelihood and cause numerous other social and economic problems.
  
  Like the US, the EC preaches against the use of subsidies. Yet they subsidize biofuel production (and anything else that suits them). Growing biofuels cannot be sustainable, there just isn't enough land, even if everyone in Tanzania and other developing countries are thrown off their land to grow the crops. Growing, processing, transporting and using biofuels does not reduce carbon emissions, they increase it. So even the rich countries are not gaining much by their quest for biofuels. Somebody must be making money out of it but Tanzanians and people in other poor countries will suffer increased poverty and hunger as a result. And there will be global level losses too.
  
  In addition to having a lot of land, which rich countries are busy grabbing right now, Tanzania also has a lot of minerals, especially gold. But various murky deals mean that the country makes very little money out of these resources. Most of the money is made by foreign owned companies, especially companies from Canada, South Africa and the UK. The royalties Tanzania gets are tiny whereas the profits the foreign companies make are huge and are amply enhanced by the privileges and tax incentives they receive at the expense of poor Tanzanians and even indigenous Tanzanian companies, who are unable to compete with the foreigners.
  
  Despite mining companies having a deplorable human rights and corporate responsibility record, laws, neither Tanzanian nor international, do not adequately protect those who have to work for the industry. In particular, laws do not protect those who lose their land, those whose environment and water supply are contaminated and those who formerly made a living as artisanal miners. Tanzania has enough valuable resources to improve the living conditions for all Tanzanians but the revenue from these resources always seems to leave the country. All that ordinary Tanzanians get is the pollution, the industrial problems and the social problems, the majority remaining very poor.
  
  In Kenya, similar things are happening. Land is being grabbed to be used to produce food and biofuels for rich countries. This viable land is currently occupied by Kenyans but is being sold as 'unoccupied' and 'marginal'. Whole ecologies are being destroyed to produce unsustainable crops for the benefit of non Kenyans, but at the expense of Kenyans. The Kenyan government appears to be doing little to protect its citizens and seems to be keen to promote the interests of this land grabbing. As if things were not bad enough in the worst affected area, the Tana River basin, Tiomin are going to do some kind of mining there, a Canadian company with a disgraceful record of wanton destruction.
  
  The only good news is that a few hundred families in the Tana River basin have been awarded 2.55 million Kenyan shillings each as compensation for their land. Unfortunately, the people involved were displaced for environmental protection reasons. It seems unlikely that there will be any compensation for people displaced to make way for the miners and land grabbers. WTO rules tend to defend such land grabbing and resource exploitation, protecting only the interests of the very rich. Condemning vast populations to generations of poverty, disease, dependency and degradation is all in a day's work. It's been going on for a long time and it's not going to stop now, not as long as there is money to be made.

• Aid is But a Tiny Fig Leaf

  Posted: April 19, 2010, 11:47 pm by Simon

  While the Icelandic volcanic cloud means that people in Europe are having to cancel or postpone trips or find alternative ways of returning from trips, Kenyans are worrying about what is going to happen to their perishable produce, such as flowers, fruit and vegetables. Europe is their biggest market. Although owners of these industries make huge profits when things are going well, the employees, who make a pittance, make nothing at all when something prevents produce from getting to market.
  
  At the same time, the BBC comments on a report that finds that the UK imports a lot of its water from other countries in the form of produce such as flowers, fruit, vegetables and other goods. Much of this imported water comes from developing countries, such as Kenya, where clean water and sanitation problems are responsible for high rates of avoidable mortality, especially among infants and children, and numerous treatable and curable illnesses. The report estimates that two thirds of the UK's water use is imported.
  
  The mass production of non-seasonal food and non-food crops by developing countries results in much of the starvation that the UK and other rich countries seem to see as 'natural disasters', to be remedied by a sticky plaster, some handout or even a 'deal' of some kind that is calculated to do more harm than good (it benefits the donor, of course). Yet the industries that claim to be such a great source of foreign currency, fruit, vegetable and flower industries, are mostly foreign owned, British owned, in fact. They pay little or no tax in Kenya and, being offshored, little in Britain either.
  
  When a country like Kenya starts to realise that their 'cash crops', such as tea, sugar or coffee don't make them much money, they seem to reach for another cash crop. The Kenyan cotton industry (along with that of many other developing countries) was wrecked many years ago by the US cotton industry successfully lobbying for subsidies to support them so that no developing country could compete. Subsidies are bad, according to the US, except when they are US subsidies. Sadly, Kenyans are calling for their government to help them return to cotton production. But this is unlikely to fly because US cotton is still subsidised to such an extent that no developing country can produce it as cheaply. And this is despite Kenya having pay and working conditions that would make Bill Gates proud.
  
  But cash crops have always made very little money. Many of them here are grown as part of a kind of agreement that was formed with British land 'owners' after independence. They were allowed to keep their land and those Kenyans producing their (the colonial's) crop, tea, for example, were bound to go on producing tea. The law is slowly changing so that people may be allowed to stop producing tea and produce some food instead (God forbid!). But with sugar, the factories are demanding that even more land be given up to it so they can produce biofuel. Never mind that those whose land the sugar cane is planted on make little or no money from it.
  
  It may well be wondered why farmers produce a non-food crop when they are starving and these crops don't make any profit for them. Well, aside from the promise to keep producing crops that only profit foreign companies, such as Unilever, farmers can't afford the inputs to grow food. They could make a lot of money from growing food and feed themselves at the same time. But as the government does little to support subsistence farmers, only being able to help the rich industrialists with tax breaks and other preferential conditions, farmers have to accept the generous offers from the likes of sugar companies to meet some of the costs involved. In the end, the farmer does all the work and gets little remuneration, if any. And they and their families starve.
  
  Biofuels, like all the other luxury and non-food crops produced in developing countries, effectively export unthinkable amounts of water, along with vast tracts of land. The 'natural' disasters of flooding, drought, famine and the rest, are not as natural as they are painted. Rather, they result from explicit policies and agreements that keep things cheap for people in rich countries, profitable for foreign companies, and if any of those people in developing countries start complaining we can always point to the aid money we send them, whatever aid money even reaches the majority of people.
  
  It's no secret that rich countries steal water from developing countries, preferring to feed ourselves luxuries and run our cars than allow undernourished and starving people to eat. But we steal a lot more than that. The majority of people in Kenya are subsistence farmers or workers. Even those who have jobs usually work for very little so that those in rich countries can afford cheap raw materials and goods. Many people have next to nothing, and that seems to be the way we in the West like it. And in return for extracting what we can, we send a little money every now and again and think of ourselves as very philanthropic indeed.
  
  There is an alternative to rich countries sending ever increasing sums of money to developing countries. That is to identify some of the ways they extract even larger and faster increasing sums of money. That way, Kenya could be assisted to develop its own flower businesses. They could produce and process fruit and vegetables, thereby making more money from them. They could choose what crops to grow and in what quantities, especially crops that could be used to produce high value goods. In fact, the list of things that constitute extraction of wealth by rich countries from countries like Kenya is very long. Then Kenyans will be in a position to tell us what to do with our aid.

• Health Aid: Supporting People or Supporting Indicators?

  Posted: April 17, 2010, 1:37 am by Simon

  While news that maternal mortality has been decreasing since 1980 has been welcomed by many, others point out that a significant contributor to maternal mortality is HIV. A lot of attention and resources go towards mother to child transmission of HIV (MTCT), but very little go towards the health and survival of the mothers. Concentration on the single indicator of numbers of infants infected by their mothers, also called vertical transmission, seems to have left the health of HIV positive mothers out of the picture.
  
  Of course, it is madness to ignore the HIV status of the mother, for many reasons. For a start, mothers are people too, not just 'cases' or carriers of disease. They, like their children, husbands and other family members, are entitled to health and to treatment when their health is compromised. And it would be madness too to ignore any other diseases, in mothers and children or anyone else. But health funding is mad. Hence the selection of a few headline grabbing indicators.
  
  HIV positive mothers can go on to transmit HIV to their infants at a later stage, through various routes, or to their partners. They are at risk of dying from Aids related illnesses or of suffering from serious and prolonged illnesses. These will also have an impact on the health of their children and other family members. Even the MTCT prevention treatment (PMTCT) can lead to drug resistance in mothers. In developing countries this can seriously affect the chances of the mother being successfully treated or cut the length of time that the treatment remains effective.
  
  It seems extraordinary that health funders still take this piecemeal approach to disease reduction, even when it directly affects their chosen indicator(s). Unsurprisingly, the report was funded by the Gates Foundation. They particularly favour somewhat rarefied approaches to health issues, selecting the bits that they are interested in and leaving the rest. For example, the foundation is interested in finding a vaccine for cholera but not so interested in clean water and sanitation, which could reduce incidence of numerous water related health issues. (They give small amounts of money to water and sanitation projects but nothing like the amount going to vaccines and the like.)
  
  A particularly worrying aspect of approaching MTCT in this piecemeal fashion is that as many as half of infant infections may result from mothers who were infected while they were pregnant or whose positive status was not detected while they were pregnant (perhaps because they were in the 'window' period, where they had not yet seroconverted). This occurred in a PMTCT programme in Malawi, considered to be one of the best. Another survey found that such missed maternal HIV infections resulted in a high percentage of infants being born HIV positive. Ironically, the paper also concludes that recently increased child mortality rates in KwaZulu-Natal could be caused, in part, by increased maternal mortality.
  
  It has been suggested that this may be a potentially useful role for pre-exposure prophylaxis (PrEP). PrEP involves putting HIV negative people on antiretroviral drugs, usually where they are thought to be at particular risk of infection. Of course, some of these women may not have been infected through sexual intercourse. It is not even clear from the article whether the mothers of infants subsequently found to be HIV positive were also re-tested or were just assumed to be positive because their infants were. Apparently, an unusually high percentage of women who were not found to be HIV positive before delivery were later found to have HIV positive infants.
  
  Concentrating on one disease or on that disease in one demographic, or even looking at absence of sickness as the only criterion for health, is not going to ensure the health of whole populations. The dominant approach to HIV and the almost universal adherence to the behavioural paradigm (the view that the disease is predominantly sexually transmitted) is wrong for many reasons that have been made clear, in particular, by our lack of success in significantly slowing the pace of transmission. It's time to look at HIV as being part of health as a whole, as being related to the totality of conditions in which people live and work.
  
  If we continue to fail to ensure good health services, education, nutrition levels, food security, infrastructure and numerous other conditions, all diseases, including HIV, will continue to spread. This will reduce people's quality of life and life expectancy. Self serving reports that show how well some favoured indicator is doing should be seen for what they are. Billions of people still suffer from and die from preventable and treatable diseases every year. That's nothing to celebrate.

• Oxfam Abandons Development, Goes for Corporate Lobbying

  Posted: April 16, 2010, 8:54 pm by Simon

  It is easy and sometimes even right to criticize NGOs, especially big, well funded ones, for spending a lot of money on dubious programmes, such as technical aid that may only benefit a handful of rich Western 'experts'. But when it turns out they are using their money to support one of the most destructive agricultural processes to date, genetically modified organisms (GMO), it's hard not to be very angry. Yet Oxfam America seems to have been nobbled by the biotechnology industry and its supporters, the Rockefeller Foundation and the Bill and Melinda Gates Foundation.
  
  Of course, Oxfam have pulled out the poverty and food security cards to make it look as if GMOs are just the solution they need. But production of GMOs requires industrial scale farming practices. Although these are found in developing countries, those involved are not poor farmers. Most farmers in developing countries are subsistence farmers. They cannot afford the sort of inputs required by GMO farming and where they have fallen for the lies and taken on GMOs, they have ended up in debt. In addition to the inputs being very expensive compared to non-GM inputs, yields at the subsistence level have not been higher, indeed, they have often been lower. So GMOs, despite claims to the contrary, do not scale down.
  
  This is not to suggest that large scale GMO farming has been successful either. In the handful of countries where this has been practiced, the US, India, Australia, Canada, Argentina and a few others, yields may have increased for the first few years. But input costs have also risen, especially pesticides and fertilizer costs, and yields flatlined or decreased after that. US GMO farmers, especially, are finding out what it's like when superweeds take over, weeds that develop resistance to even huge applications of herbicide. And Indian farmers have found what it's like when pests develop resistance to the GMO industry's noxious sprays. Even Canada is realising what it's like to face blacklisting by many of the countries who have been buying their agricultural outputs because of contamination by an organism that has been banned there for years.
  
  So what does Oxfam think they are doing, trying to trick the very people they are supposed to be helping? This may be related to funding they have received from Rockerfeller and Gates, who are wedded to the GMO industry till death do us part. Frankly, I think if Oxfam is willing to take funding from organisations that only have the interests of multinationals at heart, they should not be receiving public funding. They have, effectively, jumped ship. They should be treated accordingly. They should no more be considered to be independent or to be benefiting poor people in developing countries that they would be if they had decided to accept funding from the armaments industry. Of course, I don't know whether they already receive money from the armaments industry or not.
  
  Farmers, especially those working small and medium sized farms in developing countries, need ecologically and economically sustainable farming practices. They certainly don't need expensive and highly damaging technologies that render the farmers slaves on land whose quality is fast diminishing. GMOs will increase food insecurity, dependency, poverty and low health. Ultimately, people will die as a result of embracing GMOs. And Oxfam, along with their friends in the Gates and Rockefeller Foundations, will be responsible for the resulting poverty, death and destruction. The latter two were set up to wreak destruction, despite their stated ambitions. But I don't believe Oxfam was set up for this, I believe they have more recently been injudicious in their choice of funders. Perhaps there is time to rethink this and, if necessary, send back the blood money they have received. Alternatively, they can admit that they are no longer involved in development and concentrate on promoting and lobbying for the systematic destruction of whole societies, economies and ecosystems. And then they may as well accept money from the armaments industry, while they are at it. It could make the job quicker.
  
  Incidentally, the experience of African countries so far with GM crops is not good. Millions have been spent over a long period in Kenya to produce a GM sweet potato but nothing has been delivered yet that can outperform conventionally bred versions. South Africa found that Monsanto had blundered somewhat by supplying them with 'free' genetically modified maize that didn't produce any grain. But the industry is still doing everything it can to force more GMOs on South African farmers. Attempts to introduce GM cotton in West Africa have met with the same problems as GM cotton everywhere and Monsanto has even admitted that it has failed in India. However, their solution to this problem is that farmers buy a new and more expensive version of the failed crop. I assume West African cotton growing countries will receive the same privilege.
  
  None of the arguments that Monsanto and the rest of the GMO bunch use to defend the technology work. The evidence has always shown that conventional crops and farming practices are the only ones that work and that are sustainable. This is especially true for small farmers, those who are most likely to suffer from poverty, food security and environmental degradation problems. It is to be expected that Monsanto and other interested multinationals will lie, cheat and pay through the nose (also known as lobbying) to make us think otherwise. And why wouldn't they when they receive so much public money to do this. But we also have to be aware of the influence of the rich privately owned institutions, such as the Rockefeller and Gates Foundations, who are supporting GMO. And sadly, we have to add Oxfam into the equation, unless they suddenly remember who it is they are supposed to be working for.

• Visiting With SAIPEH

  Posted: April 13, 2010, 1:12 am by Simon

  Although I am only in Mumias on a short visit, I brought a couple of solar cookers with me, along with some black pots. I was hoping I would be asked to demonstrate the impressive, but very simple, trick of cooking food without any costly fuel. Sure enough, I was taken to SAIPEH's feeding centre, where volunteers feed 100 or more children who are orphans, in some way vulnerable or disabled. They get through a lot of fuel every day and the cost over the course of a year is in the region of $1000. This is a very sizable sum to an organisation like SAIPEH. Any way of reducing it or eliminating it would be very welcome.
  
  There were only a few people when I got there as it was far too early for lunch. But we set up the cookers to prepare some rice, just to demonstrate. We also set up a cooker to demonstrate how you can pasteurize milk or water to make them safe to drink. Solar cookers heat things up to 80 or 85 degrees, which is hot enough to cook and to kill all bacteria. In order to show that the water had reached the required temperature, we used a WAPI (Water Purification Indicator). This is a plastic cylinder with a lump of wax inside which melts at a little over 80 degrees. The wax is at the top of the cylinder when you start, but as it melts, it slides to the bottom.
  
  Both the demonstrations worked well, despite a lot of thin cloud. The sun was hot even though the cloud didn't shift the whole morning. The rice cooked faster than I expected, in about one and a half hours and the water was ready in about 45 minutes. People were appropriately impressed. Every time I demonstrate, I keep thinking, what if it doesn't work. But it always does, as long as it doesn't cloud over. But in addition to being impressed, I would like to think that people would adopt the technology. They always say they will, but people who have been demonstrating for a long time say most people never adopt it. So we have to wait. Given that SAIPEH pay for the fuel, perhaps they will make sure that the fuel bill is cut, substantially.
  
  We also had the opportunity today to demonstrate cooking baskets, at least, to some extent. There were lots of banana trees growing nearby and there were deep, round baskets available. We weren't organised enough to cook anything in one, they were too small, but I think the point got across. These can really save a lot of fuel and you can use them whether it's night or day, sunny or raining. They can be made of easy to find materials, such as straw, hay, newspaper, leaves, old clothes, etc, along with a bit of sacking material if you don't have baskets of the right size.
  
  A technology we didn't have the opportunity to demonstrate yet, we just described it, is that of fuel briquettes made from organic waste, such as kitchen waste. They are made of various kinds of waste, finely chopped and mixed so they bind into a cohesive lump. These can be dried or compressed with a simple press made of wood or metal. We haven't got a press yet but we are still hoping to get one made as a template. Then they can easily be produced by 'jua khali' workers (jua khali meaning 'hot sun', they work outside).
  
  If you combine these three technologies and put the required amount of work in, and that's not a lot of work, you can reduce your fuel bills to almost zero. Perhaps you can eliminate them but I suspect there will always be unforeseen occasions when you will need wood and charcoal. But even a few hundred dollars a year could mean better food for existing children or more food for more children. Now that the idea is there, hopefully there will be those who want to use these intermediate technologies. I'll be checking up on them now.
  
  SAIPEH support several hundred children and teenagers and this brings up many problems that children have when they are orphaned, disabled or in some way vulnerable. A meeting revealed that some girls are still unable to go to school when they are having their monthly periods. I felt so bad when I heard that there was even a girl who reported using leaves because she didn't have access to any alternative. But it is unthinkable that even some of them are unable to go to school because of something like this.
  
  Some community development workers in Kenya and other African countries teach girls to make re-usable sanitary pads out of flannel or other appropriate materials that can be recovered from old clothes. They are easy to make, especially for SAIPEH, as they have a training and resource centre that teaches tailoring. Making sanitary pads would be a great thing for prospective tailors to start off with. You can start and finish several of them in a few hours. A perfect lesson plan! Again, I hope there are people willing to adopt this simple alternative to commercial disposable sanitary pads. They are very expensive and ultimately unsustainable, both economically and environmentally.
  
  No matter how good these intermediate technologies are and no matter how appropriate they are, the main challenge is getting people to adopt them. Just being impressed is not enough. You may think that anything would be better than using leaves instead of proper sanitary pads, but these technologies have been promoted elsewhere and they haven't always taken off. For me, it's all very well doing the research and giving people the plans and diagrams, but I'd really like to crack the nut of why people seem unwilling to adopt things that seem so obviously good and how I can meet this challenge. If and when the scales drop from my eyes, I'll report back.

• Rambling in Kenya

  Posted: April 13, 2010, 12:06 pm by Simon

  Yesterday, I made the fairly familiar journey from Nakuru in Rift Valley province to Mumias in Western Province. There are many beautiful sights on the way and the weather was good for travelling, sunny but not too hot. The roads for some of the journey have been improved, some are sill in the process of being improved and others are disintegrating and in a very dangerous condition.
  
  Infrastructure conditions in Kenya have a lot to do with structural adjustment policies imposed by the IMF (International Monetary Fund) and the World Bank. These were first imposed in the early 1980s and they are still used, but they go under different names sometimes. Whereas, the road and other infrastructure improvements have a lot to do with Chinese development, which is carried out without the same level of conditionality.
  
  Much of the fertile land in Nakuru is owned by a handful of very rich people, many of whom are members of political families, the Mois and the Kenyattas, for example. And like a lot of rich landowners, they don't feel the need to grow food crops or, at least, not food crops for Kenyans. You might think that wheat, sorghum and millet are food but the large scale producers, apparently, grow these crops to sell to breweries.
  
  A few hours from Nakuru, the next big non-food product is tea, which dominates Kericho. Most of the industry is foreign owned or run and Kenyans make very little from this monoculture. It may be a world renowned product, but employees are paid very little, live in bad conditions and have few labour rights. That applies to those who have real jobs, rather than the far larger number, who have to take whatever bit of work that crops up, however rarely and however badly paid.
  
  One of the big employers there is Unilever. You can read up on their level of corporate social responsibility on the Corporate Watch website. Suffice to say, they tick all the boxes that you'd expect of a multinational; monopolistic practices, unsustainable agriculture, exploiting cheap resources and labour, environmental degradation, appalling health conditions and a whole lot of other things. It's a long and depressing read.
  
  Long before you reach Mumias you begin to see the sugar cane fields, sugar being another of Kenya's handful of monocultures that have played a big part in keeping Kenya poor for many decades. While sugar cane has long been grown in Mumias to be used as sugar, now there are plans to grow even more sugar cane destined for the biofuel market. Yet more land that could be used for food is being sacrificed for the blessed export market. The profits will go to a handful of rich people. Mumias Sugar Company does pay its employees well but the majority of people who work for the Sugar Company are not considered to be employees. They are casuals, contractors, outgrowers, etc. The majority of them make bugger all.
  
  It probably sounds like I have a thoroughly miserable time travelling through Kenya, thinking about how much of the country is dedicated to exploitation. Well, there are still a lot of beautiful sights, if you are in a position to enjoy them. There's a good reason why tourists come to places like Kenya and even the trip to Kakamega Rainforest, Mount Elgon and Lake Turkana can be a great way of seeing the country. But even the tourist industry is another case in point; very few people make most of the money. The majority eke out a living somehow, but much of the tourist revenue doesn't even stay in the country.
  
  Such conditions in developing countries may be, to some extent, influenced by their own governments. There are, indeed, many corrupt politicians and other parties and they have made themselves very rich. But governments, multinationals and other parties in rich countries have also made themselves rich by grabbing much of the wealth to be made in developing countries. And institutions like the IMF and the World Bank (and the World Trade Organisation) are simply some of the tools by which the rich and powerful extract huge amounts of wealth from the poorest and most vulnerable people in the world.
  
  Poverty and underdevelopment are not remote phenomena, far from Western style homes and living conditions. The forces that create and exacerbate poverty also bring to those living in comfortable conditions many of the cheap products that make their lifestyle possible. Tea, chocolate, coffee and other things that come, primarily, from developing countries, are only affordable because of policies created by undemocratic institutions (who, ironically, constantly talk about improving democracy in developing countries). Even Ipods, Iphones and Macs, made by a company that likes to boast about how responsible they are, depend on (high value) materials extracted cheaply from countries like the Democratic Republic of Congo.
  
  Much of Western democracy itself, and much Western wealth, depend on the terrible conditions that are created and maintained by undemocratic international financial institutions, multinationals and powerful governments in developing countres. It doesn't seem possible for every country in the world to end up with the same kind of democracy enjoyed by a handful of the world's people. I don't want to argue that democracy is impossible or that it is wrong. Perhaps, as Amartya Sen has argued, there is not enough democracy. Perhaps it is not widely enough distributed.
  
  But if Sen is right and there were more democracy in the world, I think it would look a lot different. The small number of countries that have enough, too much in fact, use more resources per head of population than the world can provide. The level of choice that some people enjoy, the range of goods and services, necessary and unnecessary, the opportunities to overconsume with impunity, could not be offered to all peoples, equally. But I haven't gone deeply enough into political philosophy yet to figure out what sort of democracy would be sustainable democracy. Perhaps I'm just rambling.
  
  I'm in Mumias to visit a very fine NGO called SAIPEH (Support Activities in Poverty Eradication and Health). Like the community based organisation I work for, Ribbon of Hope, Nakuru, they work with HIV positive people and their families, people suffering from hardship, orphans and vulnerable children. (Except that SAIPEH has been going for about 14 years, Ribbon of Hope is still small and young, not much over a year old.) Anyhow, they run all kinds of income generation schemes, such as growing food crops and livestock, teaching people trades, such as tailoring and computing and various other initiatives.
  
  I'm hoping that SAIPEH will be interested in schemes that reduce spending too, such as solar cookers, cooking baskets and fuel briquettes made from organic waste materials. For lack of a convincing political philosophy, I'll stick to a more Aristotelian form of home economics in the hope that, although people will not end up rich, they may end up with a bit more cash than they had before. After all, for Aristotle, all economics was home economics.

• Food Security Means Non-GM Food

  Posted: April 10, 2010, 1:38 am by Simon

  Not content with contaminating their own country with genetically modified organisms (GMO), American GMO patent holders are busy getting politicians and other powerful people to help them in their quest to contaminate whole continents, such as Africa. African countries haven't proved to be the pushover that these GMO multinationals would like, but there are powerful people willing to give them a helping hand, such as Bills Clinton and Gates.
  
  Despite spewing out the mantras about free markets and lowering barriers to trade, patenting is the ultimate form of protectionism. Owners of American GMO patents don't even need to grow their contaminants in America to reap vast profits. They can simply palm them off on poor farmers in far away developing countries, for whom GMOs are entirely inappropriate, and rake in the cash royalties.
  
  The two Bills are supporting what is known as the Global Food Security Bill. Despite the name, this bill aims to foist GMOs on people in developing countries by dressing them up as aid. The idea is not a new one; public money is used to open up new markets for these thugs and they pocket the profits. Only the very rich and powerful will benefit from all this. But isn't that what aid is for?
  
  For many years now, millions of dollars of 'aid' money has gone into developing a genetically modified sweet potato in Kenya. Strings have also been pulled to get some laws adjusted so that such crops can be commercialized. The problem is, this potato hasn't really taken off. Local varieties have performed far better in trials. To add insult to injury, breeders in Uganda have developed a virus resistant sweet potato using traditional methods while working on a shoestring.
  
  GMOs of any kind would be a disaster for Kenya and for any other country. Just look at the problems the US, Canada, India, Argentina and Australia are having with their contaminants. But the organisms are particularly dangerous for developing countries. The last thing small farmers need is crops that cost a lot to grow (GM seeds are far more expensive than conventional ones), that develop serious yield and pest problems and that systematically destroy the ecosystem. But that pretty much sums up GMOs.
  
  Anyone interested in reducing hunger should encourage sustainable agricultural practices that are appropriate for small farmers, because most farmers in developing countries are smallholders. They should steer clear of expensive and inappropriate technologies, such as GMOs. These were developed for rich, large scale farms, although they don't even seem to be benefiting them. For every advantage claimed for GMOs so far, conventional breeding practices have surpassed those claims. GMOs are not just unnecessary, they are highly undesirable.

• Malawi Needs Good HIV Research, Not Bad HIV Laws

  Posted: April 9, 2010, 9:34 pm by Simon

  Malawi has this cunning plan to 'outlaw HIV transmission' by making it a crime to 'knowingly' transmit HIV. A spokesperson for the ministry involved said "The underlying factor is that if anybody knowingly infects somebody...that means he commits an offence." I haven't been able to find a copy of the bill but apparently it means that if a HIV positive sex worker fails to let partners or clients know their status, they will be liable to prosecution.
  
  I wonder if their partners or clients will also be liable to prosecution for failing to reveal their status. After all, people availing of the services provided by sex workers should be equally aware of the danger of transmitting and of being infected with HIV, along with various other sexually transmitted infections (STI). The spokesperson was unable to say what would happen if both parties were HIV positive and referred to the bill as a challenge. He also said what they are doing is educating the populace. I assume he was trying to make a joke, however inappropriate.
  
  I would also like to know where the law would stand with regard to non-sexual transmission of HIV. For example, where health services use shared needles, syringes or medicine vials or engage in other potentially hazardous practices, would they be liable to prosecution? Supposing they failed to take precautions specified under normal occupational procedures, how would the law stand? Could a HIV positive mother be accused of criminally infecting her child, either in the womb, during birth or through breastfeeding? Would a HIV positive intravenous drug user (IDU) be liable by sharing injecting equipment?
  
  If you accept the received view of HIV transmission and believe that 75% of it is transmitted through heterosexual sex and only a very minor proportion through unsafe medical procedures, you may not worry about medical transmission (though this doesn't answer the questions about IDUs or transmission by mothers to their children). But if doubt were cast on that received view, if medical transmission were more common than previously supposed (admitted?), or if it were even more common than heterosexual transmission, you might consider the question more important, especially if you were a health professional.
  
  The trouble with medical transmission of HIV is that it has received very little research. Figures you hear bandied about are mostly based on assumptions which should never have been allowed to stand untested, as they have been, for several decades. But among the few bodies of data that have been collected, medical transmission has been found to be a risk in almost all of them. This doesn't mean that medical transmission has been demonstrated, just that those receiving injections have a higher risk of subsequently being found to be HIV positive. Notable also is the fact that some of this research goes back to the mid 1980s.
  
  Data from Malawi is the most shocking. 54% of HIV infections are found among those who have received injections in clinical settings. Other countries report lower percentages but the average is 21% and the mean is 19%. For me, the worst aspect of this is that none of these pieces of research are national in scale and only a handful of countries are involved (DRC, Uganda, Rwanda, Tanzania, Zimbabwe and Malawi).
  
  The Malawian spokesperson is right in saying that there no straightforward answers to questions that arise about this proposed bill, but not for the reasons he thinks. If medical transmission of HIV is higher than has been previously assumed, it would be more worthwhile, indeed, more straightforward, to investigate this and provide some remedies. That would certainly be more feasible than trying to create laws of dubious ethical standing to reduce HIV transmission.
  
  On the whole, it would be a good thing if HIV was less likely to be transmitted sexually because it is difficult to influence the sexual behaviour of whole populations and efforts so far have failed. In contrast, it should be much easier to influence the practices of existing health personnel, increase the number of trained personnel, increase the resources available to them and increase access to health services. And improving health services will have benefits that far exceed those to HIV alone. As to how providers of medical services can regain the trust they will have lost, that will be no easy matter. But I don't think anyone would opt for continuing to transmit HIV through medical procedures, if this is actually happening.
  
  The admission that medical transmission of HIV could be higher than previously thought, and even that sexual transmission could be lower, may be a hard one to make. Of course, it may not even be true that medical transmission is higher and sexual transmission is lower. But now that the possibility has been raised, we can not continue to fail to research this vital area of HIV knowledge. Let us stop lying about what we don't yet know.

• The Biggest 'Omission' in Medical in History?

  Posted: April 8, 2010, 12:34 am by Simon

  Sometimes you come across a theory that can explain so much that you wonder why you have been flailing around hopelessly for so long. One time I was looking around one of those electronics shops that you find in every terminal in London's airports. I was marvelling at the things that can be made and even purchased at fairly reasonable prices. Because I was studying development at the time, I was trying to think why the sort of ingenuity that that goes into these products, which were hardly vital to humanity, didn't go into development. The proto-theory I came up with was that some people just don't matter.
  I was horrified that this thought could go through my mind just then, because it is a value judgement, not a scientifically testable theory. Surely it has no place in development theory, especially in the specific area of HIV research, a field peopled by some of the most brilliant scientific minds alive? But the thought never left my mind because it seemed to explain so many things. How else could you explain the way people in rich countries treat people in poor countries? The more I studied, the more I realised that some people believe that (or behave as if) other people don't matter, either because they are far away, they are foreign, they are poor, they are sick and needy or are just not worth considering.
  While studying HIV, I was unconvinced that the entire explanation for the rate of HIV transmission, in some countries only, could be explained purely by differences in sexual behaviour. I was equally unconvinced that so called HIV prevention programmes could possibly have any influence on sexual behaviour. And when countries boasted about how successful they were in reducing HIV transmission as a result of these prevention programmes, I thought they were unclear about why HIV prevalence had dropped and didn't really care why, they just used the circumstance for publicity.
  I had to limit my study to make it manageable and did so by concentrating on heterosexual transmission of the virus, since it is the received view that this is the main mode of transmission in countries with a generalised epidemic, such as Kenya. And it turns out that that is one highly dangerous received view, for many reasons. Heterosexual transmission of HIV is definitely one mode of transmission, but the extent to which it drives generalised epidemics is completely unclear, and it always has been.
  So my objection to the main players in the HIV industry is this: why has so much money and effort gone into programmes that assume the precedence of heterosexual transmission when this is just an assumption? The whole idea that there are some people who have more sex than others, or more sexual partners, or who are more likely to engage in unsafe sex, is a value judgement. But it is the value judgement that has launched a thousand careers for politicians, religious leaders, social and religious leaders, professionals of all kinds and who knows what else. It is a value judgement that drives global HIV prevention policy and spending.
  There are many warning signs that heterosexual transmission of HIV does not explain extremely high rates of transmission in some countries. No credible correlation has ever been found between rates of transmission and levels of the kind of sexual behaviour that would be required to drive the sort of epidemics found in Kenya, South Africa, Lesotho, Swaziland and anywhere else. There are so many contradictions and non-correlations that many professionals in the HIV industry must have been asleep since some time in the 1980s, because there were obvious problems with the sexual behaviour paradigm even then.
  Even back in the 1980s, not long after HIV was identified as the virus that caused AIDS, medical transmission was recognised as one of the possible modes of transmission. Small amounts of research went into establishing the extent of unsafe medical practices and the results suggested that these practices could transmit HIV to many people. But little further research was carried out. WHO, various UN agencies, leaders of all descriptions, professionals of all descriptions, various globally represented organisations, institutions, universities and others flew the flag for heterosexual transmission of HIV in developing countries (though not in developed countries). There were few exceptions and they were considered to be denialists or trouble makers. There are still few exceptions and they are still considered to be denialists or trouble makers.
  Well, maybe medical transmission of HIV is not very high, maybe it is lower than heterosexual transmission. Maybe all the fuss is about nothing and maybe I'm just one more person poking his nose in where it doesn't belong. But that is the point: I want to know why medical transmission of HIV has not been properly investigated, why it is still dismissed as being almost non-existent. The recently published (though based on out of date data) Modes of Transmission Survey for Kenya suggests that medical transmission accounts for 0.6% of all transmission, based on an assumption that seems to have been pulled out of thin air. They also note a finding that puts the rate at 2%, over three times higher. But this is still dwarfed by most of the other modes of transmission, especially heterosexual transmission.
  But those who are still being branded as mavericks for questioning the received view point to many bodies of data that have managed to investigate medical transmission rates of HIV. Those bodies of data show that medical transmission is very significant, perhaps even more significant than any other mode of transmission, including heterosexual transmission. All they are asking is that these results be taken seriously and subjected to rigorous testing. If medical transmission of HIV even stands at 5%, this would still account for millions of people currently living with HIV and hundreds of thousands of people who have died of HIV.
  One of the most heartrending things about people dying of HIV, as opposed to other diseases, is that they are, because of the unexamined and long held value judgements of so many 'brilliant minds', vilified, ridiculed, shunned, persecuted, sneered at and humiliated just when they are in most need of sympathy, love and basic humanity. If it is even remotely possible that we as people are guilty of such terrible injustice to fellow human beings, surely that is in urgent need of investigation? Far from dying because they have engaged in what may or may not be risky sexual activity, people may be dying because they have followed the advice of well educated professionals.
  It's almost unthinkable that much, or even any, recent cases of HIV have been transmitted by the very professionals that are supposed to be preventing and treating HIV. But it is even more unthinkable that we could suspect such a thing is happening and do nothing about it. Maybe there is a danger that people will stop going to health professionals and stop seeking medical treatment, even vital vaccinations and life saving treatment, because of a complete lack of confidence in the profession. But that is something the profession will have to deal with because they certainly don't deserve any confidence or respect until they have fulfilled obligations that have so long been outstanding. In fact, in some countries, going to the doctor may curently be a health hazard, carrying risks of infection with HIV and many other blood borne diseases.
  In the field of HIV, nothing is more important right now than establishing the extent of HIV transmission through medical treatment.

• European Protectionist Agreements

  Posted: April 7, 2010, 1:53 am by Simon

  Recently, I expressed a sceptical view of the EU's proposed Economic Partnership Agreements (EPA) with African countries. I suggested that while the EU pretends such agreements are for the benefit of Africans, this is just a sham and that they are unashamedly beneficial to rich countries and detrimental to the development of poorer countries. The former president of Tanzania, Benjamin Mkapa, is in agreement with me, warning that EPAs are a form of neocolonialism. The EU have been quick, but unconvincing, in their denial of any underhand intentions.
  Their response is unconvincing because they are effectively just offering more of the same. African countries will produce low value goods and raw materials, which the EU will buy for as little as possible. In return, the EU will sell African countries high value products that have been produced cheaply, in part, because of the low raw material costs. Sometimes, these high value goods will even be produced using badly paid Africans, which will further increase the profits for the EU. The EU assures African countries that they will be allowed to phase out some tariffs more slowly than others. But ultimately, the EPAs need to obey the strictures of the WTO (World Trade Organisation), where 'world' means 'rich countries, especially the US'.
  While the EU is pumping out the woolly rhetoric about African countries removing barriers, they are piling up the barriers to make it more difficult for African products to reach the EU markets. It's the time honoured process of protecting their markets while accusing weaker economies of protecting theirs, a process particularly relished by the US and UK when it suits them, only to be replaced with a sanctimonious plea for free trade when the conditions are right.
  Incidentally, a piece of particularly woolly rhetoric is the 'Agreement on Sanitary and Phytosanitary Measures', which you may need to read several times only to remain totally confused. The EU can insist on certain standards for food coming into the region that make exporting by African countries to the EU too expensive. According to these measures, that is not what is supposed to happen, but it effectively means that most African countries can't export to the EU. And the EU supports those exporting goods to African countries by methods that would be considered to be subsidies if they were implemented by Africans.
  Even the private sector in Africa is suspicious of EPAs and they are the people who may be expected to have most interest in them. So if the private sector and other influential people are not about to be hoodwinked yet again by the protectionist West, perhaps there is hope that African countries will have some influence on other trade issues that have, so far, kept most of them underdeveloped.

• Medical Transmission of HIV May Be Widespread in African Countries

  Posted: April 7, 2010, 3:06 am by Simon

  A couple of weeks ago I was taken to see a woman in a rural area who was very sick. She was terribly emaciated and the place she lived in had clearly not been looked after for a long time. The woman insisted that she did not have HIV, although she also claimed not to have been tested. After a few days, she was taken to the local health centre. There, it turned out that she had already been tested for HIV, was found to be HIV positive and was put on antiretroviral drugs (ARV). But she refused to take the drugs and agreed to be sent home, as the health centre was unable to do anything for her. She died about one week later.
  All we could do was insist that she went to the health centre to be tested and take her drugs. She reluctantly went to the health centre but refused to take her drugs. It was as if that was all that was left to her to preserve her dignity. For some time, she had refused the advice of neighbours and health volunteers. And they were growing less willing to visit her, because they knew that she was going to die. On the day she went to the health centre, she looked humiliated and perhaps even angry.
  The stigma that still attaches to HIV/Aids, and even TB because of its association with HIV, may seem like a sticking point that results in people wishing to deny that they have been infected, even when the cause of their illness is undeniable. But the stigma is real. People are ostracized and treated differently because they have a disease that is associated with illicit sexual activity, either on the part of the sick person or on the part of someone with whom they are intimately connected.
  The 'behavioural paradigm' for explaining HIV transmission is widely adhered to and informs most HIV prevention programmes. From the extremely naive ABC (Abstinence, Be faithful, use a Condom) to the downright foolish mass male circumcision (MMC) campaigns, the assumption is that because HIV is mostly transmitted by sexual intercourse, all we need to do is get people to change their sexual behaviour.
  So far, I have accepted the often published claim that most HIV is sexually transmitted. But I have argued that the circumstances in which people live and work, for example, may determine who they have sex with, when and under what conditions. Trying to influence their sexual behaviour without examining these circumstances too, will result in a lot of failed prevention programmes. Most prevention programmes to date have, indeed, failed.
  But perhaps, while rejecting the behavioural paradigm, I have fallen into the trap of accepting something like a sexual paradigm, that most HIV transmission is sexual transmission. Perhaps this is not even true. I was aware that there were people arguing that non-sexual, particularly medical transmission, could be far higher than accepted by many theorists. But I had to exclude certain lines of enquiry in order to limit my dissertation to a manageable field. Now that I am no longer so constrained, I have time to revise this limitation.
  If medical transmission of HIV is significantly more common than supposed by most HIV analyses, a lot of questions could be answered. For example, perhaps more women than men, especially women of childbearing age, are infected because they receive more medical treatment. Perhaps many children who have been infected, especially those whose mother is not infected, have been infected by medical treatment. Perhaps the reason those in Northern Kenya, who have least access to modern medicine, also have very low levels of HIV because they are not being infected by medical procedures.
  I have been reading a book by Daivd Gisselquist called Points to Consider: Response to HIV/AIDS in Africa, Asia and the Caribbean, conveniently published on the internet. Some of the things revealed in this book are truly shocking. When I have finished, I have to go through everything I have written about HIV and reconsider my whole view of it. My view of development will probably remain the same, but the way I reached some of my conclusions will have to be revised, considerably.
  If Gisselquist and others are right, and I have no reason to believe they are are wrong, the woman who refused to take her medication could have been a victim of stigma, not primarily emanating from her own neighbours, but from some of the most eminent health professionals in the world. That HIV is primarily sexually transmitted in African countries is a long held, received view. Because of this received view, people who say they have not had sex in the period in which they became infected have not been believed. Women who are infected when their husbands are not are assumed to have had extramarital sex. Where couples are infected with different strains of HIV, they are both assumed to have been promiscuous, rather than just one of them.
  This received view is in need of thorough testing and it is incredible that it has been used to face down challenges for so long. The view has shaped most of the (highly unsuccessful) prevention campaigns, but also people's reaction to their being infected with HIV or the reaction of others when faced with someone who has been infected. How many innocent people may have died in shame, misery and isolation because the health profession has refused, for whatever reason, to investigate its poorly supported assumptions about frequency of transmission of HIV in medical contexts?

• Excessive Drug Prices Promote Counterfeit Drug Industry

  Posted: April 4, 2010, 1:49 am by Simon

  According to the WHO, lifesaving drugs are not exempt from the trade in counterfeit medicines. But nor are they exempt from the rights of powerful multinational pharmaceutical companies to make obscenely high profits, regardless of the cost in terms of sickness, suffering and death in developing countries. Organisations like WHO and Interpol (effectively, publicly funded) are busy trying to help these poor victims, the pharmaceutical companies, that is. Otherwise, their ability to extract higher and higher profits every year may be compromised.
  Yes, the WHO is right, it is cynical to produce counterfeit drugs, some of which may not help the person taking them; some may make them worse or even kill them. But it is also cynical for Big Pharma to put such impossibly high prices on drugs, spend far more on marketing and lobbying than on research, compromise doctors and other health professionals to push their products, produce goods for the rich world while ignoring the poor majority, using people in poor countries as cheap research fodder for drugs intended for the rich world, preventing poor countries from producing and making generic equivalents of overpriced branded drugs, lobbying the WTO (World Trade Organisation) to make laws that protect Big Pharma at the expense of poor countries and generally frustrating any attempts to regulate them, even slightly.
  I don't know how many people die from counterfeit drugs but I know that an estimated 14 million die every year from infectious diseases, many of them preventable or treatable. The policies of Big Pharma ensure that the majority of people who need drugs most will never be able to afford them. A notable exception is antiretroviral drugs (ARV) for HIV, which have only been reduced slightly in price and only because they are being paid for by aid money. And no one need worry that production of ARVs on a massive scale at slightly reduced prices causes Big Pharma to suffer in the least. If they didn't get the HIV industry to buy their drugs, the market for them would be miniscule in comparison to what it is now.
  So the humbug WHO claim to be worried about ordinary people being exposed to counterfeit drugs. But this is just an excuse to use lots more public money to protect the interests of Big Pharma. Already, public money has gone into the research the pharmaceutical industry claims to do. But most of the costs of drug research are met by publicly funded bidies, such as research institutions, laboratories and universities. Then the drug companies slap a patent on the results and pocket all the profits. If the WHO was really concerned about endangering the public they would lobby Big Pharma to do one simple thing: lower their prices.
  But that is one thing the industry will not do. Far from it, they will continue to lobby to be protected so that they can continue to make far bigger profits than most other industries. Lowering their prices, or even lowering their prices to affordable levels for drugs needed most by developing countries, would have little negative impact on their profits. In fact, like with HIV drugs, they may discover a market they have long been ignoring. But they would prefer to fight for their right to charge more than people in developing countries can afford, perhaps by lobbying for aid money to be spent on drugs other than just ARVs.
  As long as patented drugs continue to be too expensive for people in developing countries, it will be worthwhile for counterfeiters to target them with their products. As long as Big Pharma lobbies against the production and distribution of generic versions of patented drugs, people in developing countries will have no option but to look for cheaper alternatives. Big Pharma, in its efforts to maximise its profits, is creating the ideal market for counterfeiters. Getting Interpol and the WHO to spend increasing amounts of money and creating more sophisticated law enforcement systems is pointless. Counterfeiters will also become more sopisticated, as they are amply demonstrating.
  Why? Because there is good money to be made. Pharmaceutical products don't just include drugs, the number of products that are artificially overpriced because they are produced by this industry is enormous. Who wouldn't grasp the opportunity to take advantage of the opportunity to produce relatively cheap products that can be sold on at ridiculous prices, only slightly less ridiculous than the prices charged by Big Pharma?
  It's because I sympathise with vulnerable people, mainly in developing countries, that I think that drug counterfeiting should be stopped. It's not because I think the pharmaceutical industry should be allowed to hold the world to ransom. But I think the industry itself is creating the problem. The cost of drugs needs to be reduced to make them affordable in developing countries and it needs to be possible for developing countries to produce and/or buy generic equivalents of life saving drugs because they will never be able to pay the prices currently demanded by the industry.

• The Pretence of Aid

  Posted: April 3, 2010, 4:48 pm by Simon

  Some of the issues this blog is particularly concerned with include unfair trade policies that aim to keep developing countries in their current state of underdevelopment, the use of developing countries to produce low value goods and raw materials, but not high value goods, which they have to import from rich countries, and the use of developing countries for growing monocultures and single resources that are often processed in rich countries, earning poorer countries very little.
  Economic Partnership Agreements (EPA) are, to a large extent, behind these and other issues. Rich countries have been busy for a long time trying to persuade African countries to sign up to these EPAs, without much success, yet. But as the number of poor people in African continues to rise, mostly as a result of the 'pro-poor' policies of rich countries, it should be possible to persuade more countries to put the noose around their neck in return for some short term handouts that they need for an emergency.
  Perhaps Kenyans think there is no alternative, perhaps there is no alternative for them, but they seem to be getting further and further into the noose of producing cheap primary goods for export. Huge areas of land are being diverted to use for biofuels and other things that people here are not in great need of. At the same time, small farmers, who produce the bulk of what Kenyans eat, are slowly losing access to land as they are pushed off by rich industrial scale agricultural interests and as the prices rise to levels they will never be able to afford.
  Rich countries used trade tariffs to get to the position they are in today. Now they want poor countries to remove their tariffs so that the rich countries can expand their markets and compete, under completely skewed conditions, against the poor countries' markets. EPAs are dressed up as being advantageous to African countries but so far, most African leaders have not been fooled.
  The East African press generally seem uninterested in non-national matters, so I was surprised to come across an article that discusses the difficult area of EPAs in simple language for a non-political economist like myself to understand. This article sees EPAs as the wrong kind of development model and discusses a number of key points. One of these concerns EPA provisions that are highly detrimental to African countries' development. The EU claims that dismantling tariffs will promote growth, despite the fact that this has never been the case, in any country, or at any time in history. On the contrary, tariff cuts have taken countries in the oppostie direction, leading to stagnation and de-industrialization.
  Kenya is typical of the countries who will suffer if they sign up to an EPA. They depend on a handful of low value primary goods that are often produced by farmers at an extremely small profit, even at a loss: sugar, sisal, coffee, tea, fruit, vegetables and the like. It would be extremely advantageous to Kenya to use those primary goods to supply an industrial sector, if they had an industrial sector. But much of the industry they do have is owned by foreigners from rich countries, who are effectively subsidized to be here. They get tax breaks and other incentives so that Kenyan industrialists have no chance of competing with them.
  Of course, the EU would not want Kenya to develop an industrial sector, not an indigenous one, anyhow. Their economies depend on cheap goods and cheap labour from developing countries. So they dress  up their policies and 'contributions' as 'aid' and they talk the talk of development. And for the EU and other rich parties, African countries are not just sources of cheap goods and labour, they are also important markets, where very expensive goods, often made with cheap African raw materials and labour, are either sold or dumped on the African market.
  It's a disgusting thought, but all the land that has long been used to produce non-food or non-essential food products in developing countries could have been producing food for starving people here in Africa. Instead, starving Africans get a pat on the head and a hand-out from the rich world. Now that some rich countries are unable to produce enough food for themselves, they are buying up African land. Others are buying up African land to produce biofuels. Africans can expect more pats on the head and more hand-outs whenever enough Western attention is drawn to some drought, flood or other 'natural' disaster.
  And don't be fooled into thinking that most of the disasters that strike poor countries are wholly natural. Many are not in any sense natural. People starve, become sick and die during what are referred to as disasters, usually, because they don't have access to the food or the water that is being extracted by foreign interests. The 'shortages' of food that Kenya has experienced recently and will continue to experience into the future have been manufactured. The bulk of land, and therefore water, in Kenya is devoted to producing goods for export. Even those goods that consist of food items are destined for Europeans who can afford it, not Kenyans, whose buying power is undermined by various agreements with the EU and other rich countries and zones.
  

• Human Rights Are Not Just for the Rich World

  Posted: April 1, 2010, 2:16 am by Simon

  According to Dr Marcos Espinal of the Stop TB Partnership, "TB is not a medical problem. It is a development issue. It is an economic problem. It's a human rights situation." And I applaud him for saying this. If developing countries are not allowed to develop (and I would argue that developed countries are doing all in their power to stop them from developing), diseases like TB will not successfully be treated by drugs alone. People in developing countries are poor, they suffer bad health, they receive little or no education, they live in terrible conditions and their human rights are being denied. It is no wonder that TB and many other diseases are rife and increasing.
  I would add that HIV, also, is not just a medical problem, nor is it just a matter of sexual behaviour. Parallel arguments could be used to show that, so far, both HIV and TB programmes have failed to prevent the spread of the diseases and will continue to do so. If you don't deal with the conditions that result in diseases spreading, all diseases, you will not eradicate the diseases. After using little more than expensive pharmaceutical products to treat TB for many years, an estimated 440,000 people are now resistant to commonly used TB drugs. I have not been able to find estimates for the number of people with HIV strains that are resistant to first line drugs commonly used in developing countries, but resistance is a very serious threat.
  There's an interesting article on the website of the United Nations Development Programme (UNDP). They have been publishing the Human Development Report for many years now and they are about to reveal some of the main trends over the past four decades. The Human Development Report measures development by criteria other than just economic, such as health, gender, education and other things. This article notes that there has been significant progress in development, but this has come from improvements in education and health, not economics.
  It also notes that these improvements have little or nothing to do with globalization. Rather, they have been achieved by expansion of "educational and health systems, coupled by initiatives of the international community to enable access to vaccines and antibiotics." In other words, state intervention.
  The research finds that there is no correlation between economic growth and changes in non-income components of human development. It concludes that "the oft-repeated dictum that growth is a necessary condition for increasing human development is simply not true."
  So the approach to development and human rights related problem, such as HIV or TB, is to improve education, health, economic circumstances, gender imbalances, employment, infrastructure and many other things. The approach should not be to set up well financed vertical programmes that target single diseases or narrow issues at the expense of other, broader issues.
  Throwing eye watering sums of money at a problem, such as HIV or TB, will not even solve the problems of HIV or TB. Especially if most of the money is spent on technologies that are produced in rich countries. That's just taking money out of one pocket and slipping most of it into another. It's time for new thinking on development. Development is not just one thing, it's many things. And if you don't know enough about any of them, just read the Universal Declaration of Human Rights and consider how many of those rights people in developing countries are currently being denied.

• More Good News for Big Pharma: Resistant Gonorrhoea

  Posted: March 30, 2010, 11:45 pm by Simon

  Yesterday, I blogged about the fact that TB is on the rise worldwide. Funding for TB prevention, and even for treatment, are not commensurate with the threat to global health that this epidemic poses. And the rise of TB is often blamed on the current HIV pandemic. I would suggest that there is a TB epidemic of a level that can not wholly be explained by the HIV pandemic and that, like almost every disease and health issue aside from HIV, TB is being ignored.
  Those heavily involved in the HIV industry, such as Michel Sidibe, the head of UNAIDS and Michel Kazatchkine, head of the UN Global Fund for HIV, TB and Malaria, deny that high levels of HIV funding have starved other diseases of cash. Kazatchkine claims that 'over a third of of overall funding of the Global Fund is actually going to strengthening health systems'. I don't know how he came up with this estimate but it seems to me that there are only certain aspects of health systems that are benefitting from HIV cash, and those aspects relate to HIV.
  Kazatchkine says the money is not just going on condoms and drugs. I sometimes wonder if the money is even going on condoms, along with the logistics of ensuring that people use condoms all the time and properly. Even the claim that a lot of money is being spent on drugs can seem hollow when people supposed to be taking them often cannot do so because of lack of food. And 20% of the new HIV cases in Kenya every year come from vertical infection, from mothers transmitting HIV to their babies.
  Treatment of people with HIV may well have exceeded expectations. And I would like to see every HIV positive person who needs treatment receiving the drugs and support they need. But since the recent expansion of HIV treatment, millions more have become infected. Prevention has been forgotten about. People like Kazatchkine and Sidibe like to argue that distinguishing between treatment and prevention is a false dichotomy, but this is not so. If treatment played such a huge role in preventing further infection, transmission rates would be much lower than they are. In fact, the majority of people in Kenya who are HIV positive do not know their status. Perhaps there shouldn't be a dichotomy between treatment and prevention, but there is.
  And if you think the programmes to teach people about safe sex and to persuade them to use condoms have been successful, consider the figures for preventable and treatable sexually transmitted infections (STI). There are an estimated 340 million new cases of curable STIs every year. This is after over 20 years of preaching about safe sex in every country in the world. If people were practicing safe sex, transmission of most STIs would also be reduced. Prevention involves taking steps to ensure the infection is not transmitted. In the case of STIs, that could involve the correct use of condoms, minimally.
  HIV treatment and care has received much of the money available for the disease. Kenya's official strategy papers make this quite clear. Prevention has received very little money and has been pretty unsuccessful, with 5 new infections for every two put on HIV treatment, globally. And HIV has been treated as if it's just an easy matter to round up people and give them some drugs. As a result, there is growing resistance to the few HIV drugs available in developing countries. This can be compared to TB, where it has long been recognised that you can't just send people away with some drugs and expect them to take them religiously for 9 months and never see them again.
  If health solely involves treating sick people, how will you ensure the continuing health of those who are not (yet) sick? In the field of sexually transmitted diseases, gonorrhoea is now also developing resistance to the most commonly available drugs. There has been little recent research into alternative treatments for gonorrhoea (or TB) because, I would suggest, most of the money has been spent on other 'priorities' (Oh, and big pharma are waiting for public funding for their research, a very important component for these (private) companies). One of those priorities is HIV and despite ploughing a lot of money into condoms and safe sex campaigns, prevention has not received the level of funding it needs.
  Yet more evidence of the lack of success of HIV prevention work is the level of pregnancies among women receiving HIV treatment. Women with untreated HIV have far lower fertility levels, so treatment should increase fertility. But women on HIV treatment should also be receiving advice about having unprotected sex and about unplanned pregnancies. I don't believe that all these HIV positive women are choosing to have more children, though some of them may be. Because other research has shown that the vast majority of pregnancies among women who are HIV positive were not planned.
  
  Sidibe even seems to think that the global recession and climate change are distractions to the industry's fight against Aids. I would be hard pressed to find an attitude to which I am more opposed. He even has the cheek to suggest that HIV funding has not led to the neglect of other diseases because it has increased attention for TB, the two diseases being 'integrated', and that HIV prevention should take on a 'holistic approach'. Damn right, but I don't think his use of 'holistic' is the same as mine. But when is all this HIV money going to be spent on the many health issues that I and many others would claim have been ignored? Apparently, Sidibe and Kazatchkine think that's already taking place, and Sidibe feels that support from the big pharmaceutical companies is essential. Very funny.

• TB on the Rise: Big Pharma Delighted

  Posted: March 29, 2010, 12:03 am by Simon

  Although TB is often mentioned along with HIV, it doesn't get nearly as much attention, certainly not as much attention as it deserves. And it gets a fraction of the funding. It happens to be in the news now because World TB Day was just last week. Unlike HIV, TB is easier to catch but also easier to prevent. It's also curable. But like HIV, TB spreads rapidly in populations which face serious and long term economic challenges, have poor and inaccessible health systems, low educational standards and an inadequate infrastructure.
  Like HIV, TB will not be eradicated until the determinants of health are tackled. Like HIV, you can spend as much as you like on the disease but as long as people live in terrible living conditions without even basic water supply and sanitation, suffer from poor health and nutrition and face many other stresses that allow any diseases going to spread rapidly, neither will be eradicated. The huge amounts of money spent on HIV over the last three decades has done little to reduce its spread and the far smaller amounts spent on TB have been equally unsuccessful.
  Kenya ranks 13th in the 22 high burden TB countries and fifth in Africa, although it is notable that they are only rank 9th for HIV. There were 132,000 new cases last year. It is estimated that there were 2000 multiple drug resistant cases but only 4.1% of these were diagnosed. And only 48% of new TB patients were coinfected with HIV. New cases of TB are declining but the number requiring retreatment, those who either weren't treated successfully or who didn't finish their treatment, is increasing.
  I think it is important to note that just over half of the new TB cases were not people who also have HIV. TB is an epidemic in its own right. While high HIV prevalence will increase the spread, TB is spreading independently of HIV too. And why wouldn't it? Most people in Kenya live in the sort of conditions where all diseases spread rapidly. Just as HIV has been treated as if it is exceptional and as if it is possible to eradicate a disease without also dealing with the determinants of health, TB is being treated as if people's living conditions don't matter. But they do matter, very much.
  Jeffrey Sachs points out that if Africa had better health systems, HIV would have been identified a decade earlier. This is quite true, the symptoms that were later recognised as those of Aids were not recognised as being out of the ordinary. They were consistent with very poor health, poverty and malnutrition. It was only when people in more developed countries started to be infected that HIV and Aids were identified. By then, it was too late to avert a massive epidemic. Then, as now, the conditions in which people lived were appalling. 
  Nigeria has an even more serious TB epidemic, third in the world, with 100,000 new cases last year, although they only rank 21st in the world for HIV (despite being estimated to have the second highest number of people living with HIV, after South Africa). Rwanda and Malawi have the highest rates of TB in the world but Rwanda, at number 14 and Malawi, at number 8, certainly don't have the highest rates of HIV. The point I'm trying to make is that in developing countries, conditions are poor and declining but also, are not being remedied by the pouring of funds into programmes that merely treat sick people (ok, a small amount goes into prevention, but not much).
  Aside from neglecting the determinants of health in general, programmes for TB and HIV are mainly targeted at people who are already sick. Most of the money goes to treating people who are already infected. Preventing both HIV and TB has a lot in common, indeed, preventing all diseases has a lot in common. People need good living conditions, water and sanitation, education, health, employment, economic well being, good nutrition, food security and many other things. Instead, most of the aid money going into these diseases is spent on drugs and other technologies.
  PRWeb has a cringe-making release about a report on TB theraputics (which costs $3450, in case you are interested. This release enthuses about the "excellent commercial opportunity for existing as well as new companies in this marketplace." The "marketplace" is certainly growing, because if the only solution to TB is to wait until people become infected and then treat them with drugs, resistance is only a matter of sitting back and waiting. People in developing countries with TB are given the drugs and sent home to continue spreading it in their inadequte housing and with their poor nutrition and lack of education and water and sanitation.
  These pharmaceutical companies have been humming and hawing because public funding hasn't been forthcoming but now that it looks like that will be made available, they can start raking in the cash. Remember, that's public funding, because the profits certainly won't be public.
  All the conditions for the rapid spread of TB are in place and many of them are the same conditions for the spread of HIV. Little has been done to alleviate these conditions and in countries like Kenya, they have been steadily disimproving for several decades. It may be popular to blame the HIV epidemic, for TB and just about everything else that's happened since the 1980s, but this excuse won't wash. Winding down public services and public spending started before HIV was even identified. TB was around before HIV was identified. The opportunity to eradicate TB is still there, but throwing a lot of drugs and money at it will continue to fail.
  Developing countries need to be enabled to develop. Diseases are not just inconvenient pathogens that can be eradicated with some extremely expensive drugs. They require an appropriate environment and suitably weakened hosts. Current and past approaches to TB and HIV ignore the existence of appropriate environments and weakened hosts aplenty. That's why HIV and TB are spreading, despite the billions spent on them.

• Stop These 24 Crimes Against Humanity

  Posted: March 27, 2010, 11:43 pm by Simon

  Perhaps people in rich countries like to believe that some of their country’s wealth supports people in developing countries. They may think too much money or too little money goes to developing countries and they may approve of development aid or they may disapprove. But they are less likely to realise that rich countries extract exponentially larger amounts of wealth from developing countries than they give in aid.
  
  So instead of arguing for more aid money or less aid money or different ways of distributing it, people who feel strongly about development could lobby their governments to consider how rich countries could reduce the extent to which they impoverish poor countries. Below, I’ve compiled a list of 24 ways this could be done. This is what I call ‘development by omission’ and it will be noticed that every item in this list represents highly unethical behaviour, perhaps even criminal behaviour.
  
  

  1. Stop grabbing land in developing countries for food, resources, biofuels, etc, and return the huge tracts of land that have been grabbed during previous imperialist regimes.
  2. Stop growing biofuels, which only benefit rich countries (if they benefit anyone at all) and effectively steal water, land and other resources from developing countries. Biofuels mainly use food crops, so this also drives up the prices that people in developing countries have to pay for vital goods.
  3. Stop using developing countries as sources of raw materials and natural resources. Monocultures such as coffee, tea, cotton, sisal, cocoa and others keep people in developing countries in penury. They also waste land that should be used for food production.
  4. Stop trying to palm off genetically modified (GM) crops on developing countries, especially under the pretext that this will make them more food secure and will solve food shortages. GM crops represent higher costs and lower profits for farmers, even in the rich countries for which they were originally developed. They also make farmers less self reliant and more vulnerable to various hazards, natural and otherwise.
  5. Stop using developing countries as sources of cheap labour, especially in the growing of monoculture crops, non-food crops and crops intended for export. Export Processing Zones (EPZ) have been set up so that foreign companies can avoid meeting even minimum labour regulations, as well as avoiding paying tax.
  6. Stop allowing foreign companies tax holidays and other benefits that are not available to people in the developing country in question. Tanzanian companies that wish to exploit the country's rich reserves of gold, for example, cannot compete with foreign companies.
  7. Stop dumping cheap, subsidised goods, such as sugar and cotton, on developing country markets. Rich countries need to remove subsidies and allow developing countries to compete.
  8. Reverse unfair trade agreements, especially bilateral agreements, that allow rich countries to extract goods and services from developing countries so cheaply that the developing countries lose out.
  9. Stop aggressively recruiting skilled employees, such as doctors and nurses, which are in very short supply. Compensate adequately the countries who have lost most of their skilled employees over the years.
  10. Repeal the various structural adjustment policies and similar World Bank and IMF (International Monetary Fund) strictures that reduce developing countries' ability to develop. Get rid of conditional aid, especially where those conditions are purely for the benefit of rich countries and are harmful to developing countries.
  11. Change the terms and conditions for loans so that repayment does not mean that the borrowers are barely able to service the debt each year and will not be free of debt for the foreseeable future.
  12. Get rid of ghost aid in its various forms. Much aid never reaches developing countries, some is a de facto subsidy for rich country products and services and some is debt cancellation or some other kind of expedient that makes it look as if aid is much higher than it really is. Get rid of purely supply led aid and interventions that are designed to benefit wealthy companies and NGOs.
  13. Stop huge capital projects, such as hydroelectric dams, which cause more damage than good and usually only benefit some western companies who build the structures.
  14. Where foreign companies are operating in developing countries, ensure that they pay proper wages and develop good working conditions. Also, ensure that they pay tax, at least at levels paid by people and companies from that company.
  15. Stop aid programmes that simply increase dependency and do nothing to improve conditions. Also, aid that destroys local markets, such as food aid that consists of donations in kind from rich countries.
  16. Stop selling unnecessary weaponry and other technologies, especially out of date technologies that are no longer of any use. Far from protecting developing countries from this kind of exploitation, many Western governments have been party to the exploitation. Also see ControlArms.org.
  17. Stop setting up and supporting puppet regimes and undemocratic, corrupt governments. Stop interfering in the running of countries purely for the benefit of rich countries.
  18. Stop encouraging developing countries to privatise public services and public utilities, especially where that involves those services and utilities being taken over by foreign companies.
  19. Stop exporting pollution by producing the most polluting products in developing countries, for example, force growing fruit and vegetables in Kenya and flying them to Europe.
  20. Stop dumping toxic waste and any other kind of wastes in developing countries, where they are unlikely to be treated responsibly. Stop dumping computers and other used goods where there is no demand for them and no capacity for processing the resulting waste.
  21. Stop stealing indigenous knowledge and indigenous crops, genes and plants. Stop putting patents on things that have been stolen from developing countries.
  22. Stop using developing countries as military and geopolitical pawns and pretending that this is a form of development.
  23. Stop using developing countries as markets for products that are difficult or impossible to sell elsewhere. Stop forcing products on people who can't afford the consequences, such as GM crops, baby milk formula, etc.
  24. Stop rich 'philanthropists' from using developing countries and their people for their experiments and their expansionist aspirations.

  
  If rich countries stopped doing all or even some of the above, developing countries would be a lot better off. The paltry amounts of money spent on ‘aid’ would probably no longer be necessary. The number of people who live in poverty, suffer disease and other harm and who die unnecessarily as a result of rich countries’ practices of extracting wealth from developing countries could even seem like genocide. The list is by no means exhaustive.

• Do Those Who Pay Lobbyists Get What They Pay For?

  Posted: March 26, 2010, 12:38 am by Simon

  The International Policy Network (IPN) is almost beyond belief. The head of the organisation, Julian Morris, has an article on India's recent decision to place a moratorium on the growing of genetically modified (GM) brinjal (aubergine, egg-plant). Morris puts this decision down to their use of the 'precautionary principle', which Morris doesn't approve of. He refers to India's high rates of poverty and malnutrition, implying that their decision to reject GM brinjal (for the moment) will contribute to these problems.
  For several reasons well known to Indian farmers, GM crops do not reduce poverty, far from it. For a start, GM seeds and other inputs are much more expensive than conventional ones. Secondly, the usage of these inputs goes up, steadily, the longer the crops are grown in the same place, so profits go down. Thirdly, yields go down, reducing profits even further. Fourthly, none of the other promised advantages of GM crops have materialised. GM has been an expensive waste of money, of land and of people's lives.
  As for malnutrition, the previous points make it clear that GM crops are not going to have much positive impact on this. We have been promised crops with higher nutritional value but, in addition to getting less food from GM varieties, there is no nutritional benefit. According to Wikipedia, the precautionary principle "states that if an action or policy has a suspected risk of causing harm to the public or to the environment, in the absence of scientific consensus that the action or policy is not harmful, the burden of proof that it is not harmful falls on those who advocate taking the action".
  What could Morris have against such a principle in relation to GM? There is more than a suspected risk of harm, of several kinds, to the public and the environment; there is little or no scientific concensus but nor has there been much scientific research; the burden of proof should lie with the proponents of GM, but they have consistently failed to do any research that could allay fears. Morris says his disagreement is that you can't prove a negative. But proponents are not being asked to prove a negative, they are being asked to carry out adequate research to show that GM crops are safe to humans, animals and the environment, economically viable, politically viable, ethical and many other things. The risks of not doing this research are too great.
  The Indian minister in question, Jairam Ramesh, did not simply grab whatever expedient he found handy and place a moratorium on GM brinjal. He held a lengthy and comprehensive consultation. This is something an industry paid lobbyist who runs an institution that pretends to be an educational think tank, such as Morris, would have little understanding of. People who voted for Ramesh were asked their opinion and they said 'no', overwhelmingly. If Morris had his way, Ramesh would have paid large consultancy fees to Morris and his ilk and done what they advised, regardless of what Indian farmers and consumers wanted.
  Morris goes on to fault the use of the precautionary principle by the EU to ban animal growth hormones. He sees this decision as flawed (really, read the article!). But his grasp of basic logic is as poor as his knowledge about GM organisms. He argues that water and oxygen would be banned under the EU's interpretation of the precautionary principle 'if they were classified as pesticides'. That's like saying that pedestrians would have to obey speed limits if they were classified as vehicles.
  Like many interested parties who have their snouts in the GM gravy train, Morris sees any opposition to GM or any other dangerous technology as anti-science, anti-technology, rather than sensible criticism and protest against health and safety issues being decided purely on the basis of profits for multinationals. He seems to have little time for anything remotely like a scientific argument. He's not too astute politically, either. The "small but politically savvy band of opponents" in India that he refers to are none other than the Indian electorate, people who will be most directly affected by decisions about further exposures to GM risks.
  The IPN website claims to have 'ideas for a free society' and to be 'bringing down barriers to enterprise and trade'. It would be more accurate to say 'this is as free as it gets, put up with it'. If I thought Morris was trying to clarify moot points, to analyse certain alternative interpretations of data, to shed light on difficult issues, I would at least defend his right to do that, even if I didn't agree with him. But there is no sense, science, logic, even political clout, behind what Morris writes. He seems to be writing utter nonsence because that's what he gets paid to do. But if the quality of his arguments are anything to go by, he doesn't get paid very much.

• Viva La Via Campesina

  Posted: March 25, 2010, 7:16 pm by Simon

  Today I received an email from La Via Campesina, an " international movement of peasants, small and medium-sized producers, landless, rural women, indigenous people, rural youth and agricultural workers". This communication declares that La Via Campesina characterizes this current moment as "one of arrogance and authoritarianism on the part of the United States, the European Union and transnational corporations". It goes on to state that:
  
  The increase of military presence and military bases in various parts of the world, “humanitarian” invasions and occupations which indicate war, the occupation of markets and territories, and the military presence to control energy resources, water, and natural biodiversity are all tactics derived from civilization’s crisis of capitalism and the logics of exploitation, racism, and patriarchy. These tactics also work to disguise the climate crisis in illegitimate negotiations.
  
  Mtandao wa Vikundi vya Wakulima Tanzania (MVIWATA, the Tanzanian Network of Farmers' Groups) is a member of La Via Campesina, so I hope they attend the movement's 'Assembly of Social Movements' in Bolivia in April. Perhaps they will also represent their neighbours, such as Kenya, Uganda and others. Only a handful of African countries are presently represented. Kenya is not. But they need to be.
  
  It's hard to think of any strategy that could be worse for Tanzania and other developing countries than a concerted move towards large scale farming. Yet most members of a group of several hundred 'researchers' recently agreed that "the domination of the agricultural sector by small scale farmers is a serious problem".
  A serious problem for whom? For wealthy politicians, who own much of the country's best land? For the multinationals, who want to control the country's ability to feed itself? For those who want to see more African land dedicated to the production of biofuels that will allow people in wealthy countries to continue their wasteful lifestyles? For those who see Tanzanian land and people as 'assets', to be bought up to enable them to produce food for people in wealthy countries?
  These 'researchers', who must spend their time reading tabloid newspapers and the outputs of right-wing, imperialist think-tanks, rightly point out that small-scale farmers lack capital and skills. But they conclude that they should therefore become the de facto slaves for those unscrupulous enough to take over much of the country's land, natural resources and productive capacity.
  If people lack skills, and it's not just Tanzanian small farmers who lack skills, this is because of the continuing failure of the education system. Many people don't attend school at all, many attend for a few years and many leave with very little practical knowledge of any kind. But this is not a reason to send in the large scale commercial farmers, ready to "inject capital and technology". People need better education, whether they are small scale farmers or from any other walk of life.
  If the infrastructure is failing people, the infrastructure needs to be improved. Foreign land grabbers and multinationals are not going to do that. But in order to market goods even to Tanzanians, the country needs proper transport networks, reliable and widespread electricity supplies, communication networks and the like.
  If, as these people suggest, Tanzanian agriculture is scaled up, what will happen to the subsistence farmers? They probably make up the largest economic group in Tanzania. The researchers' answer is the 'outgrower' system. Farmers become 'outgrowers' for some factory or exporter, producing a crop, usually a monoculture, usually not a food crop, to be exported. The farmer gets a very small price, they middle person gets a large price and the destination country converts the primary good into some high value product, often sold back to Tanzania at extortionate prices.
  The country's Prime Minister Pinda uses the examples of tea, sugar and sisal to demonstrate how successful the outgrower system has been. Perhaps Pinda doesn't go out much but I think he will find that the majority of tea, sugar and sisal workers and outgrowers earn a pittance. And these crops are not essential food crops. People need to feed themselves and their dependents and they need to produce enough food to ensure the country's food sovereignty, the right of peoples "to define their own food, agriculture, livestock and fisheries systems, in contrast to having food largely subject to international market forces".
  To avoid being tricked out of what's left of their natural resources and land, Tanzanians need to be aware of philosophies such as that of La Via Campesina. Most Tanzanians fit into one or other of the movement's categories. Because those Tanzanians who don't belong to any of those categories, rich businesspeople, politicians and the like, are ready to sell everything to the highest bidder. And, as usual, the money won't 'trickle down'.
  La Via Campesina's objectives include the preservation of land (currently threatened by massive levels of land grabbing), water (threatened by all agricultural production for export, but especially biofuel and non-food crops), seeds (threatented by the attempts by genetically modified organism producers to control seed supplies) and other natural resources (threatened by natural resource exploitation which is almost entirely controlled by foreign multinationals). Other objectives include food sovereignty and sustainable agricultural production based on small and medium sized producers.
  If Pinda and his colleagues are concerned about the country's low agricultural output, there are many initiatives that can be employed. As mentioned, improved education and infrastructure. But also, an improvement in the economic circumstances of the majority of people. The country is relatively rich in resources, but they are being effectively stolen by foreigners. There's (so far) no shortage of wealth in the country, distribution is the serious problem.
  Most Tanzanians are just about getting by, right now. If agriculture is scaled up, by whatever means, the majority will lose the little access they have to food and other vital goods. Tanzanians need to feed Tanzanians. They don't need to be exploited by commercial and political interests. And the same applies to Kenyans and other Africans.
  The final word must go to La Via Campesina:
  The current industrialized agribusiness model has been deliberately planned for the complete vertical integration and to dominate all agriculture activities. This model exploits workers and concentrates economic and political power. La Via Campesina advocates a decentralized model where production, processing, distribution and consumption are controlled by the people the communities themselves and not by transnational corporations.
  

• Deliberate GM Contamination of Kenya's Maize?

  Posted: March 24, 2010, 11:52 pm by Simon

  India's notorious genetically modified (GM) cotton plantations, which even Monsanto now admits are a failure, were not established after consultation or adequate research. The GM seed was introduced surreptitiously and spread far and wide and was eventually accepted on the grounds that it was too late to avoid it. Monsanto have profited considerably from this 'accident', having upped the prices for their seeds and other inputs many times over the years. One of the many failures of these GM seeds is that fertilizers and pesticides need to be used in ever increasing quantities.
  
  Now, the pests have developed resistance, no amount of pesticide will control the problem. Yet Monsanto's solution to this is to roll out a new version of their GM cotton seed, with a new set of inputs and even higher prices. The seed has contaminated much of India's cotton growing areas and much of the country's arable land. But no amount of destruction is enough for Monsanto. They want to control what India does with its cotton and, eventually, all its other agricultural products.
  
  I have argued elsewhere that what happened to India could also happen to other countries and whole continents. Well, it seems like someone is already trying to contaminate Kenya's staple crop, maize, with GM maize. 40,000 tonnes of GM maize was imported from South Africa earlier this year, at a time when the country had a surplus of the crop. A Kenyan company called Louis Dreyfus Ltd imported the stuff. It is sitting in Mombasa Port right now.
  
  Questions are being raised about how this could happen and worries are being expressed about some of the possible effects of GM contamination. It is possible that some Kenyans are confused about the dangers that GM contamination poses. If this consignment were distributed and used as seed, farms directly affected would also contaminate farms around them. Maize is the most commonly grown crop here and it's grown for Kenyan consumption.
  
  But other crops, grown for export, could also become contaminated. One of Kenya's top exports is fruit and vegetables and much of it goes to Europe. Europe has fairly strict laws about allowing the importation of GM contaminated foods. Kenya could end up exporting very little. Tea and coffee are also among its top exports but they too could end up being compromised by GM contamination. Anyone who thinks that opposition to GM foods is just anti-scientific, luddite or in any way mistaken should do some reading up on the subject.
  
  One wonders who is behind allowing GM products to enter the country, who could profit from such a move? Has it happened before and is Kenya's maize already contaminated? And will this consignment of contaminated maize be allowed to be distributed or will it be sent back to South Africa, who have already fallen for the GM trick? I don't feel very confident about the future for some of Kenya's most important exports.

• Education is Not a Prophylactic, it's a Human Right

  Posted: March 23, 2010, 12:58 am by Simon

  When a school girl becomes pregnant here, she is usually excluded from school. Ostensibly, she is allowed to return to school once she has delivered but, in practice, most never return to school. She is excluded on the grounds that she is a 'bad example' to her peers. The boy or man responsible for her pregnancy, apparently, does not set such a bad example. School boys who make school girls pregnant, if identified, are not excluded. Adults who make school girls pregnant can't be excluded, but they are rarely punished. Sometimes the adults who make school girls pregnant are their teachers.
  
  So I was surprised to hear that seven teachers, one of whom is a principal, have been interdicted for such an offence in Bomet and Chepalungu districts, Kenya. In Bomet, 37 girls have become pregnant and have dropped out of school. Whether any of the girls are underage or not is less important than the fact that the teachers have behaved inappropriately for people in their position. It is hard to believe that they have not taken advantage of their position, in addition to breaching the trust of both their pupils and the parents of the pupils.
  
  An official in the district referred to the teachers as 'amorous', which doesn't seem to be the most appropriate term and seems to miss the seriousness of the offences. Amorousness is not a crime but sexual assault and sexual assault on a minor are. Teachers are supposed to educate their pupils to enable them to avoid things like underage sex, sexually transmitted diseases and unplanned pregnancy. The schools may be willing to allow the girls to return to school later but the damage has been done. Some may return, but they will be at a serious disadvantage as a result of their experience.
  
  Another article suggests that education is 'crucial to lowering [HIV] prevalence' because HIV prevalence in Tanzania has dropped among those with secondary education whereas it has remained static among those with little or no education. I object to the suggestion that education is good just because it reduces the risk of HIV. Education is a human right. It is an intrinsic good, not just an instrumental good that reduces HIV prevalence.
  
  However, the article's conclusions must be difficult to establish because primary and secondary students who become pregnant, the ones who were least likely to be using condoms (and therefore at most risk of contracting HIV and other sexually transmitted infections), are excluded from school. They are no longer in the demographic in question. But they can not be excluded from the 'little or no education' demographic. This may skew the figures, somewhat. (I don't have access to the full paper, so the authors may have allowed for this possibility).
  
  I'm glad to hear that education officials are realising that when a girl gets pregnant, a male is involved, either a man or a boy. They are also starting to admit that some teachers are involved and are punishing the perpetrators, rather than just the victims. But education, and education for girls, in particular, still appears to be seen as something less important than education for boys. And it also appears to be seen as a way of reducing HIV prevalence, rather than a human right. Well educated boys and girls, men and women, will be able to ensure their own health and welfare, that's why it is a human right.

• The Gates/GM Progeny

  Posted: March 22, 2010, 12:49 am by Simon

  Some of the most deceitful and unscrupulous people in the business world want to exploit Africa and one of the richest people in the world is spending huge amounts of money trying to help them. This person, Bill Gates, considers himself to be a philanthropist. Yet he is party to efforts to tie farmers into agreements that will commit them to expensive farm inputs, such as seeds, fertilizers and pesticides, will probably reduce yields, will have significant health consequences, will increase dependence and food insecurity and will generally make things worse than they already are.
  
  Someone who really wanted to benefit people in developing countries with a lot of money at their disposal could do many things. In agriculture, they could develop indigenous crops that are selectively bred to resist drought, flooding, increased salinity and other adverse conditions. In infrastructure, they could provide people with clean water and give them access to better and more sustainable forms of energy and fuel. This would also confer great health benefits. There are numerous things that could be done to improve people's economic conditions, their education and their skills.
  
  But Gates prefers technical solutions, mostly ones that will make his foundation, along with some people connected with it, rich. Never mind that these 'solutions' will worsen the situation in developing countries, that doesn't seem to be a worry for this 'philantrocapitalist'. Perhaps he's just an old style capitalist in disguise. Genetically modified (GM) crops have been a disaster in developed and developing countries alike. His efforts to tackle a handful of diseases while ignoring the conditions that allow those diseases to spread will have few long term benefits. Just because he is rich, he shouldn't have the right to interfere with the welfare of so many vulnerable people, especially at the same time as claiming to be doing good.
  
  Another article sees Gates as propping up a form of neo-colonialism. GM crops are an inappropriate, imported technology, designed for large scale industrial farming like that predominant in the US. Most African farmers are small farmers and they are the ones likely to suffer if they are pushed out of farming by GM. It's not the big farmers and landowners who can afford industrial scale farming that are suffering from food shortages. And those who are suffering from food shortages will quickly find that GM will not feed them, either. They are short of food because they are poor, GM foods will only increase the prices and reduce access further.
  
  It's time that people realised that GM does not have any advantages for poor people, or even for relatively well off people. It is designed to make money for the handful of multinationals that develop the technology. And anyone who claims to be doing good by imposing GM on poor farmers in developing countries is a liar and an opportunist.

• Development is Not All About Money

  Posted: March 21, 2010, 12:43 am by Simon

  It's basic science that if you insulate a hot cooking pot properly, the food inside will continue cooking even after you remove the heat source. But however basic, probably most people in the world cook with a continuous heat source, gas, electricity, parafin, wood, charcoal, whatever.
  
  So it comes as a surprise to some people, people who would recognise the basic science, that you don't need to keep the food over a continuous heat source. You can bring things to the boil and then transfer them to a heat box, hay box, cooking basket, fireless cooker, whatever you want to call it. This insulated container will allow the food to continue cooking. Even if it's something slow to cook, like beans, it will eventually cook completely.
  
  And when people don't even have ready access to the basic science, seeing food cook without any obvious heat source seems like magic. Of course, there is an obvious heat source, but when the food is removed and put in a stone cold container, it still cooks. Using this method you can save a lot of money on fuel. I don't think I need to rehearse the benefits of cutting fuel use or cutting costs of any kind.
  
  The technology goes way back but interest in it seems to wax and wane. I've heard it was popular during and after the second world war, when there were shortages of food and fuel. And not only is the technology widely known and cheap, it can even be totally free to make one of these devices. Then it saves you money and you can use it to cook, keep things hot, even keep water hot all night so you can use it to wash with in the morning.
  
  Here in Nakuru, working with Ribbon of Hope Self Help Group, I'm hoping that most people will be interested in making and using this neat trick. Most of them use charcoal or wood. These are expensive and trees are in short supply. It also requires a lot of work to search for fuel. Any way of cutting fuel use and costs would be welcome as most people in and around Nakuru are poor. And using cooking baskets even reduces smoke inhalation, water use and degradation of the nutritional value of the food because it cooks at low temperatures. And washing up is easier!
  
  You can buy cooking baskets, marketed as fireless cookers, in the supermarkets. They are fine looking and work very well. But they are expensive. Not many people would shell out the equivalent of a whole week's salary, perhaps even two week's salary, for one of these. But the good news is that they are easy to make and they can be made using locally available materials.
  
  On Friday we went to Athinai, a place totally dominated by sisal plantations and some factories that use the raw material for very basic products, such as ropes. The best of it is exported as a raw material, earning the company less than it should and earning locals even less. Especially considering the factory's habit of not bothering to pay people for months and even years.
  
  Anyhow, the factory has some by-products, some of which are dumped, some of which are sold for good money and some of which are sold for very little money. The dry fibres, even the ones that are not fit to be sold, make perfect padding for cooking baskets. People in Athinai can get it in large supplies, free of charge. If they can't get enough, or if the factory starts to charge for it, they can use rolled up newspapers, dry banana leaves, hay, straw or anything dry and light that is a good insulator.
  
  Instead of weaving expensive baskets and using other materials that go into the beautiful cooking baskets you see in supermarkets, I got a couple of used sacks in the market, one small and one large. People can get sacks free of charge if they know where to look or who to ask. Then all they have to do is stuff the large bag, make a little nest for the samll bag, which will hold the pot. A piece of material of some kind, stuffed with the stuffing and tied off or sewn, will do as the lid. Then tie off the big sack to make it all snug and you're cooking.
  
  In front of the people who turned up for the demonstration, we stuffed a pile of sisal waste, something people there are so familiar with, into the sack as described. A pot of rice was brought to the boil and transferred to the cooking basket. And 40 minutes later people were shown the cooked rice. Not only were they astounded, but they were invited to take the whole thing apart so they could be sure there was no trick involved, which they did.
  
  Cooking just for myself, I spend about ten shillings a day on charcoal but people with families can easily spend twice or three times that amount. It is estimated that you can cut charcoal (or wood) use by half by employing a cooking basket. So the amount saved is considerable. If someone earns 150 shillings a day working in the fields and they spend 600 shillings a month on charcoal, it's like getting an extra two day's wages without having to do the work. 24 extra days a year!
  
  Rather than just concentrating on income generating activities, Ribbon of Hope is also looking at ways of cutting expenditure. These cooking baskets are perfect because they need not cost anything and they start saving you money straight away. Coupled with solar cookers, the amount of money people could save throughout the year begins to look like an excellent bonus. If you only use the solar cooker on 100 days of the year, that's another 6 day's wages to add to make a cool extra one and a half months. And as we don't have to give people this estimated 4,500 shillings a year, we think it's a pretty sustainable way of helping people with their finances.

• Genetically Modified Cotton Has Failed, Says Monsanto

  Posted: March 14, 2010, 12:54 am by Simon

  Thanks for telling us after so many people have wasted their time and money and many people have even lost their lives as a result of this failure. Scientists who have not been bought off by the biotech industry have been warning against the use of these crops for years. They have been calling for proper research into what their true consequences are before imposing them on an unprepared world. But now it's too late.
  
  What about all the people who have destroyed their land because of the industry's lies? What about the farmers who have run into such huge debts that they have found no way out but to commit suicide? If anyone knew that these crops were designed to fail, it was Monsanto and the rest of the industry. In some cases they have failed to do proper research, in other cases they have supressed the results of their research. Instead of doing the groundwork necessary, they have simply paid off powerful people to do their dirty work. Who needs salespeople when 'democratically elected' leaders will do the work at a far lower cost?
  
  The president of the European Parliament, Jerzy Buzek, may have been bought off by Monsanto or the industry as a whole. Or maybe he's just brain dead. He has said that he is against GMO (Genetically Modified Organisms) but that they are inevitable. What could he mean by this? That the GM industry is going to do what it wants, regardless of what we insignificant members of the electorate want? That all the people who could possibly prevent GMO from being imposed on us have been bought off?
  
  We can only speculate. Buzek goes on to say that because we can't win the battle, he is not going to fight it. He also said that Europe would lose out on 'competitivity' if we don't accept GMOs. There's a bit of overdetermination here; does he feel that we shouldn't fight something that is advantageous to us or does he feel that we shouldn't fight a battle we cannot win? He only needs to argue for one of these, not both. They could both be true but we don't know which one sways this foolish man. If you object to my calling Buzek foolish, just read the rubbish he comes out with about only genetically modified rice being able to grow in Bangladesh.
  
  Given the evidence for Buzek's small brain, he probably has a short memory and a limited capacity for research and comprehension. But GM cotton was released in India because it had already been passed around unofficially and had already contaminated a large proportion of the cotton sector. It wasn't released after careful consideration and proper consultation (don't be silly!). I'm sure this was not as a result of anything the GM industry did, no doubt it was just an accident. But that is no reason for Europe or any other continent to make the same mistakes.
  
  And just in case Buzek is worried about the silly rumour that the Vatican was pro-GM, that was just bunkum. The GM obsessed cardinal who was so keen on compromising the health and welfare of so many people has been replaced with what must be one of the few Catholic leaders who has a grain of sense. Cardinal Peter Turkson realises that GM crops could be used as "weapons of hunger and poverty". Not only does he realise this, but he actually considers this to be an undesirable outcome. He realises that GM will lead to the greater dependence of the weak and poor on the strong and rich, environmental degradation, higher costs and an increase in the number of food insecure and starving people in the world. Already, the number of starving people has increased steadily as the percentage of GM crops has increased.
  
  Some commentators have wondered about why Monsanto might want to claim publicly that GM cotton has failed. They have pointed out that Monsanto has now produced a new generation of GM cotton. Monsanto knew long ago that the first generation had failed and they now want people to change to the new generation, which employs a second modified gene and requires an enlarged set of inputs in terms of pesticides and artificial fertilizers. It also requires greater expenditure on those wonderful pieces of intellectual property we used to call seeds, those things we used to be able to collect for free at the end of the growing season.
  
  No, you don't have to back out of GM cotton just because the whole live experiment has failed, and you probably can't, anyhow. You just have to buy more expensive seeds and invest in more expensive pesticides and fertilizer. After all, you are part of this experiment. If it goes down the pan, so do you.

• Solar Cookers: Free or Just Cheap?

  Posted: March 13, 2010, 1:34 pm by Simon

  I want to find community development projects that either make money or reduce costs that are themselves free or almost free. I've started with a simple solar cooker, made by Solar Cookers International (SCI), in Nairobi. But they cost 500 Kenyan shillings (around £4.50), which would also buy you about 12 kilos of the staple food, ground maize meal. That's food for quite a few people, and I wouldn't blame people for saying 'it's a great idea but I can't afford it now'. Especially when you can buy a charcoal burning stove for about 150 shillings.
  
  Of course, charcoal is a significant expense and people with families can use 15 or more shillings a day worth of it. True, you could point out how much less charcoal you would use if you invested in a solar cooker. But the word 'invest' is the big problem. Many people wouldn't have the amount of money they need to invest all at once. And even if they had the money, they still might use it for something else, such as a solar powered light or a battery powered torch. People use their money as they see fit and make their spending decisions based on their own criteria.
  
  I love SCI's cookers, I use them myself. I have the luxury of being able to afford several, which is ideal on a sunny day. They are also great for demonstrating the concept because they fold up and I can easily carry three or four, along with the other paraphernalia needed to show people how to use them. They are resilient and so simple, I'd recommend them to anyone. They are cheap, but not free.
  
  However, when the money available is a hundred or two hundred shillings a day, perhaps less, these cookers are not going to fly off the shelves. I have tried suggesting to people that they could make their own, given that they are simple and require cheap materials. I've said I would come and help them to make cookers so they would have them for a maximum of about 50 shillings. This has been met with some enthusiasm, but not much. I'm not terribly sure why this is, but I'll be looking out for the explanation.
  
  Anyhow, when you demonstrate the use of solar cookers, people are excited, inspired, even stunned. They start off by dismissing the possibility of cooking with a piece of shiny cardboard, regardless of whether you paint the pots black or any other colour. But when they see their everyday foods cooked they are speechless. Even ugali, the tasteless and almost nutrition-free (it's pure starch) staple, boiled maize meal, cooks far more easily than it does on a charcoal stove. At least some people are interested. But there's still the problem of cost.
  
  So after demonstrating their use in Salgaa, half an hour West of Nakuru, I said I'd come back and help people to make them. They make all sorts of things themselves, so cutting out a shape in cardboard and sticking on shiny paper shouldn't be a problem. The cardboard can come from large boxes and the shiny paper could be aluminium foil. These are cheap. Compared to the manufactured solar cooker, it's really cheap, almost free. But that doesn't impress people. They have to pay for cardboard boxes, they are very useful. And aluminium foil is not cheap enough for some people, though the amount you'd need for a solar cooker is small.
  
  Well, it's possible to get large amounts of cardboard very cheaply, perhaps free, if you look in the right places. And it's possible to get very good reflective paper, very durable, much better than aluminium foil. I wandered the streets looking for products that use this material and discovered that new vehicle wheels are wrapped in this untearable material, which is almost shiny enough to see your face in. Also, supermarket products, such as chocolate, sweets, tea and various other things are wrapped in similar materials.
  
  I knew I would be met with more objections, we don't have a car, we don't eat chocolate, etc. But neither do I have a car nor do I eat most of these products. The thing is, someone does. They are not stacked in the supermarkets for no reason. And when people have finished with things, they throw them away. Over the fence, in a ditch, anywhere. Occasionally, they throw things in a bin and they end up in a dump. But still, this means that this great reflective material is available, you just have to look.
  
  I looked and enquired and asked whoever I could think of. I was met with complete incomprehension when I said I didn't want to buy vehicle tires. But when it was realised that I placed a value on the material they were wrapped in, availability suddenly dropped. It was clear that I would have to pay money if I wanted this stuff, being white, and therefore incalculably rich. But the people who were going to make the solar cookers, they wouldn't have to pay money. Not much, anyhow. And people here are good at finding things they need or getting them very cheaply. So I left it up to them to collect the materials.
  
  This hasn't worked so well. On the appointed day, I turned up to find 40 people, 2 cardboard boxes, one too small to be of much use, and three wrappers, around half a square meter of reflective material altogether. But I had brought glue and glue brushes and most of the materials were there to make a start. I said what had to be done and sat down and told people to go ahead. Eventually one person volunteered and a few others joined in. They couldn't complete the cooker, but I think it was clear to everyone there how easy it is to make the cooker. I'm just hoping that they will also see that they have to collect the materials needed, because I can't do that.
  
  Of course, for less than £200 I could buy every person there a solar cooker. For about £50, I could supply them with all the materials to make their own. But how sustainable is that, for a start? And how many people would use the solar cooker if I presented them with it for free? This would not be sustainable, not at all. And I have given people with plenty of education and free time presents of solar cookers. Not one of them has used it. I know solar cooking is a hard sell, in terms of people actually using the technology. And I also know that you can't just thrust it on people.
  
  It's going to take more time. There are community leaders in Salgaa who are very keen. Slowly, we will push the issue and hope that even a handful of people will start to find some way of including the solar cooker in their day to day lives. Who knows what the result will be. Solar cookers are not the only example of free or almost free community development projects, but this is the first time that I have tried one of them with the aim of establishing 'free or almost free' as a development model (or micro model). It's early days and I'll report back in due course.

• Cut Corruption, Don't Cut Aid

  Posted: March 10, 2010, 11:48 pm by Simon

  I arrived in Nakuru in September of last year expecting to work for an organisation called ICROSS (International Community for Relief of Starvation and Suffering), supposedly to work on a HIV related project. However, in my first week in Nakuru I realised they didn't have any active projects. Officially, they were waiting for funding. But as I was led from one 'site' to another, I realised there was something not quite right about ICROSS. It was hard to put a finger on, but the first thing I found strange was that only a couple of people had ever even met the guy who headed ICROSS, Mike Meegan (also known as Mike Elmore-Meegan, Dr Meegan, Fr Meegan, Br Meegan and probably a few other names not worth repeating). Some had heard of him but most didn't even recognise the name.
  
  Well, it quickly turned out that none of the 'sites', these community based organisations and support groups that I was being taken to see, had any real connection with ICROSS. ICROSS would just collect up organisations and include them in their proposals when they were looking for funding, which was all the time. The only function the organisation seemed to serve was to find funding. Anything worthwhile that was achieved was done by a handful of volunteers, along with some of these organisations that had been 'absorbed' by ICROSS. Of course, ICROSS would always take the credit.
  
  So, to those who are worried about how this work will be affected by the demise of ICROSS Ireland? For a start, it's only ICROSS Ireland that has closed. ICROSS Kenya continues its 'operations'. But even if that were to close, very little would happen on the ground in Nakuru. ICROSS simply didn't do very much here, aside from pay visits when they wanted to show potential funders or publicists around. They would take a few photos, maybe hand out something small that they had acquired from some donor or other, then head back to the Nairobi office (where none of the projects were based).
  
  The many small organisations that ICROSS claims (incorrectly) to have founded just continue as they did before ICROSS arrived. Some will be better off, some will be a small bit worse off, but most will continue as if nothing had happened. Because nothing has happened to most of them. Some of them will continue to welcome anyone from ICROSS because there is a slight chance of a handout, a few may collapse because they only got together to pick up anything being given out by organisations like ICROSS, but for most, ICROSS will be a faint memory.
  
  As to what happened to all the money ICROSS has raised over the years, these newspaper articles are silent. In addition to the one above, there is another in the Sunday Times, one in the Irish Mail on Sunday and one in the Irish Examiner. These can be added to the collection of articles on the organisation's suspect activities, going back years. For the moment, we can only guess at what the money was used for.
  
  The numerous scientific papers that have Meegan's name on them may seem suspect now, too. But judging from what I've heard, he is unlikely to have had anything to do with the data, at any level. None of the people involved in one of these projects in particular had ever met the man and he never visited the sites where the participants lived, where data was produced and collected. Let's hope that's the case, because many would not wish to rely on data that could be seriously flawed.
  
  But I wouldn't want people to think that no harm has been done, that no one has been depending on all the money donated to ICROSS over the years. After spending a few weeks finding out that ICROSS wasn't doing anything effective in Nakuru, I asked Meegan to make some money available, urgently, as people were sick and in need of help. He and I disagreed on this matter and I finished working with ICROSS before I had even started. Some of the sick people who were in dire need died and many will continue to suffer and die. Meegan likes to boast about how many people he knows have died of Aids here in Kenya. But some of them are dying because aid money is not getting to them.
  
  On a broader scale, also, it matters very much that money intended for poor people, sick people and starving people is not getting to them, regardless of whether it is diverted to repressive regimes, rich foreign contractors, greedy governments or where ever else it may go. If charities, aid organisations, governments, consultancies, commercial organisations or other parties are corrupt, that needs to be remedied. But there are too many people who would like to see aid cut or stopped altogether. Why punish the people who are already suffering because of the conduct of those who are supposed to be accountable, who are from wealthy countries, who are well off themselves? Aid is not the problem, corruption is.
  
  It is extraordinary that Meegan seems to have surrounded himself with so many prominent people. The few people I know who have met him find him utterly unconvincing and I agree with them. But he seems to have been able to fool a lot of people for a long time. Audits and investigations have been carried out over the years and both he and his organisation have been found wanting. Yet ICROSS continued their fundraising and somebody continued, presumably, spending the money. Just not in Nakuru. Hopefully this time will be different.

• Lucky Those British Choppers Happened to be in Kenya

  Posted: March 8, 2010, 12:11 am by Simon

  Apparently some tourists were rescued by helicopter when there was flash flooding in the Samburu area. The British Army and Airforce helicopters just happened to be in the area because they 'train' there. It's lucky they were able to rescue the people in the tourist areas. None of the tourists were reported as having any injuries. An elephant research centre was not so lucky. The BBC article doesn't mention if there were any non-Britons or non-tourists involved.
  
  In other areas, six people are reported to have been drowned and five others are missing. The AllAfrica.com article doesn't say if there happened to be any British helicopters there. Livestock, homes and properties have been destroyed in many areas, including Samburu. Many people have been displaced. Interestingly, Kenyan helicopters were also involved in the airlifting of tourists in Samburu. Perhaps it's easier to spot white faces against the muddy background.
  
  One of the deaths was in Mogotio, where flooding a couple of months ago displaced several hundred, many of whom are still living in tents. Another person died and one is missing just outside Nakuru town, in Kaptembwa. Three people were killed by flooding further North. While many have already been displaced in Western province, many more are threatened with flooding as rivers are close to bursting their banks. Exact figures are unclear but the number is said to be 'below 2000'. But thankfully the 600 tourists (although this number includes tourist lodge staff) said to be affected are all OK, having lost only their luggage.
  
  Many areas are being warned to prepare for more flooding and other hazards that come with the very wet conditions, such as cholera, malaria and other water related diseases. Farmers have been holding off sowing crops in many areas because the rain has been too heavy and those who have planted are in danger of losing their crops. Maize seeds are being distributed in some areas, although this is unlikely to benefit many people for some time. Let's hope those British helicopters and emergency services will still be available if and when disaster strikes.

• Political and Religious Leaders Overseeing the Spread of HIV

  Posted: March 6, 2010, 9:43 pm by Simon

  There's an interesting article on Aidsmap.com about how Ugandans who think they may be HIV positive are less likely to refer other family members for HIV testing. In a survey, people were asked before testing if they thought they were likely to be HIV positive. A majority said they thought they were likely to be. Of course, only some of them were. But most of those who are HIV positive in the country do not know their status. This doesn't bode well for a country that is said to have been so successful and progressive in its fight against the disease.
  
  The very people who are most likely to be HIV positive are least likely to go for testing. So you would think that the Ugandan government would aim to target these people, make it easier for them to get tested, increase access to HIV facilities, reduce discrimination and stigma. Instead, the government is going in the opposite direction, trying to whip up anti gay feelings and making such strong threats against people even suspected of being gay that most people will be less willing to find out their HIV status, whatever their circumstances.
  
  The Bahati Bill will make a lot of people avoid even discussing HIV or sexuality because if someone is found to be gay, HIV positive and sexually active, they will face the death sentence. In order to cover up their sexuality, many gay people are said to have heterosexual relationships, even to marry a heterosexual partner. Their partner will even face a lengthy prison sentence for not reporting that they were married to a gay person. Currently, only an estimated one quarter of HIV positive people know their status. If this bill becomes law, that figure should go down even further.
  
  Some leading American Christians are said to be behind Bahati's bill. But the Catholic church is equally adamant that condoms shouldn't be used to prevent unplanned pregnancy, HIV or other sexually transmitted infections. They even lie about the effectiveness of condoms, which would seem to be in breach of the ninth commandment. But as far as they are concerned, it is 'artificial contraception', and therefore immoral. The use of condoms is currently being debated in The Philippines, where HIV prevalence is low, but rising.
  
  You would think that political and church leaders would aim to reduce transmission of HIV and to stamp out stigma and discrimination. But, on the contrary, they seem to be against any measures that target some of the most significant channels to HIV infection. We must look beyond political and religious leadership if we are to have any hope of making progress in the fight against HIV.

• Women Are Not Mere Instruments in the Fight Against Aids

  Posted: March 4, 2010, 11:37 pm by Simon

  One of the recurring themes on this blog is my claim that HIV transmission is not just about sex. In fact, sexual transmission of HIV is not just about sex. What I mean is that there are circumstances surrounding sexual behaviour that determine whether the risk of HIV transmission is higher or lower. And if those circumstances are ignored by the many so called HIV prevention programmes, those programmes will fail.
  
  So far, most HIV prevention programmes have been designed with the assumption that reducing HIV transmission is all about influencing sexual behaviour. This is sometimes referred to as the 'behavioural paradigm'. And most HIV prevention programmes have failed. UNAIDS emphasizes the fact that HIV is now the leading cause of death in women of reproductive age. Considering current rates of maternal illness and death from non Aids related causes in developing countries, this is truly shocking.
  
  But here is the more shocking bit: "up to 70% of women worldwide have been forced to have unprotected sex". If women are subjected to violence to this extent, this is the real outrage. That women do not have the right to choose when to have sex, whether to have sex, with whom to have sex or any of the other circumstances is horrifying. These are the sorts of circumstances surrounding sexual behaviour that I am talking about.
  
  But these rights are not just about sex. If a woman doesn't have these rights, you can be sure there are many other rights she doesn't have. The problem here is that the rights of a huge proportion of women are being denied. Women do not have rights just so that they don't contract HIV or any other sexually transmitted infection. And if a woman does have these rights, the issue of whether she does or doesn't have a say in the circumstances surrounding sexual intercourse will not arise. Not everyone will make the best decisions, of course. But the problem is that at present, some parties are being denied this right.
  
  Michel Sidibe, the executive director of UNAIDS, is wrong on several counts. 'Gender issues' do not need to be addressed because this is a way of reducing transmission of HIV. Gender issues need to be addressed because they have so long been ignored. Ensuring rights for women is not just a useful way of ensuring that the Millennium Development Goals are realised. Women are not mere instruments in the fight against Aids.
  
  In Africa, 60% of the people living with Aids are women. Women are far more vulnerable to being infected than men. Yet so much HIV programming ignores the circumstances in which people live and work. The recent emphasis on mass male circumcision is a good example of an intervention that falls for this behavioural paradigm. It also purports to protect men, to some extent, from HIV. The extent to which it protects women is very unclear.
  
  But most HIV prevention programming uses the same paradigm and has done ever since HIV was found to be mainly a sexually transmitted infection. Women's rights have been mentioned, often in this instrumental way that UNAIDS seems to favour. Even economic, health and educational inequalities have been mentioned. Well these are the issues that need to be targeted, not just mentioned. But most of the big money goes into the tired old finger wagging about what people should and shouldn't do in bed.
  
  The issue of violence against women does not need to be 'integrated into HIV prevention programmes'. This is completely the wrong way around. The issue of HIV prevention needs to be integrated into programming that addresses gender inequalities in social intercourse, marriage, work, education and health. HIV is not bigger than all these and until these are successfully targeted, HIV will continue to elude our best efforts.

• It's OK, Apparently Journalists Are Supposed to Lie

  Posted: March 3, 2010, 1:54 am by Simon

  In an article about the Polish journalist and writer, Ryszard Kapuscinski, Neal Ascherson claims that "there is no floodlit wire frontier between literature and reporting". This is interesting because he feels that being a "great story teller" does not make someone a liar. Which is true, except when they are supposed to be writing an article that people assume is 'reportage'.
  
  I don't know about Kapuscinski but if there is no frontier between literature and reporting then why would anyone bother to read the daily tripe? Journalists churn out a lot of rubbish concerning things they know precious little about, but people read papers and listen to radios and TVs every day to find out what is happening in the world. When they read some jumped up hack going on about how there couldn't be global warming because it's very cold today, they think that the whole issue about climate change has been trumped up.
  
  So when it comes to genetically modified organisms (GMO), consumers of journalistic bullshit (the majority of mainstream reporting) think of Frankenstein foods, or whatever crap the 'profession' has dreamed up to ensure that the last thing people do is think or become informed in any way. Neal Ascherson may write for The Guardian, a 'moderate' paper, but lying and reporting are not the same thing and if a journalist lies, he or she is a liar.
  
  What I'm saying about GMOs will probably be of no interest to journalists because I am not opposed to them just because they may be dangerous to humans, animals, plants, water supplies, in general, the whole global ecosystem. Although, I admit it, the fact that no one knows exactly what effect long term consumption of GMOs has on those who consume them (because no credible research has been done), does seem like a glaring omission. I am opposed to the fact that a few multinationals want to control the whole of humanity's ability to provide enough food for itself. Not only do they want this but they already control a massive proportion of global food production. To cap it all, many of the most powerful idiots in the world are in favour of this, with the support of...big media owners.
  
  Ok, I've skipped past the journalists because they are just doing a job and they are paid for by some revolting Murdoch-like character who is trying to do for global media what Monsanto is trying to do for food production. But Ascherson makes a good point, don't bother reading what journalists have to say, unless you like a good read. As for science reporting in the mainstream media, forget it.
  
  Domination of global food production by a few multinationals should be bad enough but approval of GM potatoes or any other GMO in Europe (or anywhere else) will also be a disaster because such crops will contaminate other crops around them. We know that they will because the evidence is clear from every field trial of GMOs. We know that there are other dangerous drawbacks to GM crops and also that none of the promised advantages of these crops have materialised. So what they hell are we growing them for?
  
  I wouldn't wish to blame lying journalists for doing any more than following orders, or whatever it is they do, but if they want to brown-nose the bosses of companies like Monsanto, the least they could do is declare their interest. Because every time they throw in a straw man argument like 'Frankenstein foods', they are scoring a goal for the GMO industry. Monsanto can just claim to be using the crops for animal feed or biofuels. But then the problem doesn't go away. Once GMOs are used, the damage is done.
  
  There are enough arguments against the use of GMOs, aside from the dangers to human health. But these arguments are much more difficult to answer. So rather than get the biotech industry to answer them, they are presented with arguments that they have a ready prepared response to. A response that has been well sold by journalists. And have you noticed the way articles often point out how widespread GMO contamination already is, as if to say it's only a matter of time before there is no longer any point in protesting? That's how they got GM cotton into India. Thanks journalists.

• Mass Male Circumcision: Science or Politics?

  Posted: March 2, 2010, 12:19 am by Simon

  Following the claim that a drive to test Kenyans for HIV resulted in 1.5 million people being tested in three weeks, another paper claims that 36,000 (male) circumcisions were performed in two months. I have serious doubts about the first claim and I have serious worries about the future health of the 36,000. In 2004, Kenya had 16 doctors for every 100,000 people and per capita spending on health was $9.10. There were 72 hospitals in Nyanza and 30.3 beds per 100,000 people.
  
  Most of the circumcisions were performed in Nyanza because it's the only province with relatively low rates of male circumcision. In fact, it's only the part of Nyanza where the Luo tribe predominates that circumcision rates are low, standing at about 48%. HIV prevalence is high in Nyanza and especially high among the Luo. It's around double the national rate of over 7%. While this is said to be because of low rates of circumcision, it is not clear whether there are other factors that may result in high HIV prevalence among this tribe.
  
  The scientific papers claiming that mass male circumcision can significantly reduce HIV transmission are notable for the frequency with which they are cited rather than for their great number. And perhaps the evidence is overwhelming, from a scientific point of view. Perhaps this is the one big breakthrough that the world has been waiting for. But some of the areas where circumcision rates already stand at almost 100% in Kenya also have high and increasing rates of HIV transmission. For example, prevalence is rising in Coast province and it is higher than the national average, even though circumcision rates are nearly 100%.
  
  So what awaits Luos who have been circumcised? Some people I have met who are already circumcised believe that they don't need to use condoms and that seems to be a common view. Some even believe that condoms 'don't work' if you are circumcised. Apparently people who are queuing up to be circumcised now are also being given advice about using condoms once they are able to have sex again. I suspect people are getting circumcised because they think they will no longer need condoms. They may well be getting advice that says they still need to practice safe sex, but if they are heeding this advice then they could just skip the circumcision.
  
  The scientific evidence claims that being circumcised reduces the risk of HIV transmission by 60%, regardless of sexual practices, for example, whether a condom was used, whether one has multiple partners, etc. Still, I just don't see what people think they can gain from being circumcised unless they think they can dispense with the need to use a condom. And maybe a 60% reduction in transmission will make some think the risks of unsafe sex to be small enough to be worthwhile.
  
  Kenya's intention to spend $56 million on a small percentage of the population to prevent a handful of sexually transmitted diseases, given how little is spent on health per capita, seems strange. But spending this kind of money on an intervention that may not have anywhere near the effect it is expected to have is rash. Why, in a country that has so many health priorities, is so much being spent on this handful of diseases and targeting this small demographic (adult male Luos)? Yet the main funding sources, PEPFAR, the Gates Foundation and the Global Fund are all behind the initiative.
  
  I hope this mass male circumcision campaign is worth it and HIV transmission rates drop significantly in the Luo population. But I just wonder if people who have swallowed the hype know that they will only be well protected from sexual transmission of HIV (and some other sexually transmitted infections) if they always use a condom, properly. Because if there are any other factors behind high rates of HIV among the Luo, aside from those relating to sexual transmission, it could be some time before they are given any consideration.

• GMOs: You Pay Me to Shit in Your Garden

  Posted: February 28, 2010, 9:33 pm by Simon

  Supposing I were to re-engineer my domestic sewage system so that it dumps sewage from my house into my neighbour's garden, my neighbour would be quite upset, right? But supposing I were to take it a little further and sue my neighbour in court for refusing to pay me for manuring his garden, that would really add insult to injury, wouldn't it? It sounds ridiculous for me to be claiming that I am the injured party, when I have, without permission or discussion, used my neighbour's land as if it belonged to me.
  
  Well, that's how GMOs (genetically modified organisms) work. If I grow GMOs on my land and they contaminate my neighbour's land, my neighbour will have to pay royalties to the seed manufacturer, even though my neighbour may grow non-GMOs or organic crops. My neighbour's crops have been contaminated, not in some way blessed with the bountiful gift of genetically modified crops. I should be compensating my neighbour because the crops now grown on my neighbour's land will no longer be non-GMO and will no longer be organic.
  
  My choice to grow GMOs in the first place is questionable enough, because it is inevitable that they will eventually contaminate my neighbour's crops. But I have effectively also taken the decision that my neighbour should no longer have the right to grow non-GMOs or organic crops. Where did I get this right and why does my neighbour not have the same level of autonomy over their land that I have over mine?
  
  Farmers in Brazil and Argentina are facing this very absurdity, that the serial rapist is taking their victims to court for compensation for the use of their genetic input. Those contaminating the land, the land belonging to those who wish to have nothing to do with GMOs, are set to be paid for their contamination. Australia is busily trying to patch up their laws so that unwitting non-GMO farmers can be protected. But the multinationals that produce GMOs are rich and they are not going to give up easily.
  
  Absurd though this is, it is exactly what awaits any country that is tricked into allowing GMOs to be grown on their land. Individual farmers will not have the right to choose whether to fall for GMOs or not; if their neighbours accept the thirty pieces of silver, their land will also quickly become contaminated and they will also have to pay royalties, they will also be stuck with weeds that are resistant to certain pesticides, their soil will become degraded and they will be forced to buy expensive fertilizers. Their yields and crop quality will also suffer.
  
  Consumers, also, will have to pay for the greed of the few farmers who are willing buy into the plot. Eventually, consumers will not have the choice of GMO or non-GMO crops, they will all become contaminated. It is simply not possible for both GMO and non-GMO crops to be grown in the same areas. While non-GMOs may attract a premium for a while, the price will quickly rise before they become unavailable.
  
  The only solution is to hold out against GMOs, regardless of what carrots the GMO manufacturers hold up, whatever threats they make or whatever lies they propagate about 'food security' and the rest. They are interested in deciding what people grow and eat and that's the way things are in countries like Brazil and Argentina. The costs to the farmers are higher and growing, therefore the costs to consumers are also higher and growing. The only ones that benefit from GMOs are the multinationals.
  
  If anyone has seen the wonderful Italian film, The Bicycle Thieves (or the more recent Bejing Bicycle), they may notice a similar irony, where the person who has been wronged is made to pay for their victimization. How has this cruel and dangerous absurdity been allowed to arise in the first place? Why do faceless multinationals have so much power and influence that they can pay for a policy of appeasement, while they treat the defenceless as guinea pigs in their deadly experiments? And will we simply say 'never again' after conventional farming has been destroyed? There may be time to prevent this disaster in some countries, but it has to be now. The consequences cannot be reversed.

• World Domination Trumps Science in the GMO Industry

  Posted: February 27, 2010, 9:21 pm by Simon

  One of the most scary things about genetically modified organisms (GMO) is that they are not being pushed because there is scientific evidence that they are a potentially useful tool in improving global food security. Firstly, global food security is not primarily a problem of a lack of food, it is a problem of unequal access to food. Secondly, GMOs have been shown to lead to decreased food security, for several reasons. Yields are not higher, they are the same or lower. GMOs do not show any signs of being resistant to drought or pests. And overuse of pesticides has given rise to pesticide resistant weeds, just as critics predicted it would.
  
  Scientific evidence for or against GMOs is irrelevant because the GMOs are all about world domination. The issue is one of geopolitics rather than science. It is an attempt by some of the most powerful multinationals in the world to gain control of all the arable land in the world. When you grow GMOs, you use GMO seeds and GMO products. You can't save the seed for the next growing season and the amount of fertilizer you need every year will increase because of soil degradation. The amount of pesticides you will need also increases because of ever growing resistance. If you try to return to growing conventional crops, they will become contaminated and there is a risk that the GMO manufacturer will either claim royalties or prevent you from growing the crop. And you will find your markets rather limited too, as Canada has found.
  
  India may have successfully rejected the genetically modified brinjal (aubergine or egg plant) by putting a moratorium on its production. But India rejected the crop because of the flawed scientific arguments that were used to try to force it on the country. If the science is irrelevant, the moratorium is merely a political matter. Already the powerful and well paid pro GMO lobby there is busying itself with laws and regulations that will prevent people from criticizing GMOs with threats of fines and prison sentences. Ironically, they say that you are not permitted to criticize GMOs without scientific evidence.
  
  There is no scientific evidence to show that farmers should not become indentured slaves to these multinationals. It is a human rights issue, not a scientific issue. The scientific arguments against GMOs have been available for years but they are dismissed, out of hand, dismissed by a lot of sales pitch and political bluster. Those opposed to GMOs are branded Luddites and said to be anti development and denying people in developing countries access to this life saving technology. US soya farmers, Canadian cotton farmers and Indian cotton farmers know just how life threatening this technology really is.
  
  There was a facetiously titled programme on the BBC recently called 'Food Fights'. It wasn't about GMOs, specifically, it was about large scale land grabbing by rich countries, multinationals and investment portfolio administrators to grow food, biofuels and anything else they need in developing countries. It is clear that this land grabbing is not even intended to benefit those in developing countries, yet the programme gives the impression that it is a viable answer to global food insecurity. The programme is not completely biased, but it allows some palpable falsehoods to remain unscrutinized.
  
  For a start, this sort of land grabbing is said to be the only alternative to the present situation, where developing countries depend to a large extent on food and other kinds of aid. The only real alternative for developing countries is for them to become self sufficient and self reliant, which is the opposite to what this neo-colonialism offers. Rich foreigners are not looking for an alternative, they are looking out for their own interests, regardless of the costs to those in the countries where they propose to extract everything they can get.
  
  Although it is not a GM crop, the example of sugar cane fields is examined because sugar cane is one of the favoured biofuel crops planned for Kenya. Even before biofuels and stories about food insecurity started, sugar cane was grown on farms as if the farmers were nothing but indentured slaves. This is still the case. The sugar company supplies all the inputs and does all the mechanised tasks. Once they have extracted what they want, the little that is left goes to the farmer. Often, farmers produce the sugar cane at a loss but there is no other cash crop with a ready market. In some cases, they lease the crop on their land to the sugar company to get some ready cash. Come the harvest, they have nothing left after they have paid their bills.
  
  Farmers in this sort of situation already know what it means if foreign interests take over large tracts of arable land in Kenya. Hundreds of thousands of hectares of land, referred to as 'marginal' is threatened with this kind of incursion. And those who object are referred to as Luddites, anti-development, whatever. Those using this 'marginal' land will be dispossessed and the whole ecosystem that the land supports will be destroyed. And GMO manufacturers don't even need to lease or buy the land, like the sugar companies.
  
  But this is the sort of world domination that GMO manufactures want. They don't want people to be able to produce their own food or to choose what farm inputs to use. They want farmers to effectively give over their land to a multinational that will tie the land into a system that will be virtually irreversible. Yields will decrease and input costs will increase, but the farmer will be forced to continue purchasing products from that multinational, and that's the important thing. Human rights, food security and environmental destruction are irrelevant to multinationals. As for the science, it is a handy political tool sometimes, but other times, it just doesn't give the right results.
  
  [The possible contribution of GMOs to antibiotic resistance is discussed in this interesting article. While it doesn't fit into the above posting so well, it is of particular significance to countries that have a very high HIV and TB burden because these countries also have reduced access to drugs and often have to make do with older versions, for which pathogens are more likely to develop resistance in the near future.]

• The Free or Almost Free Model

  Posted: February 26, 2010, 7:19 pm by Simon

  Walking around Nakuru town today, I was thinking about why a particular project was going so slowly. The project involves showing people how to make simple solar cookers. They just require cardboard or something similar, reflective paper, glue, tape and a blade. But the main problem has been getting hold of the materials in large enough quantities at as low a cost as possible. It's all very well to say 'just buy them' but I don't have a budget and if I buy them, what use will that be to the free or almost free model.
  
  I would like to think that certain things can be constructed using free or very cheap materials. In Western countries, such as the UK, you can get all the cardboard you need by visiting a supermarket or department store. But here, you have to pay. I don't know about the lowest price yet, but I had to pay the price of half a kilo of maize for a single cardboard box. They are reused until they can no longer be called a box, and that's a very good thing. You don't see lots of cardboard box waste lying around, not until it's completely useless. Because this 'waste' is valued, it doesn't present the sort of litter problem they have here with plastic bags, say.
  
  Similarly, I wanted to find some kind of durable reflective paper. I know that lots of sweets, biscuits, chocolate and other products are wrapped in such paper. Even better, car tyres are wrapped in a very durable reflective paper. Having identified these sources, I now need to identify places where people can get the stuff in large enough quantities. I'm still working on that. Some shops I visited were reluctant to hand over any more than a small sample, others simply said they didn't have any to spare. Perhaps this stuff is also reused for something, perhaps people are just holding out for an appropriate price. Tin foil would be Ok but it's expensive and not very durable.
  
  Anyhow, I think people who are making these solar cookers should source the materials by themselves. They will get a much better price and will be better placed to source the materials for free. I just want to know that the materials are available so no one can tell me that I'm asking them to do something impossible. I'm getting closer, but I'm not there yet. Once I have found a good place to get adequate amounts of cardboard and reflective paper at a good price, hopefully free, then I can tell people where to go and get started making the cookers. I'll throw in a free pot of glue and anything else that is required!
  
  I've had similar experiences with cooking baskets (also called fireless cookers). The main material for these devices, which insulate cooking pots sufficiently to allow partially cooked food to cook completely, is some kind of stuffing. An ideal kind of stuffing is a waste product from a local blanket factory. However, this waste product is also used for furniture, pillows, quilting, etc. So, again, you have to pay for it. Enough for a medium sized cooking basket costs about the price of two kilos of maize meal, enough to feed quite a number of people. I'm sure buying it in large quantities would bring the cost down but it's a challenge to the free or almost free model. Alternative, waste from local sisal factories could be used, but this too costs money as it is used to stuff furniture.
  
  Another of our proposed projects is to construct a press that can compress briquettes made from organic waste. I spent some time looking for someone who could make such a press (it's not as easy to find someone as you might think!). When I found one, I gave him some plans I had found on the internet, a variety of wooden and metal ones. I was surprised that he recommended making the press from metal because the sort of high strength wood required would be very expensive. On the other hand, the metal could be sourced from scrap metal dealers. The labour would be cheap and I'm expecting to have a version of the press in the next week or so.
  
  The briquettes can be made out of many things, fruit and vegetable peelings, charcoal dust, sawdust, waste from food production and other sources. Getting large amounts of waste in the right form may not be so easy. Sawdust has to be paid for, though the other materials are free (unless the word gets around that they are valuable). But they will probably need to be chopped or crushed so they can be mixed in the right proportions. And chopping or crushing machines are available, but they are very expensive. Ok, expensive means tens or hundreds of dollars. But where you only stand to make a few dollars a day profit at the most, no one is going to shell out large amounts for materials.
  
  Economy of scale would make a huge difference, of course. But the aim of these projects is to be small and cheap. They need to be small enough and cheap enough for people who have very little money and probably very little education. If the money, training and education were readily available, there wouldn't be so much of a problem. So I'm looking for as many of these 'free or almost free' ways of either making money, saving money or a combination of the two.
  
  Luckily, the organisation I'm working with, Ribbon of Hope, in Nakuru, has a number of other projects. We grow crops and support people to produce things that get them an income. Some of our clients keep livestock and we are investigating the possibility of breeding rabbits for food. These are all good 'bread and butter' projects because they provide people with income or food or both. But the more we can branch out and find other ways of making money, especially ways that don't require much capital, the better. Hence my aim to work on the free or almost free model to see how far it can take us.

• Experimenting with Diversity

  Posted: February 24, 2010, 11:55 pm by Simon

  It's odd how the weather can go from very dry to very wet quite unexpectedly. During the wet season, there was sometimes too much rain all at once, which threatened to wash away crops which were about to be harvested. Rain delayed the harvest of beans, which also resulted in some losses. Then the dry season started, so after harvesting, we returned to the practice of irrigating the other crops that were planted to overlap with the harvesting, a field of watermelon. And then the dry season was interrupted by a week of torrential rain, which threatens the watermelon, due to be harvested in Late March.
  
  With any luck, the dry weather will return and what is left of the watermelon crop, hopefully most of it, will do well. But the field is waterlogged and some of the smaller fruit and plants have been overwhelmed by the thick mud that has been stirred up. All we can do is make sure water is not collecting anywhere and that any plants and fruits that can be saved are saved. Things have been looking brighter and drier for the last two days.
  
  And with the brighter, sunnier weather, we at Ribbon of Hope have been able to return to demonstrating solar cookers. We had a good day at Mogotio, North of Nakuru, last week before the heavy rains started. Over thirty people came to see the demonstration and the debate about whether it was or wasn't possible to cook with 'a piece of silver cardboard and a saucepan painted black' was noisy. Scepticism turned to interest as we checked the food's progress about one hour in; interest turned to amazement when we invited people to test out the result half an hour later.
  
  Today, we went to a town called Salgaa, also North of Nakuru. Closer to 40 people turned up and asked many questions as the rice and ugali (boiled maize meal, the staple food) and sukuma wiki (kale) cooked in the hot sun. In fact, giving a lot of time to answering questions was good because many people cook things one way and one way only. Today, they saw their beloved staple food cooked without using boiling water and without stirring. The whole thing can be put on to cook while the chef attends to other things. And that's just one of the many advantages of cooking this way!
  
  Our aim is to increase self reliance through a variety of income generation schemes and ways of reducing day to day costs. So next week, we hope to return to Salgaa and show people how to make a solar cooker. Buying one is good, because people can save a lot of money and learn a great technique. But if they could make a solar cooker themselves, they could save even more money and they would always be able to make another when the original one wears out. Someone today was asking me if it was really sustainable to sell people a solar cooker for 500 Kenyan shillings (about 4 UK pounds). Well, it is a lot more sustainable than using charcoal or wood. But being able to make these cookers, and it's not difficult, would really put the icing on the cake.
  
  On the opposite end of the scale in terms of self reliance, there is a big problem with the country's dependence on maize for almost all their food needs. It is not an indigenous crop and, for various reasons, it is becoming less productive. Because the weather has been so unpredictable lately, it would be far better to grow more resistant crops such as millet, sorghum, amaranth and many others. These do better in challenging conditions, like drought and flooding. But they also tolerate poorer soil and require less fertilizer and pesticides, substantially reducing the costs that farmers face.
  
  Many farmers remain too dependent on a government that has never actually done very much for them. The scandal of the subsidized maize scheme, which allowed well connected people to make money out of 'relief' food supplies while the costs to ordinary people continued to rise and around a quarter of the country faced serious shortages, was less than a year ago. But the failure of farmers to produce enough food is partly their own fault. Some try to produce cash crops that end up making money for someone or some industry, but don't make much for individual farmers. Others, most farmers in fact, rely on rain fed agriculture, rather than employing some relatively simple method to harvest rainwater.
  
  Small farmers are, of course, in need of ready cash, no less than non-farmers. But there are also those who produce far too little food for their own family and yet also make too little from cash crops to purchase additional food. There should be enough land in Kenya for the country to be food secure, regardless of how weather patterns are changing. True, the government should do a lot more, but perhaps people shouldn't wait for their politicians to do things that it has never done before. Hence the need for anything that increases self reliance.
  
  Sadly, I am not an experienced farmer, I have to go around asking people for advice on what to plant and how to deal with problems that arise. But I feel that the very practice of experimenting with diversity is a good thing in itself. Equally, I think people need to experiment with cooking and eating different things and cooking them in different ways. I can't claim to have many converts yet but this kind of experimenting can be done without spending very much money. And development at low cost is, I think, well worth striving for, especially given the relative lack of success with development at high cost.

• A Pill for Underdevelopment

  Posted: February 22, 2010, 11:40 pm by Simon

  An article published on the 24 of December last year claims that a three week drive to test as many people for HIV as possible succeeded in testing one and a half million people. Perhaps my scepticism is misplaced, but I find it hard to believe that over 6600 people were tested every day for three weeks. Still, if it's true that the country has the capacity to test this number of people this quickly, their aim to test 80% of the adult population by the end of 2010 should be fairly easy.
  
  Unfortunately, providing antiretroviral treatment (ART) for everyone found to be in need of it may not be so easy. The Kenyan government has only ever provided a fraction of the money needed to supply ART to everyone who needs it. Most of the money came from donor funds, such as the (US) President's Emergency Fund for Aids Relief (PEPFAR), the Global Fund and the Clinton Foundation. But they are not due to increase their funding in line with the surge in numbers being found to be HIV positive. The Global Fund has even stopped some expected funding due to serious financial irregularities.
  
  The funding gap is thought to be 2.5 billion shillings this year but will rise to many times that in the next few years. Kenya is currently almost out of stocks of some drugs and the Ministry of Health is applying for emergency funding that should tide them over for six months, if the money is forthcoming. The problem will be exacerbated by new World Health Organisation guidelines that recommend the use of more expensive drugs and putting HIV positive people on ART at an earlier stage of disease development.
  
  Meanwhile, the advocates of 'treatment as prevention' are back in the news. They claim that rolling out ART to everyone found to be HIV positive and testing every adult about once a year could prevent nine out of every ten infections. If this is true in practice, testing everyone regularly and treating everyone found to be positive would be even better than very high levels of condom use (levels that have probably never been achieved). Of course, the approach to funding would have to be completely changed as current funding would be nowhere near high enough to cover the costs of 'treatment as prevention'.
  
  Another study claims that the sort of mass screening suggested above could allow HIV to be eradicated in 40 years (in South Africa). My reaction to these articles, and I'm thinking specifically of Kenya, is that if it were possible to test many millions of people every year, it may also be feasible to put millions on treatment. And if it were possible to successfully treat so many people, then transmission rates should drop radically.
  
  But I would question the feasibility of testing most sexually active adults in Kenya every year. This is a country where health services are in very short supply and high quality services are only available to the very rich, if at all. Long term care for the chronically ill is in even shorter supply. Is the country really going to raise the money for and implement the vast improvements in health infrastructure that would be required just to make this level of HIV screening possible? And if this happens, will the country also develop its capacity to provide long term care to millions of HIV positive people for several decades to come?
  
  Even if the money is forthcoming, I find it hard to believe that Kenya's levels of health care, education, infrastructure and social services will be raised sufficiently to make anything like these predictions about 'treatment as prevention' become a reality. Maybe it is true that 1.5 million people were tested in three weeks. And maybe the sort of funding required to eradicate HIV will be provided. But I can't help remaining highly sceptical.
  
  My discomfort stems from reflecting on the fact that HIV spread rapidly in Kenya at a time of high and increasing levels of poverty and unemployment. Levels of health and education provision were low and are still decreasing. Health indicators, especially for maternal, child and infant health, were particularly poor and most have been disimproving since the 1980s. Gender inequalities have never been given very high priority and those among whom HIV spread most rapidly, women, commercial sex workers, men who have sex with men and intravenous drug users, are as vulnerable now as they were three decades ago.
  
  If it is true that HIV transmission is related to the conditions in which people live and work, as I would maintain, provision even of astronomical levels of funding to test and treat millions of people will still fail to address these conditions. Therefore, I'm suggesting, HIV could still be a problem for countries like Kenya in 40 or 50 years time. In fact, we have hardly even started to address HIV transmission because we continue to ignore the conditions mentioned. But that's just my take on it.

• Homophobia is the Problem, Not Homosexuality

  Posted: February 21, 2010, 9:16 pm by Simon

  Rabid homophobia continues in Kenya and is being actively promoted by political and religious leaders. Police had to 'rescue' three men accused of being gay in a coastal town. When you are 'rescued' by Kenyan police, you know you are in trouble. There was also a case of two men said to be getting married being arrested by police after neighbours complained about them being 'notorious gays'. Meanwhile, a Muslim and a Christian leader are united in their opposition to their town being turned into 'Sodom and Gomorrah'.
  
  These religious leaders feel that if gays are not persecuted, their community will be 'doomed'. This is odd, because Kenya currently faces numerous instances of massive criminal acts being carried out by the country's most powerful and wealthy people. The country is, in a sense, already doomed. At least, a lot of people's lives are doomed.
  
  Hundreds of millions of dollars of funding for education, HIV and internally displaced persons have been stolen, the people behind the post election violence have yet to be tried and will probably never be punished, the power sharing government is a farce, the constitution promised in the first hundred days of 2003 is as far away as ever, millions are facing starvation while donated food is being stolen by politicians and surpluses are being destroyed because of lack of storage facilities. The list goes on and on.
  
  Facing these conditions, why are religious and political leaders so obsessed with homosexual activity? They seem to think that the practice of men having sex with men or women having sex with women is going to turn the heads of heterosexuals and make them into homosexuals too. They imagine that same sex practices are un-African and that they didn't exist before being 'imported' by colonials.
  
  They see homosexuality as a crime but who are its victims? The victims of corrupt politicians, church leaders, police, businesspeople, both foreign and indigenous, are clear enough. Most Kenyans are victims of the excesses of the wealthy and powerful. But who are the victims of the 'crime' of homosexuality?
  
  Of course, there are victims of rape and sexual assault. But perpetrators of sex crimes are already covered by the law. It's just that these laws are not usually upheld, especially when the crimes are carried out by the rich and powerful. The police, who are so quick to go after people who are accused of being gay, are not usually interested in ordinary everyday crime, unless they happen to be involved in it themselves.
  
  Just why is the public so ready to become a baying mob of vigilantes when their target is a defenceless individual or group of individuals? They would achieve a lot more by objecting to the real criminals in this country but the most they do is complain about them. Not that I'm advocating mob justice, but there seems to be no sense of proportion in people's reactions to crimes.
  
  Meanwhile, a politician in Uganda, Otto Odonga, has said he would agree to be the executioner even if the person being tried for homosexuality was his own son. Another politician there seems to think bisexuality is something that has been 'imported' into Africa. But thankfully, at the same meeting, someone else said that he had seen homosexual activity when he was young and that it was not a new thing. Like in Kenya, people in Uganda seem content to be living in one of the poorest countries in the world, made poorer by greedy leaders, as long as they can let loose their mob law against homosexuals or those thought to be homosexuals.
  
  Interestingly, the Ugandan politician who wants to introduce draconian laws against homosexual activity, even against those who witness or know about homosexuality (or who are suspected of witnessing or knowing about it), David Bahati, thinks that everyone is susceptible to being turned into a homosexual. This means that it is possible for him or his friends, colleagues or family members to be 'made into' a homosexual, given the right influences. This seems like a very odd for a homophobe to hold.
  
  What these Kenyan and Ugandan politicians should really be asking about is where the homophobia was imported from. Homosexuality exists in every country and always has, as far as anyone knows. You can't 'import' it. But homophobia is actively encouraged by religious groups, especially extreme right wing Christians. Several prominent American Christians and Christian groups are said to have been backing Bahati and people like him. No doubt they will support anyone who promotes their bigotry. Homophobia is the curse that Kenyans and Ugandans should be worried about, not homosexuality.

• Punishing Victims; Protecting Perpetrators

  Posted: February 20, 2010, 1:56 pm by Simon

  Several Christian organisations and churches in Kenya are claiming 'victory' because the draft constitution has been rewritten to specify that life begins at conception. They threatened to sabotage the whole constitution if this was not done. As a result of their threats, other clauses have also been removed. Kenyans will not now have a right to health care, in particular, reproductive health care. Also, the clause stating that no one may be refused emergency medical treatment has been removed. And there is a phrase that specifically rules out abortion unless the life of the mother is in danger.
  
  Abortion is already illegal in Kenya, but this has not prevented several hundred thousand woman and girls seeking abortion every year. The majority of these abortions, an estimated 800 per day, are unsafe, being carried out in insanitary conditions by untrained personnel. Those who go through these unsafe abortions are less likely to seek professional medical attention and less likely to receive it. As a result, over 2000 die every year, adding considerably to the thousands of maternal deaths that occur.
  
  In what sense have these Christian groups achieved a victory? They don't appear to be opposed to the fact that rape and forced sex often goes unpunished because it is carried out by the more powerful against the powerless. It is carried out by adults against young people, even children. Those who should protect the victims, church leaders, political leaders, teachers, police and others, are often the perpetrators.
  
  If, as Christians are so fond of claiming, life is sacrosanct, why are the lives of certain people so unimportant? Why are human lives so unimportant as to be denied the right to health and the right to make their own reproductive decisions? Women should be able to choose when to have children, under what conditions and with whom. Where these rights have been denied, why should they be made to pay for someone else's crime?
  
  Nothing that these Christians have done will reduce the incidence of unsafe abortions, of seriously compromised reproductive health for women, of women suffering and dying unnecessarily. Nothing that these Christians have done will reduce the incidence of rape and forced sex. Victims of crime should be entitled to protection, not punishment. Perpetrators of crime deserve punishment, especially when those perpetrators are in a position that gives them a level of power that they subsequently abuse.
  
  One priest has said 'we should not victimise the innocent unborn children' but what about the woman or girl who has already been victimised and is now to be punished, perhaps for the rest of her life? Kenya is in dire need of good leadership and the interference of interested parties, whether they be political, religious, commercial or whatever else, is frustrating this need. The country also needs good health care and equal rights for all people, regardless of gender, sexual orientation, tribe, wealth and anything else. But some of the Christian churches clearly have other ideas.

• Lack of Logic in the Received View of the HIV Pandemic

  Posted: February 19, 2010, 8:15 pm by Simon

  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.

• GMOs, the Antithesis of Sustainable Development

  Posted: February 18, 2010, 11:29 pm by Simon

  Yesterday I went to see a lovely farm in Ngubreti, just a few kilometres north of Mogotio, in Kenya's Rift Valley province. Of course, if you like farms, many of them are beautiful. But when the climate is hot and dry for most of the year with flash floods that can wash everything away, the odds could be stacked against the farm being beautiful. This farm is beautiful because the farmer has employed numerous techniques to get as much as he possibly can from a twenty acre plot.
  
  This farm has 30 or 40 orange trees, 80 or 90 mango trees, vegetable crops, grain crops, animal fodder, 20 or 30 beehives, a tree nursery (which has already produced 2000 seedlings), cattle, sheep and, most importantly, water pans for collecting and storing as much as possible from those flash floods. It's hard to believe there is so much variety on this small farm but it's encouraging to see everything doing so well, given the amount of work that has been put in over the years.
  
  One of the sickening things about institutions like the World Bank and the IMF (International Monetary Fund) is that they can (and do) produce research to show that the way forward for farmers in developing countries is to increase support for farm inputs, provide extension programmes, improve infrastructure and other somewhat obvious things.
  
  Obvious, except that the same two institutions also give loans with conditions that include reducing public sector employment, cutting expenditure on extension programmes and banning anything that could be considered a subsidy, such as grants, loans or anything else to help farmers afford farm inputs, fertilizer, pesticides and the like. Never mind that these are allowed in rich countries, that's not the point. The point is that these institutions are run for the benefit of rich countries and what is good for them would never be allowed in developing countries.
  
  Well, the new head of the UNDP (United Nations Development Program), Helen Clark, has now said that she thinks there should be more public funding for agriculture, for extension services and for research that improves productivity and yield. There should also be public funding to help farmers to reduce inputs. The last one is especially gratifying because 'modern' agriculture often involves a constantly increasing dependence on things like fertilizer and pesticide. So there would still be inputs but the financial costs would be significantly lower and the environmental costs incalculably so.
  
  In the case of the farmer in Ngubreti, I said the water pans were the most important initiative on his farm. The failure to avail of cheap water harvesting techniques in the area is quite extraordinary. But this farmer has taken heed of what the local agricultural extension officers have taught him. He has two water pans, one that is just fed directly, the other which is fed by run-off water from the main road. These supplies ensure that the farm does not run out of water, even during prolonged dry periods.
  
  I shouldn't leave out the point that the head of the UNDP was actually responding to a question about genetically modified organisms (GMO). Ms Clark said that world food security depends on getting "back to the basics" with agriculture, it does not depend on GMOs. She also said that crops for biofuel competed with crops for food, despite the lies to the contrary that we so often hear from those investing in biofuels. So congratulations to Helen Clark. She could really benefit farmers in developing countries.
  
  The farm in Ngubreti was the scene of a number of agricultural extension programmes yesterday, including improved cooking stoves, cooking baskets, solar lighting and phone charging, beekeeping, water harvesting and various other ways of increasing the productivity of small farms. I'm hoping that Ribbon of Hope can try some of the things being done there, especially water harvesting and perhaps growing tree seedlings.
  
  It is clear from visiting a farm like this that GMOs have nothing to offer, especially in the sort of dry areas that make up so much of Kenya's land. The farmers are almost all smallholders, whereas GMOs are designed for farmers with huge tracts of land (that they can afford to waste, presumably). The farmers are poor but GMO seeds cost several times more than conventional seeds. Inputs for GMOs are far higher than inputs for conventional crops and increase over time (and conventional crop farmers usually put by their own seed every year). Organic methods, which increase yields, improve resistance to pests and to bad growing conditions and therefore cost less, are inimical to GMO production.
  
  GMOs are the antithesis of organic farming, indeed, the antithesis of sustainable agriculture. And there are many other problems with GMOs, as GMWatch.org make clear. It's good to know that much of Kenya's land is, as yet, unspoiled by modern agriculture. The same is true of much of the land in most developing countries. So it's time to ensure that it stays that way by resisting GMOs and anything else that compromises the future of the world's food security.

• Generating Self Reliance

  Posted: February 15, 2010, 11:36 pm by Simon

  Sometimes I get carried away when I'm blogging and I write something quite different from what I set out to write. The other day I wrote about how food insufficiency could affect people's likelihood of transmitting or becoming infected with HIV. That's fine, but my intention was also to say why I ended up working for a community based organisation that aims to help people become more self reliant, to produce food or goods that they can sell, or to identify ways of cutting their day to day costs. But now I think the answer should be clear.
  
  Ribbon of Hope Self Help Group, Nakuru, are working on a number of projects involving both HIV positive and HIV negative people in poor communities. Those projects range from growing food crops and keeping livestock to making things for sale here and abroad, providing various services and spreading intermediate technologies, such as solar cooking. The main thing is that we find income generation activities that are easy for people to do, even if they have very little money and training. If people are able to make or save some money, they will be more self reliant and better able to cope with the many stresses of life.
  
  Today was a great day for solar cooking. The location was ideal, about one kilometer from the Equator, and the sun was hot. We got there in time to set things up, not that that takes very long, and then started to answer the numerous questions people had. We were in a conspicuous area, so groups of people would form and disperse throughout the morning. I have no idea how many people came to see food being cooked using bits of reflective cardboard and pots that were painted black and stuck in a bag. But when the food was cooked, there were around thirty people willing to taste the rice, boiled maize meal and cabbage. If I'd known so many people were coming I would have prepared something more appetizing. But there will be plenty of opportunities to go back and demonstrate again!
  
  Will this prevent HIV from spreading? Not on its own, no. But there are many intermediate technologies that can provide people with cheap or free energy, solar cookers are just one example. We will be demonstrating others when we have the equipment. There are also many ways people can make money. We are researching the ones which will be most suitable for this particular context, poor, rural, isolated, etc. We want each person or family to take on more than one way of making or saving money, in fact, as many as possible each. The Scottish say 'many a mickle makes a muckle', here in East Africa they say 'haba na haba hujaza kibaba' (little by little fills the pot).
  
  Those who collect HIV data are probably not going to note a drop in HIV transmission in this area next year, or perhaps even several years from now. HIV is going to continue to spread in an area where the disease is endemic, where people are poor and lack health facilities, where a good level of education is rare, where basic things like food and water are in scarce supply, where infrastructure is falling apart and where most people don't work.
  
  But Ribbon of Hope aims to reduce poverty to the extent that some people will be able to send their kids to school, pay for their health care and provide them with adequate nutrition and clean water. And when those children leave school, they will have a better chance of being able to find work, being better educated and healthier than the generation before them. They may even have developed some entrepreneurial skills and know good ways to make enough money to do the same for their children.
  
  Most HIV money is spent on very expensive projects that target one disease and only one aspect of that disease, sexual behaviour. As long as the contexts in which this sexual behaviour takes place are ignored, most of the money is being wasted. Health, nutrition, food security, education, infrastructure and many other things are crying out for money but unless sexual behaviour is somehow involved, they will not be funded. This approach has not worked. HIV rates have waxed and waned in certain areas and in certain demographic groups. But rates are still high and the levels of sexual practices said to spread HIV have remained relatively unaffected by the hundreds of millions of dollars that have been thrown at the problem for over two decades.
  
  People's sexual behaviour is at least partly determined by the conditions in which they live and work (in addition to physiological conditions, hormonal levels, etc). But their health seeking behaviour, their diet, the way they raise their children and their attitude towards education are also constrained by these same conditions. If you want to influence people's sexual behaviour, and especially their attitude towards sexual health and risk, you need to look beyond their sexual behaviour in isolation. This sexual behaviour is likely to be pretty much the same all over the world. But the conditions in which people live and work are very different in Kenya than they are in, say, Ireland.
  
  There are exceptions, but most people I have met who are HIV positive spend their days getting on with the same things as people who are HIV negative, and worrying about the same things, too. They need to earn money, pay bills, raise their children, support their dependents, get by and perhaps even think about the future, if there is any money or energy left over for that. That's why I think a community based organisation that helps people achieve these goals is doing more to reduce the spread of HIV than all the expensive HIV prevention programmes that UNAIDS can think up.

• There's a lot of talk these days ...

  Posted: February 14, 2010, 8:06 pm by Simon

  There's a lot of talk these days about the need for a new Green Revolution, especially in Africa. Behind this talk, there is often the assumption that the original Green Revolution was an unmixed blessing, which it was not. Countries most profoundly affected by the revolution saw land ownership patterns change to the extent that small farmers almost disappeared and small farming became uneconomic for most. Farming become more intensive, with devastating environmental impacts, it became more mechanized, generally more expensive and less scalable.
  
  Some countries in Africa did experience some of the excesses of the revolution, though you wouldn't always think that when you read about the phenomenon. So now there is AGRA, the Alliance for a Green Revolution for Africa. This is funded by some of the funders of the original revolution, a number of prominent philanthropists that includes Bill Gates and several powerful international institutions. Again, the assumption is that such an initiative is an unmixed blessing.
  
  Kenya has a number of problems at the moment relating to land ownership. There are pressures for the number of people owning land to go down and the amount of land each owner owns to go up. One of these pressures comes from the many countries and institutions that want to invest in African land to grow food for themselves. Another pressure comes from those who want to exploit cheap African land and labour for biofuels. And a third pressure comes from the desire of biotech companies to spread their genetically modified crops (GMO).
  
  All these pressures go to exacerbate the already serious problem of food shortages that millions of Kenyans face every year. The new green revolution, the 'opportunity' to grow GMOs, the great foreign direct investment (FDI) that is being 'injected' into the country, all these incursions on the country's food sovereignty are being presented as a chance for Kenya and other African countries to reverse their fortunes.
  
  What most Kenyans know and what most of the people hawking these 'solutions' wish to ignore is that hungry people need food. Those interested in investing in Kenyan land are not coming here to provide people with food, they want to grow food to export it to the highest bidder. Biofuels are being produced for the Western market. GMOs are not a gift, except in the Trojan Horse sense. Once people grow GMOs, they are effectively working for the multinational that produces the seed, fertilizer and pesticides that all necessarily go together.
  
  Kenyans need to produce their own food and the only way that can be done is if the millions of people who own or rent small farms, the vast majority of Kenyans, are enabled to do that better. They need access to information, skills, tools and techniques that will benefit them as small farmers. They need to reduce their dependence on rain fed agriculture by availing of some of the many irrigation and water harvesting techniques. They need to grow more varieties of crop, rather than depending on a few non-indigenous staples, such as maize.
  
  Malawi has been praised for its 'green revolution' but things are not so straightforward there. As in Kenya, people there still need better access to land and to more land. They need to reduce their dependence on imported fertilizers and adopt some organic methods. Countries like Malawi and Kenya simply dump tonnes of organic waste every year that could provide better sustenance to their crops than the artificial fertilizer that requires much more water than is readily available and eventually poisons the soil and water table.
  
  People here have been promised so much, they have been promised massive production levels, copious foreign markets and great wealth. These things have been promised for decades and yet all Africans have seen is greater poverty, starvation and dependence. Whatever will result in food security in Africa, it will need to arise in Africa. None of the many foreign initiatives have ever resulted in Africans being better off, probably none ever will. The sooner people see this, the better.

• HIV and Sexual Behaviour

  Posted: February 12, 2010, 8:49 pm by Simon

  It sometimes appears that it is difficult for big HIV donors and NGOs to accept that they can waste a lot of money concentrating solely on trying to influence people's sexual behaviour with a view to cutting HIV transmission. They seem to have the attitude that sexual behaviour takes place in a kind of social vacuum and that it is completely unrelated to the way people live their non-sexual lives. Perhaps these organisations don't view gender inequalities, economic inequalities, differences in educational status or social status or intergenerational differences as having any bearing on sexual behaviour.
  
  A paper entitled 'Food Insufficiency Is Associated with High-Risk Sexual Behavior among Women in Botswana and Swaziland' is part of a whole body of research that challenges the view that targeting individual sexual behaviour should be the main approach to cutting HIV transmission. This 'behavioural' view tends to imply, without arguing or demonstrating, that the cirucmstances in which people live and work are irrelevant to their behaviour, their sexual behaviour and, therefore, their relative risk of becoming infected with HIV, or of transmitting it if they are already infected.
  
  The paper finds that food insufficiency results in increased sexual risk taking, especially among women. The sorts of sexual risk are inconsistent condom use with non-regular partners, transactional sex, intergenerational sex (usually where the female is the younger party) and lack of control over the circumstances of the sexual relationship. The paper recommends targeted food aid and income generation programmes and also an improvement in women's social and legal status.
  
  The fact that HIV is sexually transmitted does not mean that transmission can successfully be reduced merely by 'teaching' people about safe sex, by distributing condoms and facile 'messages' or by lecturing people, children and adults, about right and wrong. This is not a new discovery. But as soon as HIV was found to be sexually transmitted, the whole issue was hijacked by political and religious (and later commercial) crusaders. And it's only occasionally that people have been able to wrestle back some control over HIV as a human rights, health or development issue.
  
  If the conditions under which HIV spreads are to be changed, people need health, education and social services that are accessible to all, female as well as male, rural as well as urban, poor as well as rich. People need to be enabled to ensure their own health and the health of their children and dependents. People need their rights to be recognised and upheld by the law. The right to food is particularly important.
  
  Seeing the connection between food insufficiency and risky sexual behaviour shouldn't take much genius. Surely those who think HIV is just a matter of sexual behaviour don't think that being hungry or having hungry children makes people feel a stronger sexual urge or enjoy risky sex more? So if the limit of their HIV prevention programmes consists of things like behaviour change communication, mass male circumcision and, eventually, HIV vaccines and microbicides, they will find HIV continuing to spread.

• Behaviour Change for Journalists

  Posted: February 10, 2010, 11:59 pm by Simon

  The BBC can be funny sometimes, though not very funny. The title of one of their articles runs "Is Zuma's sex life a private matter?" and they promptly answer it in the negative by writing about it. Perhaps the author would have been wiser to ask about the president's attitude towards women and equality, since they have taken the liberty of asking about his sex life. But even an organisation as well (publicly) funded as the BBC often can't resist asking the same questions as almost every other journalist in the mainstream media.
  
  The media needs to get past the connection between HIV and sex. True, HIV is mainly transmitted sexually. But rates of HIV transmission depend on many other things, such as the relative economic circumstances of the people involved, their relative levels of power in relationships (whether ephemeral or otherwise), their levels of education and access to information, their levels of health and nutrition and the like. Indeed, the nature and accuracy of the information to which people have access may also be significant; exalted claims about the role of the media in HIV publicity campaigns certainly suggest this.
  
  Studies have shown that there is no strong correlation between rates of HIV in different countries and levels of what is considered to be unsafe sexual behaviour, for example, multiple concurrent partnerships. In other words, some places where rates of multiple concurrent partnerships are low, HIV rates are high and vice versa. High rates of HIV transmission in South Africa are, to the extent that they are well understood, explained by many things other than sexual behaviour.
  
  If the BBC is really concerned about HIV transmission, it shouldn't be beyond the capacity of the corporation to research the subject a bit better than the average tabloid newspaper. They could even have discussed the fact that Zuma didn't use a condom during his extra-marital relationship and is well known for being against the use of condoms. Sadly, there is very little to HIV prevention in South Africa, or any other developing country, aside from condoms.
  
  It may never become a popular view that HIV has numerous transmission routes and that many of the circumstances in which people live and work determine whether they will be infected with HIV and whether they will go on to infect others. HIV will probably always be viewed as such an extraordinary disease that it is transmitted in isolation from people's overall health and welfare, and that issues such as gender, power and politics are completely irrelevant. But it seems unlikely that the BBC will stick its neck out and adopt an unpopular view.

• India Tells Biotech Industry Where to Put its Aubergines

  Posted: February 9, 2010, 8:54 pm by Simon

  The good news today is that India has decided to place a moratorium on subjecting the country to genetically modified aubergine (eggplant/brinjal). The usual industry 'scientists' and 'experts' did everything they could and managed to drum up (pay for) the support of some senior politicians. But this time common sense has prevailed.
  
  It remains to be seen whether the country is sensible enough to treat other genetically modified organisms (GMO) the same way. It will also be interesting to see if other developing countries are tricked into accepting GMOs based on the industry lies about their increasing yields, being more nutritious, being better for the environment, being drought resistant and whatever make-believe rubbish they come up with.
  
  Sadly, it's too late for India's cotton farmers. They were promised increased yields, but yields have stayed the same or decreased. They were promised lower costs from reduced pesticide use but pesticide use (and therefore costs) is steadily increasing. Seeds for GMOs are far more expensive than those for conventional crops. Prices have also increased far more rapidly and farmers are not permitted to store cotton seed for later planting.
  
  In addition to damaging the environment, especially through reduced biodiversity, the whole of India's cotton industry is contaminated with genetically modified cotton. It is probably not possible to reverse this process so if any farmers are still trying to grow conventional cotton crops, they will soon face demands for payments from the multinationals that sell the seeds (something already happening with Brazilian soy beans).
  
  As a result, many Indian farmers have gone bankrupt or are facing bankruptcy. The costs are so high that others have tried to pull out of cotton production. Some have found that they have no viable alternative livelihood remaining and leave farming altogether. And thousands of farmers have committed suicide because their businesses have been ruined by this genetically modified cotton, a phenomenon that has been going on for at least a decade.
  
  Only a few countries have been rash enough to grow GMOs on a large scale and only a handful of crops are available in genetically modified forms. But the industry seems to have unlimited amounts of money available to 'persuade' powerful people to support them. In addition to DfID, the Gates Foundation is also interested in GMOs. It's hard to know whether the Gates Foundation has bought into the hype or whether they have bought into the industry. Ok, it's not hard to know, they have well and truly bought into the industry.

• Why are DfID Giving 'their' Money to the Rich?

  Posted: February 8, 2010, 8:29 pm by Simon

  In many developing countries, a substantial majority of people live in rural areas. The majority of rural dwellers depend, directly or indirectly, on agriculture of some kind. And most of those engaged in agriculture are smallholders, producing food for their families, their local market and perhaps a bit beyond that. Even a lot of people who don't depend on agriculture grow some food for their own use. Small scale food crops, fodder crops and stock keeping is so widespread in Kenya, where over 80% of the population lives in rural areas, that it would be difficult to estimate their value in the overall economy.
  
  On the other hand, 'aid' from the UK's Department for International Development (DfID), seems to assume that the best way to help poor people in developing countries is to give the bulk of their money to large and wealthy sectors of agriculture. DfID favour large-scale agriculture, high use of expensive, environmentally destructive technologies, such as fertilizer, pesticide, various pharmaceutical products, heavy machinery and genetically modified organisms (GMO).
  
  Small farmers, who can't afford these technologies and who are stuck with relatively undestructive farming methods that preserve biodiversity are therefore denied the opportunity to investigate ways of increasing their yields in sustainable ways. DfID seems particularly opposed to the production of food crops and stocks, spending only 3% of their of aid on food (.3% in Sub-Saharan Africa). MPs are calling for the figure to be raised to 10%.
  
  DfID probably hasn't realised that these small farmers produce most of the food that people live on in Kenya. Many of the rich farmers in Kenya produce for export, things such as tea and coffee and a lot of non-food crops such as flowers and sisal. A lot of land is even being used to produce crops for biofuel, which, whether for export or the domestic market, is not going to help starving people very much. DfID even supports programmes that 'donate' food aid, which is just a form of dumping that suits Western countries but serves only to destroy local markets in developing countries and leaves many of the putative recipients worse off than they were before.
  
  Any institution that supports GMOs has no right to call itself an 'aid' agency. GMOs are the prerogative of wealthy and rapacious multinationals who want to control the food market in order to maximize their profits. Such institutions also have no regard for the importance of biodiversity, which is under serious enough threat but will be even more rapidly destroyed by widespread use of GMOs. An example is the current attempt to introduce genetically modified aubergine (eggplant, brinjal) into India, where there are currently several thousand varieties. If these modified aubergines are introduced, all others will either die out or become contaminated.
  
  Every few weeks there is an article about some kind of crop that will supposedly save a country or reduce levels of malnutrition or increase yields or whatever. These articles don't usually say so, but if you check further, you'll often find that the crop in question is genetically modified. The article may even talk about biodiversity and sustainability and all sorts of lovely things. But if GM is involved, then neither biodiversity nor sustainability are involved.
  
  There are many reasons why GMOs should not be grown anywhere, yet some GMOs now dominate in a few countries, such as cotton in India and maize and soya in the US. Many farmers in countries like India, the US and Canada are now regretting the fact that they bought into GM but it's very hard to get back out again. Yet the industry still churns out its lies about GM being high yielding, uses less pesticides and herbicides, is more drought resistant, grows well in marginal land, etc. It's hard to understand why so many seem to fall for their lies.
  
  But DfID, with all its money and expertise, could not possibly be in the dark about the dangers of GM or even the inappropriateness of funding only large scale, industrial agriculture in developing countries. The question is, who has nobbled them and what are they getting out of supporting the biotechnology and other industries that stand to profit from their big spending?

• Orphanages Versus Community Based Care

  Posted: February 7, 2010, 1:48 pm by Simon

  Given the numbers of orphaned, abandoned and otherwise needy children in developing countries such as Kenya, the issue of whether institutional or community based care is preferable is a difficult one. There are badly run institutions and well run ones. But there are also children who face their greatest dangers in their own homes, from their parents or from their carers. From what I can see in Kenya, social services often don't get involved in cases where things go wrong, either in institutions or in community care settings.
  
  A study with a large sample size published a couple of months ago looked at both types of care, comparing cognitive functioning, emotion, behavior, physical health, and growth. The conclusion was that community care is not better and that, for some indicators, institutions are better. The authors of the study advise against aiming to transfer as many children as possible to some kind of community care setting. This is good advice if the children are in a well run institution or if an adequate level of community care can not be guaranteed.
  
  However, the organisation I am working with, Ribbon of Hope, does not advocate merely keeping a child in their community. We advocate for children to be cared for with the support of other people in the community, in addition to their carer or carers. We would like to see children receive any state support to which they are entitled. And we would like to help provide their carer with the means to provide for the child.
  
  Many children in institutions have one living parent and many more have close relatives who are living. But there are also children who may not have any close relatives or whose relatives are unknown and untraceable. So I wouldn't argue that there is no need for institutions to care for children.
  
  But there are institutions that have been set up with the express aim of making money. I don't know how many of these bogus orphanages there are compared to legitimate orphanages. I just know that several bogus orphanages have been set up in the immediate area around Nakuru. There are also institutions that cannot cope with the number of children they are trying to provide for and conditions for the children, and even the staff, are terrible.
  
  The only well run orphanages I have seen receive very large sums of money from benefactors. It's right that institutions providing for children receive large amounts of money, of course, but most institutions are not able to attract enough money and the children can suffer as a result. Keeping children in an institution usually costs a lot more than providing assistance for them to live in a family setting. Therefore, there may be a good case for more children being raised in a family setting when that is feasible.
  
  In addition, many of these well run orphanages are funded by private donations and are at least partly administrated by foreigners. This is not a bad thing in itself but it does suggest a lack of sustainability and a high degree of dependency. It can be difficult enough for local people to confirm that children presented to them are really orphans but for non-local people it can be impossible. Some people see orphanages as an opportunity to cut their own costs by sending one or more of their children there and claiming the children belong to a deceased relative.
  
  So the stark dichotomy between institutions and community care for orphans is not helpful. Both settings have their advantages and disadvantages. It is quite true that institutions should not aim to transfer as many children as possible to community care. But I think there should be fewer orphanages and far more children should be cared for in a well supported environment. Some of the money available, both state, donor and private, could better be used to provide families with everything they need to give a good home to children who have been orphaned, abandoned or are otherwise in need of care. The study in question is a good one, with a sound methodology, but I don't think it took into account the scenario where the carer is actively supported in providing care.
  
  Incidentally, people often ask about how you can tell whether an orphanage is legitimate or not. They even ask the same question about charities, philanthropic organisations, philanthropists, NGOs, CBOs and the like. I don't have a list of things but the Information in Context blog gives advice on this and other matters. The only rule of thumb I have at the moment is that when people or organisations seem to obsess about numbers, size and quantities, to the exclusion of all other criteria, this can indicate that they are more interested in raising money than in changing things for the better. That always makes me suspicious.

• Predicting the Predictable

  Posted: February 5, 2010, 8:35 pm by Simon

  Often in natural disasters, it's not the disaster itself that causes widespread injury, loss of life and damage to property. Where people are well off enough to protect themselves and their property against whatever disasters may occur, far fewer people suffer. Therefore, the magnitude of natural disasters in developing countries is often measured in people killed, injured or displaced. But in developed countries, the magnitude is usually measured by insurance claims for damage to property.
  
  There are exceptions, of course, but generally where people are vulnerable, natural disasters have a high human cost. Where people are less vulnerable, property is more likely to be the main loss. Developed countries, such as Japan and the US, experience natural disasters without anything like the human costs experienced by developing countries, such as Haiti. The hurricane that devastated New Orleans is not an exception just because it happened in the US. A lot of the people most affected were poor, vulnerable and marginalised.
  
  When a natural disaster hits a vulnerable country, the disaster itself may not have been entirely predictable, at least, not by people in that country who were able to do anything about it. But it is pretty predictable that, when a country has little infrastructure (especially water and sanitation), minimal health services, low levels of food security and the rest, most disasters will have a huge human cost. Insurance claims may well be negligible for people who have very little to insure and no money to insure with.
  
  Kenya and most other Sub-Saharan African countries are like Haiti in many ways. They have been treated as pawns in the political and commercial games of various Western countries; they have few social services of any kind and little or no resilience to any kind of disaster; they have huge debts and widespread poverty, poor health and malnutrition. We don't know what disasters await them, we just know that there will be disasters and that the consequences will be severe. Perhaps when some disaster strikes, there will be massive press attention, pledges of money, influxes of aid agencies driving white four wheel drives and resolutions to cancel debts.
  
  But all these pledges and other post disaster phenomena won't reduce the immediate impact of the disaster. The human cost will be high. The press will bemoan the fact that the country is so poor and infrastructure is so bad and debts are so high and politicians are so corrupt and whatever else they tend to bemoan in developing countries when it's too late. The amounts of money that are pledged, and even the amounts that actually reach the country, may be far higher than the amounts that were previously needed to strengthen the country's capacity. But that doesn't result in money being spent on increasing the capacity of developing countries to increase their resilience.
  
  Kenya has what could turn out to be a pathological attachment to maize, a non-indigenous crop introduced by the colonials because it's cheap and it's easy to grow large amounts on small areas of land, it fills you up, although it has little nutritional value. This pathological attachment could be compared to Ireland's staple food in the decades before the Great Famine, though I suspect the potato may be a bit more nourishing (or perhaps I'm biased). The potato is not indigenous to Ireland and eventually the inevitable happened. The ideal conditions came together for potato blight that wiped out most of the country's crop.
  
  Much of the currently used agricultural land in Kenya is covered with crops that can not be used for sustenance, such as tea, sugar or coffee. Much is used for non-food crops, such as sisal or flowers. And much of the food that is grown is maize. For many years, maize crops have been threatened or have even failed because of the dependence on rain fed crop growing. But the country still plants mostly maize and it's still mainly rain fed.
  
  The question is not whether disaster will strike in Kenya, it is when and how bad it will be. If the crops just fail in places where there is not much rain, several million people will be affected. If places that usually get a lot of rain have problems, several million more will be affected. Some countries around Kenya, even many areas in Kenya, have recently seen army worms attack, and they can obliterate entire fields. And there are other pests and factors that can take a large area by surprise. Maybe this year most people will survive, maybe not.
  
  But one thing is certain: millions of people are vulnerable. And they are vulnerable in more than one way. If a crop fails, they risk starvation. If the aid agencies come in, the food may not get to people in time because of the infrastructure problems or because of widespread corruption. Or people may die of whatever diseases start spreading, unchecked because of the terrible health service. There's a hair's breadth between Haiti's circumstances and Kenya's circumstances.
  
  It's now that the press should be clamoring for education, health, infrastructure and other social services to be improved, now that pressure needs to be put on the government to deal with corruption, now that individual people need to stop depending on rain fed agriculture, now that they should grow (and consume) things other than maize. And now is the best time to cancel the huge debts that developing countries have been arm-twisted into amassing for decades. Recognition that these circumstances make people vulnerable to inevitable disasters doesn't need to wait until it's too late.

• Discovering Poverty

  Posted: February 4, 2010, 12:31 am by Simon

  Only a few months ago there was great excitement about the 'discovery' of oil in Isiolo, in Kenya's Eastern province. This is not the first time oil has been 'discovered' there. Tens of millions of dollars have been poured into exploration without any commercially viable discovery. A few hundred thousand dollars were put into making local people think that they will benefit from being an oil producing region and no money at all went into cleaning up the pollution and environmental damage caused over the years.
  
  A local politician was predicting that "Kenya will join Uganda in celebrating the status of a new oil producer". So far, Kenya is not celebrating. But neither is Uganda, despite discovering huge quantities of oil. This is not a new story of developing countries having enormous mineral wealth while their own people make nothing and lose a lot. It's the same old story of Nigeria, Sudan, South Africa, Botswana, Tanzania, Uganda and, indeed, Kenya. There's no reason why the story should change, as long as wealthy countries can get hold of all the oil and other resources they require.
  
  As Uganda is finding out, deciding who gets to profit from the oil deposits is not up to them. It's up to their senior politicians, a handful of business people and a bunch of rich foreigners. If anyone who doesn't belong to one of those groups happens to have property or interests affected by work of extracting oil, that's their tough luck. Sure, some people will be employed for a while, but most of the top jobs will go to foreigners or to people who are already pretty well off. A hell of a lot more people will lose their livelihood, most of them being subsistence farmers and others who are just getting by.
  
  Local consultation, democratic accountability, sustainability, environmental impact, social impact, these are all as relevant as condoms at a USAID sponsored HIV awareness programme. Tullow Oil and that bastion of corporate social responsibility Royal Bank of Scotland will be able to wallow together in their ethical vacuum without having to worry about petty matters like human rights, environmental contamination or mass evictions of people from their land. And no one need worry, the Ugandan government will compensate the oil company if anything threatens their profit margins.
  
  Kenya should note what's happening in Uganda at the moment. Not that their politicians are likely to behave any differently if oil is discovered here. But maybe civil society groups here can start now, before the sort of secret negotiations seen in Uganda get going. It's hard to imagine what a developing country successfully extracting a natural resource would look like, where people in that country actually gained from the process rather than suffering greater poverty, disease and death.
  
  Maybe oil will not be discovered in Kenya, or perhaps not yet. It's not that natural resources are a bad thing, but as long as developed countries and multinationals always have the upper hand when they are discovered, the resources might as well remain in the ground. Some Kenyans may not know how lucky they are, but many in Isiolo would still remember the fallout from the various explorations and 'discoveries' of the last few years.

• Speaking from Inexperience...

  Posted: February 3, 2010, 12:57 am by Simon

  An old and extremely rich German wearing funny clothes and a bizarre hat who, ostensibly, has neither knowledge nor experience of sex or sexuality, is going to the UK to share his outdated, uninformed, biased and bigoted views on homosexuality with anyone there who is still prepared to listen to the current pope. One of his defenders says he is only saying what his followers believe about this subject, but that doesn't wash. He is supposed to be a leader and I think he has made his views pretty clear on other occasions.
  
  The pope feels that recent legislation in the UK runs counter to natural law. What 'natural law' is he talking about? Is he talking about the findings of a scientific community or some community of experts or is he merely using a meaningless phrase that anyone can use to support whatever prejudice they happen to be hawking? My question is merely rhetorical, by the way. I could claim that it runs counter to natural law to abstain from sex (or to purport to) but the fact that having sex is natural to many people does not preclude others from deciding to abstain. This is not because there is any 'natural law' involved, it's just that people are entitled to decide for themselves.
  
  Such laws as the ones the pope is complaining about, the Equality Bill and the like, do not "impose unjust limitations on the freedom of religious communities to act in accordance with their beliefs". They have no bearing on religious communities doing anything except things that are already illegal, such as discriminating against others on the grounds of their sexual orientation, for example. I would hate to have to list for the pope the excesses that have been perpetrated over the centuries by religious communities and the lengths that his colleagues have gone to in order to allow such excesses to continue, despite their being proscribed by (positive) law.
  
  Religious communities acting in accordance with their religious beliefs, whatever that happens to mean, doesn't itself sound like something governed by 'natural law'. Or perhaps the pope would claim otherwise. Perhaps some religions are more natural than others. Perhaps having no religion is 'unnatural', at least, according to natural law. But to be frank, the pope's defender seems to have to resort to meaningless arguments to defend his boss. For example "[the pope] wants his reasoned voice – formed by the treasures of the Christian heritage which is deeply embedded in our culture – he wants that voice to be heard", etc, blah blah.
  
  The current pope follows a long line of popes who have done everything they can to perpetuate various forms of bigotry and discrimination. I'm surprised he is intending to spread his vitriol in the UK, where I imagined most people to be fairly unswayed by any particular religion. But he has certainly done a lot of damage in African countries he visited. Perhaps he hopes for the same level of 'success' elsewhere. The man seems to have little respect for concepts like human rights and democracy and I hope he gets an appropriate reception, wherever he goes.

• Do Wealth and Power Exclude Wisdom?

  Posted: February 1, 2010, 1:01 am by Simon

  To quote the late comedian Linda Smith, "I don't mean to sound racist, but rich people are weird." The very good climate change blog, climateprogress.org has an article about Bill Gates and his maunderings on climate change and related issues. The guy seems to know very little about climate change and all his information seems to come from corporate funded mouthpieces like Bjorn Lomborg.
  
  Gates seems to think most of the current worries about climate change are pointless and that none of the proposals made by activists and experts should be considered. But he thinks that there will be a technological solution or two to the problems of clean energy, energy efficiency, etc (one of those solutions being nuclear, which he thinks is 'as good as' renewable).
  
  This would sound very familiar to Gates-watchers. He advocates technical solutions to health problems, diseases such as HIV, TB, malaria, cholera and rotavirus. He also advocates technical solutions to problems like food shortages, food insecurity and low levels of food production (in the form of biotechnology). And for climate change, he advocates bioengineering. He's certainly consistent, so far.
  
  Despite all his money and his rich and influential friends, Gates seems to be very misinformed and is falling behind on his knowledge of current research, but read the climateprogress.org article for the full details. He's into 'altering the stratosphere to reflect solar energy', filtering 'carbon dioxide directly from the atmosphere' and 'brightening ocean clouds'. Do we really want this lunatic to be let loose on the only life supporting planet we know of?
  
  There's also a very strange article on allafrica.com purporting to be about poverty eradication that is really about a deal between the richest man in the world (Gates) and one of the richest and most rapacious corporations in the world (Coca-cola). The Gates Foundation is providing most of the capital, over 10 million dollars, to allow 50,000 Kenyan and Ugandan farmers to sell fruit to Coca-cola for 'fruit-juice' production.
  
  The article is very short on detail and I don't see why Coca-cola can't get these farmers to sell fruit to them without the help of Gates. But is it really a good thing that these farmers are going to sell their healthy food products for what will be a very low price to an organisation that will convert them into an unhealthy and very expensive beverage?
  
  Coca-cola is better known for covering otherwise beautiful areas with their revolting logos and other excrescences, for marketing harmful products to people who are starving and in need of fresh water, for polluting water supplies and using up water supplies in areas where water is scarce and for maintaining a very poor record of corporate social responsibility (see corpwatch.org for further details).
  
  Rich people and organisations are weird, but they can also be sinister, completely undemocratic and downright inhumane. I'm not calling for a law against being rich or even curbs on how rich people can be. But I think rich people and organisations should be subject to the same laws as other people and organisations. And poor people should be protected from the excesses of the rich and powerful. Why should a handful of very rich people and organisations be able to dictate the future of the planet and the futures of all its inhabitants?

• Let Them Drink Sewage, As Long As They Buy Our Drugs

  Posted: January 30, 2010, 8:12 pm by Simon

  There's a suburb, a slum area, not far South of the town of Nakuru and it always smells bad. Well, perhaps all slums smell bad, but some smell worse than others. As you walk through the main street of Kaptembwa, there are deep trenches at the side of the road, apparently having something to do with the 'sewage system!. But all around, there is stagnant water and raw sewage. When there is a lot of rain, this effluent flows through the streets and even into people's houses. It also mixes with the water supply, such as it is.
  
  I don't know how long Kaptembwa has been like this. People who have been there a long time say there has never been any proper sewage disposal. Now, children play in foul smelling puddles, with terrible consequences for their health. Adults also have to walk through the mess and put up with the smell, the dirt and even the diseases.
  
  Places like Kaptembwa are ideal breeding grounds for water borne diseases. You could vaccinate every child against something like rotavirus and you would still have lots of them sickening and dying of water borne diseases. Both the children and the adults living in such areas need adequate sanitation and reliable supplies of clean water. No amount of vaccine will get rid of the health hazards caused by such conditions.
  
  But also, people are entitled to some level of dignity. They should not have to live in dreadful and threatening conditions. Those who claim to be concerned about their health should consider these conditions first, not the headline grabbing but ultimately weak solution of vaccines or drugs. People shouldn't have to drink water that smells of sewage.
  
  But for some reason, rotavirus vaccine has been much reported recently. Perhaps it's because the Gates Foundation has mentioned the development of the vaccine as one of their primary goals, perhaps it's because the pharmaceutical companies who are behind this lucrative prospect are good at issuing press releases. Journalists are certainly good at citing press releases, regardless of the levels of sales puff they may contain.
  
  Among the three articles I came across today about Gates, Glaxo Smith Kline (and others) and their rotavirus vaccines, all say very little about water and sanitation. They ooze on about how brilliant all this medical technology is but they don't mention, or are not quoted as mentioning, that vaccines will be useless without high levels of spending on water and sanitation infrastructure. It could be wondered if all these groupies care, one way or the other, about how people are forced to live.
  
  One of these articles cites an academic as saying that vaccines "represent the best hope for preventing the severe consequences of rotavirus infection". There is probably a sense in which this 'expert' is right but failing to mention water and sanitation renders the statement hot air. Vague mention is made of water and sanitation in the other articles but the focus is on the vaccine, as if children who are suffering from poor nutrition, multiple vitamin deficiencies and various parasites are going to be magically made healthy by a vaccination for one of the many water borne conditions that are endemic in developing countries.
  
  One of the articles even mentions some the problems of rolling out large scale vaccinations, and the rotavirus vaccine in particular, in countries that have poor health systems and inadequate infrastructure. This article even mentions the high cost of vaccination programmes. Why is it that the Gates Foundation and other institutions don't seem to mind high costs when the main beneficiaries are pharmaceutical companies and other rich establishments?
  
  All the articles list figures for how many lives could be saved by a rotavirus vaccine and the usual sort of stuff. But they don't list the figures for how many lives could be saved by spending money on a cheaper but far more urgent way of reducing deaths from water and sanitation related causes. I can't think why.

• Religion and Health: Interference or Complementarity

  Posted: January 28, 2010, 8:40 pm by Simon

  Following my speculations about why some people seem to imagine that they can be made very rich by a miracle, a friend sent me an article entitled Religion, Spirituality, and Medicine. This article is a "comprehensive, though not systematic, review of the empirical evidence and ethical issues" and concludes that "the evidence of an association between religion, spirituality, and health is weak and inconsistent".
  
  Perhaps more importantly, the authors question the ethics of mixing religion and medicine, a question that would still arise even if there was stronger evidence of an association between religion and health. One could ask, which religion would a doctor recommend or agree to discuss? What would they do with someone who didn't believe in any religion? Would each medical professional require special training and what kind of special training? (The authors of the paper did not raise all these questions, but they arise from considering the problems of combining medicine with religion).
  
  Even if people go to a doctor without any expectation that the doctor is, to a large extent, a scientist, that doctor is obliged to do things that are supported by scientific evidence and avoid things that are not so supported. The fields of science and religion are completely different and the practitioners of each field work in different ways. Is it even feasible for doctors to also become experts in religion (as if religion were just one thing!)?
  
  If I was renting a damp room that affected my health badly, should my doctor write a letter to my landlord and ask for my conditions to be improved? Medical advice could be brought to bear on an employer who was exposing me to health risks, but this is a matter for employment laws. The doctor doesn't intervene directly. Yet we know that environmental conditions are closely connected with people's health. We know that economic circumstances are closely connected with people's health but we don't expect our doctor to recommend a pay rise. Even government health advice about healthy eating is considered to be taking things too far by some.
  
  I accept that certain beliefs can be comforting and I certainly wouldn't suggest that people should be told what to believe and what not to believe or how to express their beliefs. If they see praying as part of their recovery from illness or as helpful in bearing an illness from which they will not recover, no one has the right to interfere. But when it comes to prescribing medication, the doctor is the expert, not the religious leader. And when it comes to praying and giving religious advice, the religious leader is the expert.
  
  In fact, I find it exasperating that there are many churches in developing countries who don't seem to be able to make that distinction. They feel they are experts in marriage, reproduction, sexual behaviour and protecting against sexually transmitted infections (STI). They are not experts, generally they know even less than lay people and should certainly have less experience. If you can't persuade someone to give up having sex or sex outside marriage, the least you can do is tell them how to avoid becoming infected with an STI, infecting someone else with one or giving rise to an unplanned pregnancy. Otherwise, these leaders are failing to do what they can to prevent serious consequences.
  
  If religious leaders wish to give medical advice, they had better know what they are talking about. As for advice about sexual behaviour, contraception and reducing the spread of STIs and unwanted pregnancies, many don't seem to have had a lot of success and should leave the job to someone who has the appropriate knowledge and training. In the same token, doctors should discuss religious matters with patients if they feel able to do so and if they are requested to do so but it should never be seen as a type of medical care or treatment.
  
  If someone has a particular set of religious beliefs, presumably they hold those beliefs regardless of their health or lack of health. It seems unlikely that they just 'adopt' those beliefs in the hope that they will get well. Whether someone is religious or not, some will suffer illnesses and injuries and all will die eventually. If the 'belief' is purely conditional on their health, the person's piety would be quite questionable. So I don't see why a religious person would be interested in whether religion is in any way connected with health outcomes in the first place.

• Poverty Breeds Religion? Religion Breeds Poverty? Both?

  Posted: January 26, 2010, 11:01 pm by Simon

  Firstly, I must make it clear that I don't mean to appear biased, that I am just writing from my point of view. But this is hard for me. I have no problem questioning the motives of very powerful people like Bill Gates or the ethics of multinational industries, such as pharmaceuticals or biotechnology or even those of international institutions, such as the World Bank, the International Monetary Fund (IMF) or UNAIDS. But when it comes to talking about the ordinary people that I meet and interact with every day, I realise I could sound like I'm making some pretty unwarranted assumptions.
  
  I am trying to understand certain things here (in the world, but also in Kenya), that's partly why I'm here. I think that we in the Western world, people and institutions and practices and other entities, do a lot to impoverish people in developing countries. I have argued the point on many occasions and will do so in the future. My whole concept of 'Development by Omission' is based on many instances of this very phenomenon. But I also wonder why some people seem to choose certain kinds of impoverishment or choose not to do things that are well within their capability that may raise their living standards and those of their dependents.
  
  Rather than giving lots of examples, though there are many, I'd like to concentrate on one. I wonder if people who see their situation as desperate turn to what can be a very extreme adherence to some religion. I'm thinking especially of Christianity, in particular the more evangelical ones, though they all seem to be evangelical here. Some people give money they can ill afford to a church, some give it to a pastor. Some even give everything they have got in the hope that a miracle will change their lives. Many pastors and churches encourage these beliefs, it's how they make their money. However, all churches depend on donations for most of their income (or wealth).
  
  Belief in miracles seems to be very widespread, not that miracles can occur, but that anyone and everyone may well have their lives transformed if they just pray a lot and, of course, send lots of money to churches and pastors who claim to be able to make this a reality. Even if I believed that miracles can occur, I don't accept that you can simply wish them to occur, pray for them to occur and least of all pay for them to occur.
  
  I don't see people's wish to have their lives transformed, even their wish to be very rich, as greed. I think if I had nothing I might be more likely to want a lot than I would be to want just enough. Perhaps it's because I've had enough for so long and generally find that fine, a lot would be great, but it's unlikely to feel that much better than enough. I don't wish to preach (God forbid!), I'd love to have an income or, at least, the guarantee that I will one day have an income. But for now, I'm getting by. But I'm not just talking about what people wish for, which can be indefinitely great; I'm talking about what some people seem to sincerely believe they may one day attain.
  
  Greed is what we see in the pastors and churches themselves who extort money out of poor people with promises of great wealth. Greed is what we see in the people who spread misleading information about pyramid schemes and the like and thereby prey on poor people. Greed is the biotechnology multinationals, who want people to think they are getting a good deal when they are in fact entering a form of indentured slavery. Greed is the pharmaceutical companies who keep their prices artificially high and lobby governments of rich countries, who obligingly use public money to subsidise these products and call it aid.
  
  Desperation could be one reason for turning to a religion, even believing quite irrational things or accepting irrational interpretations of the bible. But maybe there are many reasons. Many terrible things are being done every day in the name of religion but maybe only some of them are meant to be terrible. The people running a 'children's home' we came across recently may well believe they are following the word of the bible. They certainly say they are. True, they have stolen most of the donations to the home and put the lives of many children at risk, but it is vaguely possible they started out trying to do something good, while at the same time making enough money to keep their own households and send their children to (relatively expensive) schools.
  
  Perhaps there is just a lot of religious fervour in Kenya, for various interpretations of the bible, for various different churches and for various different religious personalities, perhaps it's not desperation at all. But similarly irrational beliefs seem to be held about foreign people and how rich they all are and how they just come here to give out money. Ok, some foreigners do that, but several times every week, sometimes several times in the day, I am asked for money, often by people who have asked me many times before. And I know others who have had the same experience.
  
  Some people seem to believe that if only they could get a scholarship or if only someone would sponsor them to go to Europe or the US (or somewhere else) or if someone would set them up in business, or if they would marry them, they would be ok, they would be very happy. Maybe people everywhere believe these things, I don't know, maybe people here are just more honest about it. But I think there is a difference between wishing for something and actually expecting it to happen.
  
  Is it desperation that fuels this apparent devotion (or whatever it is)? Or does devotion to the belief that material wealth will be thrust upon all those who pray enough or give enough to pastors and churches or ask enough foreigners keep people from doing things to change their own circumstances? They could question preachers who keep promising them what is just material wealth. They could question where all the money they give goes to when they are poor and the preachers are wealthy, often staggeringly wealthy. I'm not saying there is work aplenty for everyone, sadly, there is not. And though there is wealth enough for everyone those who have most of it, and they are few, are not likely to part with it quickly.
  
  I don't feel I'm much closer to understanding people's seemingly pathological attachment to religion, miracles, pastors and churches. Biased I may be, but I blame churches, not for poverty, but for influencing people in such a way that many people here behave quite irrationally. I blame religion for people's apparent belief that, although they can do nothing to change their own situation, someone, God, rich people, pastors or someone else, can make their lives better. I think the evidence is fairly clear that there is no one who will help most people except those people themselves. But then, when has evidence or experience ever had much impact on religion?

• Gates the Autocrat: Malignant or Benign?

  Posted: January 25, 2010, 12:15 am by Simon

  It's nice to get a long letter, except perhaps when it comes from Bill Gates and it's 14 pages long. But I feel obliged to try and keep up to date with what he and his foundation are up to. Their various concerns are very interesting but I'm always curious about the ways the foundation chooses to approach these concerns.
  
  For example, the foundation is particularly interested in vaccines for pneumonia and rotavirus and concentrates much of its attention and funding on a relatively small group of diseases. This vertical approach to health, which could better be called a vertical approach to disease, is not one that everyone would be comfortable with. Huge amounts of money and resources for a few diseases could easily result in people suffering from or dying from some of the many other diseases commonly found in developing countries.
  
  Indeed, people's health (as opposed to their diseases) have a lot to do with their environment, their living and working conditions, water and sanitation and, of course, nutrition and food security. The determinants of health are arguably more important than a few of the individual diseases that are seen as particularly worth funding. Even susceptibility to the diseases the foundation is funding is to a large extent governed by, for example, nutritional levels and food security. These, as I shall claim below, are being seriously compromised by the same foundation.
  
  When it comes to TB and HIV, especially, this vertical approach runs a high risk of widespread resistance developing to whatever drugs are made available in large enough quantities. The Gates Foundation puts a lot of faith in technology, in vaccines and the like. These are all very expensive approaches, both to prevention and treatment. It is absolutely necessary to treat people who are ill, but it could be questioned how sustainable, as a whole, the foundation's approach is. Or maybe sustainability is not an issue and resistance can be dealt with by newer round of (even more expensive) drugs.
  
  After all, rotavirus, polio, pneumonia and to a different extent malaria and HIV, are very closely related to the conditions in which poor people live, not just to a group of disease agents or pathogens. Can a high dependence on drugs for prevention and treatment of diseases work to save lives and reduce suffering when, at the same time, health services, education systems, infrastructures, food and food security and social services are almost non existent?
  
  Of course, this is not necessarily the foundation's concern. But Gates and Co. must want their expensive interventions to work. They hardly put huge amounts of money into something that doesn't work. But what results do they expect? They surely expect a lot more people to be cured of diseases and a lot more people to be vaccinated against diseases. But it could be argued that another 'result' of the foundation's work is to enrich the pharmaceutical and other companies that receive much of the money being handed out.
  
  I am not claiming that the money is just being handed over to multinationals. But the foundation's money that is not being disbursed is being invested to maximize its profit. It is being invested in pharmaceutical companies and others, regardless of their impact on poverty levels, distortion of markets, the environment, etc. There is a danger that the foundation is funding some of the problems it purports to be remedying.
  
  So much for health, I'm finding it hard to get my head around whether the foundation is doing good work or if it is, at best, diluting its possible benefits, at worst, sneakily throwing money at multinationals that are closely tied to the foundation's wealth. But when it comes to genetically modified (GM) organisms and the multinationals who produce GM products, I have less doubt about what to think.
  
  GM crops have not succeeded in giving any of the benefits claimed by industry hype. All GM crops grown on a large scale have had massive drawbacks that farmers in poor countries cannot afford. Developing country farmers are mostly subsistence farmers. They get enough from their land to eat and to trade for the following year's costs and perhaps a few other household costs. Even small additional costs will eat into money that they need for school fees, health, food and whatever else.
  
  Taking on GM crops means that the costs that have to be met every year by farmers is higher than the costs of traditional crops. But also, the costs go up every year. GM seeds have to be bought every year and they have increased in cost much faster than traditional seeds. Fertilizers need to be purchased in higher quantities every year and their cost is also much higher than organic methods of fertilizing. Pesticides are more expensive and not only do more and more have to be used every year but eventually, the farmer needs to find new ways or new pesticides to continue growing the GM crop.
  
  The Gates Foundation doesn't seem to favour sustainable ways of approaching diseases. They certainly don't favour sustainable agricultural practices (something that is flatly denied by Gates in his letter). And they don't seem to favour increasing self reliance among people in developing countries. Perhaps I'm judging the foundation too harshly but I think these questions need to be raised because there are too many people who are making so much money out of this type of philanthropy that they will never raise them.
  
  I think we'll have to wait a long time to find out who gains most from the Gates Foundation but I suspect some of the most powerful companies in the world will do very well indeed. After all, if they don't do well, the foundation's investments will not do well and it's funds will eventually be eroded away. I would question the aim to give what Gates calls 'recognition' to these multinationals when recognition usually seems to mean profits. At present, the foundation appears to be paying the inflated costs demanded by these multinationals and making it worth their while keeping their prices high.
  
  Maybe people in poor countries will gain more than they will lose from some of the foundation's projects, but it will be hard to tell. And there will certainly be huge losses for any country that buys in to the hype of GM. Countries that are already suffering from these losses, such as the US and Canada, may be able to afford them but developing countries can not. It seems as if many people in the developing world are depending on the whim of an autocrat. All they can do is hope that he is a benign one.

• Income Generation Activities Galore

  Posted: January 24, 2010, 12:12 am by Simon

  Just over a year ago I appealed to people I know, especially on Facebook, to help me to identify possible income generation activities suitable for developing countries where little capital, skills or infrastructure are available. I was overwhelmed by the slightly fewer than two responses I received and the first one didn't fly. So I set about researching on the internet, contacting people and talking to anyone who was prepared to discuss the subject. Now that I have started making a list, I decided to post it here on my blog so that others trying to research the same thing won't have to start right at the beginning. And maybe some people will even contribute to the list!
  
  The list is by no means exhaustive and the categories are just based on the way things look from here. They overlap to some extent and they are in no particular order, though I think the first two are particularly important because local acceptability can make or break an income generation activity, no matter how 'good' it may seem. And some of the activities that are already widely carried out have a lot to recommend them. The community based organisation I work with, Ribbon of Hope, already grow a number of crops and have financed several livestock programmes. But it's time to branch out, try new things, diversify and ensure that people get the maximum benefit possible.
  
  The approach we are likely to take is to ask our clients what gaps they feel there are in their local market, what local materials are available or could be made available. Also, what skills are there, what do people already know how to do. There must be local products that we don't know about and sometimes it turns out that people can make or do things but just hadn't realised the value of that skill. I'm not sure in advance what we will gain from this or how we are going to elicit the sort of information we want, but I think it could be a valuable exercise. Rather than just teaching people a skill or a few skills, we would also like them to be able to assess all the opportunities that exist and consider acquiring as many skills as possible. So that's the first category.
  
  The second category is to get people to help us make an inventory of what could be produced in the area and sold in a local market or business. I'm thinking of things like sunflower or sesame oil, peanut butter, jam from seasonal fruits, honey, butter, cheese or anything else, even things that are already produced but for which there is little or no market, yet. I'm thinking of a campsite I stayed at in Tanzania which sourced things like this in a relatively remote area. The result was spectacular because many of these products here are only available in highly processed, branded forms (which taste disgusting). They should be produced locally if at all possible.
  
  Ribbon of Hope already supports several shambas (smallholdings), which I have mentioned several times on this blog. Those smallholdings should produce everyday foods that people in the area need but they could also produce high value crops, such as sesame and sunflower seed, where clients can also produce the sesame or sunflower oil. These have the advantage of yielding highly nutritious oil cake as a by-product, which makes excellent animal feed. We should produce animal fodder, especially fodder that can be stored for use during dry periods, which are all too regular and protracted here. And there are all sorts of interesting crops we could consider growing, just to keep things diverse.
  
  Dairy cattle, goats and chickens are a well tried income generation scheme and they are usually successful. Because they are such a good bet, they can require a fair amount of capital, which some of the more risky and less well tried schemes don't. But not everyone can afford to take risks. I'd say, get the low risk schemes started first and then add the others in at leisure. We mustn't forget the hides and furs of stock such as cattle, goats and sheep, either. Certainly, there are many uses for sheep wool, regardless of the quality. But another type of livestock that you don't see so much around here is rabbits, especially the very big ones that are bred for meat. There must be many uses for their fur, too.
  
  There are good opportunities for different types of food processing here, especially food drying. Fruit and vegetables can be solar dried at very low cost. Many crops, such as mango, pineapple, banana and tomato flood the market at certain times of the year and a lot is dumped. These are all good when dried. Ribbon of Hope produced a beautiful crop of coriander in the last few weeks and this would be as good dried as fresh, except that it would be a far more viable crop if we could dry large amounts of it. Mushrooms are grown locally and are a potentially lucrative and nutritious crop that is also good dried. Yoghurt is already widely produced, cheese isn't so popular and maybe there's a reason for that. But many things could be made with local ingredients, such as biscuits, cakes, bread, cassava chips and the like.
  
  Some of the areas here are blighted with a monoculture, especially sisal. But I'm sure people could be persuaded to make things of higher value rather than rope, which is how most of the local sisal ends up. We'll see what people who have been surrounded with sisal all their lives come up with. Not too far from here, silk worms are farmed, so that's another possibility. I've mentioned before the possibility of producing reusable sanitary pads. There are probably going to be lots of objections but many people, especially young girls, can't afford disposable ones so it's worth some effort. Leather goods may be another possibility, especially if local people are successfully breeding relevant livestock. No doubt there are other artisanal products, such as pottery, candles and whatever else. Sorry for being vague but the gaps will be filled in eventually.
  
  Ribbon of Hope has already funded a successful project selling water and this raised surprisingly large amounts of money. Another possibility would be to pasteurize water using solar cookers or solar heaters and selling it. Included in this category, not many people in this dry province of Rift Valley use irrigation, nor do many people harvest rainwater. This is short-sighted and even journalists are apt to bemoan the fact that there is an unwise dependency on rain fed agriculture throughout Kenya (if journalists notice, it’s probably been a problem for decades). It's time to change this, even if it's only to a small extent. Equally, many people don't irrigate their land, even when there is a source of water close by. Since Ribbon of Hope started irrigating its fields, neighbouring farmers have started borrowing their pump. So it is catching on!
  
  One of my favourite types of income generation activity or cost saving activity relates to fuel or energy. I have mentioned solar cookers, such as simple reflective boxes or more complicated parabolic cookers. These are great for cooking food, drying food and for pasteurizing water or milk. Some of our projects involve milk production so free pasteurization would help reduce costs a lot. I've also mentioned fuel briquettes made from waste of various kinds. People could produce these for their own household but they could also produce them for sale in the local area. Wood and charcoal, the most common cooking fuels, are expensive and likely to go up in price. Solar is cheaper, cleaner and better for the environment and could be used to supplement other sources of fuel. Biogas is more difficult to produce but we are hoping to get some to train us in how to produce the stuff.
  
  Some trees and shrubs could be a useful addition to any shamba. The Kenyan government is thinking of introducing a law about people growing a certain number of trees per acre. True to form, they are not giving any advice as to what trees should be grown and which should be avoided (there are some serious problems that result from choosing the wrong trees). And people with very small, possibly rented shambas, will not want to risk reducing their yield by sticking something unproductive in their fields. But there are productive trees and ones that are good for the soil. There are some that produce fruit without compromising the field crops and others that produce oils and even animal fodder. There are trees that can benefit in various ways, so these should be carefully selected.
  
  Finally, some organisations end up with assets that they only sometimes use, such as equipment and tools. These could be rented out to neighbouring farmers or swapped for other benefits, such as labour or tools that are lacking. Tools and machinery are prohibitively expensive here, which is why so many farmers try to fly by the seat of their pants and sometimes fail. Even rainwater harvesting and irrigation involve costs that small farmers can't always meet. But they might be able to share, for a fee, of course. Ribbon of Hope's neighbours have increased their yields so much in the last few months by using their petrol pump that they could easily afford to pay a small fee.
  
  Well, that's it for the moment, but that's quite a list. I'll continue researching and noting progress (and problems) and I'll add links to further information when I can get around to it. I hope people find this list useful and if anyone has other ideas for income generation activities, please let me know. Thank you in anticipation!

• Relative Deprivation in Urban and Rural Settings

  Posted: January 21, 2010, 8:51 pm by Simon

  It's been a mixed week so far for Ribbon of Hope in Nakuru. We spent the first few days in the hot, dry Mogotio, a few hundred metres from the equator. Despite the heat and lack of rain, there is a river nearby. Ribbon of Hope purchased a petrol powered pump, and later a foot operated pump, to irrigate their fields there. The results on our fields was so good that owners of neighbouring fields have been borrowing the pump to irrigate their crops, again, with encouraging results.
  
  We have started trying to harvest the sizable crop of beans but very heavy rains at the end of the growing season resulted in extensive new growth, which means that each bean plant contains a mixture of beans that are ready to harvest and beans that are still green. The ones that are ready to harvest are starting to pop out of their pods and the green ones need to stay in the ground for another few days or even weeks. It's a bit of a dilemma and we are looking for ways to work around this. But the field has produced and continues to produce other vegetables and, in the end, it will more than pay for this year's and perhaps next year's costs.
  
  The recently rented field that has been planted with watermelons is doing well and the constant irrigation, weeding and other work required gives casual employment to several local people. Mogotio is very short of jobs, most people do casual work of some kind and that's scarce enough as well. The area has depended for a long time on the sisal industry, which dominates the area completely but product output is very low and, for some reason, the sisal factories don't seem to like paying their employees. For some employees, arrears go back years.
  
  So there are people who are happy to work in fields and there is a ready market for the produce. The soil is very good and with proper tending, seems to be well suited to quite a range of vegetables. Some of Ribbon of Hope's modest aims of reducing poverty and dependency to a small extent in Mogotio have been realised and we hope that this progress continues well into the future. It is a credit to the people there who have been so willing to work hard to ensure that things have worked out well.
  
  There are several other similar projects in other villages and they have not all worked out so well. One perfectly viable smallholding has been neglected to the extent that there is little there now but weeds. My colleague and I felt ashamed when we walked around it because it stands out from the surrounding fields, which are packed with greenery, maize, beans, fodder crops and others. This sort of wastage of money, labour, resources and opportunity needs to be avoided, but how? Lots of people say they want help but Ribbon of Hope has limited resources. The only way they can help is by starting sustainable projects, ones that require a small initial outlay that can eventually be returned to the organisation.
  
  One of my colleagues pointed out to me when I arrived in Nakuru that the rural based projects tend to do well but urban based projects, or projects involving urban based people, tend to fail. This has been demonstrated to me over and over again. Big NGOs don't tend to go to villages, even ones quite close to big towns. Villages and rural areas seem to be overlooked by funds, schemes, initiatives and projects, yet many people there welcome any opportunities that present themselves.
  
  But people who are based in urban areas seem to have NGOs knocking at their doors (beating them down, even). It is not an exaggeration to say that there are people who join each and every group in order to see what they can get from it. Some have several different group meetings every day of the working week. If they don't get something to take home, something immediate and tangible, they lose interest very quickly. Ribbon of Hope runs relatively short term projects but even three to four months is too long for some people who are used to receiving cash handouts, food, clothing, per diems, courses in making things (which they subsequently never make) and who knows what else.
  
  There is a lot of poverty in urban areas, I wouldn't wish to suggest otherwise. And I'm pretty sure there are plenty of people who know nothing about this system of 'support group hopping' and are unaware of benefits that they could really do with. But small community based organisations who can't provide people with something to take home cannot compete with organisations who can. So perhaps, given our size and means, we should concentrate on rural based groups. Perhaps we shouldn't try to box above our weight.
  
  The last remaining urban based group that we worked with may now be drifting away and I won't be shedding any tears for them. As for the remaining rural based groups, most are doing well, not as well as Mogotio, but it's early days. We have some great ideas to try out over the next year or so. There have been more encouraging signs than discouraging ones and perhaps now is a good time to do some selective pruning and simply rip out the plants that will hold back the others in the long run. Sorry for the cheesy ending but it seems apt.

• Kenyans Don't Need Rights, Especially if They Are Women

  Posted: January 20, 2010, 12:37 am by Simon

  The Kenyan MPs reviewing the draft constitution have decided that women will not have equal rights to men in marriage. They don't at present, so no change there. And a big missed opportunity in the fight against domestic violence, family impoverishment and indeed, the spread of HIV and other sexually transmitted infections (STI), along with unplanned pregnancies, including those among women who are HIV positive.
  
  These extremely well paid MPs have decided to exclude much in the constitution that relates to rights and the role of civil society. This includes religious groups (and the Kenyan National Commission on Human Rights), so I'm sure the MPs will be persuaded to change their minds about the former! But Kenyans certainly, these MPs feel, don't need rights to water, housing or food (or social security, health, founding a family, safe environment, access to quality goods or efficient administrative action). It could be wondered what rights Kenyans are deemed to be entitled to by these (Kenyan) MPs.
  
  One of the reasons that the use of condoms for reducing the spread of HIV, STIs and unplanned pregnancies has not been too successful is that women say they don't have the option to refuse to have unprotected sex with their husbands or partners. Effectively, they don't have the option to avoid becoming pregnant, even when they don't want more children or when they know they or their partners are HIV positive.
  
  The Christian churches, the ones whose part in running the country may or may not be threatened by this constitutional review, of course, object to the use of contraception. The fact that it could prevent all sorts of social problems, such as the ones mentioned above, is irrelevant. Harm reduction will probably never cut any ice with Christian dogma. But it is unlikely that women's rights will fare any better in the ultimate male dominated institution.
  
  However, on the insistence of the same Christian churches, the controversial paragraph that mentions the right to life without stating when life begins has been altered to stipulate that life begins at conception. Are all Kenyans Christians? Clearly not, but some vocal sectors of the civil society that these MPs seem to want to silence appear to have a lot more say in the new constitution than others.
  
  Abortion is already illegal in Kenya. With very few exceptions, the hundreds of thousands of abortions that take place in Kenya every year are, therefore, unsafe. These unsafe abortions contribute to the maternal death rate of 30% and an estimated 2000 women die every year from unsafe abortions.
  
  So the Christian churches are interested in the right to life of the unborn, but they don't seem to be so interested in the right of women to choose whether to become pregnant or even to choose who can make them pregnant or when. Women who know their partner or husband is HIV positive do not have the right to refuse to have sex or to insist on the use of a condom. Why are these Christian churches not as concerned about the rights of the very women who are expected to carry, give birth to and raise children where they do not choose to, perhaps because they or their partner is HIV positive?
  
  A canon who was interviewed about this matter said that 'pregnancy is God's design' and that men and women are 'responsible to control themselves and engage in sex as a husband and wife', which, if you are a Christian, may well be true. But is the canon not aware that a lot of sexual activity doesn't take place between husbands and wives, that a lot of people have sex with people other than their husbands and wives, that some people don't get to choose when, where and with whom they have sex? The Christian churches, of all churches, should be aware of things like this.
  
  If the Christian churches wish to oppose the use of contraception and a woman's right to choose, they need to pay some attention to the rights that women are currently being denied. Because it is in part the denial of these rights that is giving rise to huge numbers of unplanned pregnancies in the first place. If they sincerely want to reduce unplanned pregnancies, transmission of HIV and other STIs, sexual and gender based violence and other social problems, they would need to reconsider their position on contraception, for a start. If they are unable or unwilling to do that, these churches will find their relevance to the majority of Kenyans, especially poor Kenyans, diminishing as quickly as it has done in Western countries over the past few decades.

• Compulsory HIV Testing for Pregnant Women is Counterproductive

  Posted: January 18, 2010, 7:58 pm by Simon

  It's probably a good thing that Uganda has merged the provision of sexual and reproductive health with HIV programmes. It remains to be seen whether they do a good job of it and the fact that both functions will still be provided by two different government departments doesn't bode well.
  
  But the proposed introduction of mandatory HIV testing for pregnant women is worrying. Most countries in the world have considered mandatory testing at some time and many have resisted it. The WHO has opposed it and, as far as I know, continues to oppose it. Not only is it considered to be a human rights abuse, but it is also thought to be counterproductive.
  
  If it is a human rights abuse to carry out mandatory testing for specific groups for any disease, then it is an abuse to single out pregnant women for HIV testing. One of the dangers is that fewer women will attend ante natal clinics, with potentially disastrous consequences. But at present, Uganda is not providing ante natal care for all pregnant women. Will they start to provide it? Where will they get the money? And will ante natal care become mandatory too?
  
  All people have the right to medical care, to treatment for illnesses, prevention of diseases, general health, reproductive and sexual health, etc. But what Uganda is proposing is that it will no longer be a woman's right to choose to be tested for HIV if she is pregnant, nor will it be her right to choose whether to be treated or not, nor will it even be her right to keep her HIV status confidential.
  
  Ugandan health and social services are not able to cope with current levels of HIV, they have had constant problems testing people, treating people and maintaining supplies of medication. The country's health services function poorly and wouldn't function at all if it wasn't for high levels of donor support. But someone has now decided to make it even less likely that a large and vulnerable section of the population will seek health care just when they are most vulnerable. It is not just the pregnant women who are put in danger by such a proposal, it is also their unborn babies, perhaps their children, their partners and others.
  
  The Ugandan government is not able to guarantee the safety of women who have been diagnosed as HIV positive. It is not able to guarantee that they will not be rejected or even persecuted by family and neighbours. It is not even able to guarantee that women will get adequate care to live a healthy life and raise their children to be healthy and strong.
  
  HIV testing needs to remain an option to all people, including pregnant women. It needs to remain something people freely choose, something to which they can give their informed consent. That means they need to be counseled and advised before testing and supported after testing. This is the only way to ensure that the maximum number of people will agree to be tested for HIV. It is also the only way to support people in continuing to live a healthy and peaceful life in their own community and to take every step to avoid infecting others.
  
  Compulsory HIV testing will not stop HIV from spreading. It will only make people fear testing, especially those most likely to be infected. Compulsion will result in the very people who most need to be tested avoiding testing centres and any place else where they may have to face a test, such as ante natal clinics and hospitals. Then, by the time people infected with HIV are identified, they may already be at an advanced stage of the disease and may well have infected many others.
  
  The Ugandan government needs to encourage women to attend ante natal clinics when they are pregnant, not compel them to do so. People, whether pregnant or not, need to be advised to know their status, with regard to HIV and any other transmissible disease. If there is any chance of influencing people's sexual and reproductive behaviour, it is more likely to be achieved through education and support. It will certainly not be achieved through coercion, as Uganda and other countries have already spent nearly three decades finding out.

• Fiddling with Technical Fixes While People Continue to Die

  Posted: January 17, 2010, 2:17 pm by Simon

  Time reports on a study which raises concerns about HIV drug resistance. Most Kenya government documentation about HIV treatment is concerned with getting as many people on treatment as possible, or appearing to do so. Where the aim is to get as many drugs out to as many people as possible, resistance is probably not so visible. After all, you need to monitor people regularly and carefully for signs of resistance and funding doesn't always stretch to that.
  
  It's not really clear how many people in Kenya are currently on HIV treatment. Figures vary a lot and don't always make it clear whether people who were once on treatment but have since died are included. Probably a few hundred thousand are on treatment at the moment, maybe three hundred thousand. But it's even less clear how many are on second line treatment. Second line treatment is given to those who have developed resistance to first line treatment and it's prohibitively expensive.
  
  Most of the hundreds of millions of dollars of HIV money is spent on drugs, either for treatment or prevention. No one would want to deny people who are suffering from HIV/Aids access to necessary drugs, of course, but there must be a limit to how much money can be spent on drugs to the almost total exclusion of other aspects of treatment and prevention. I don't know what that limit is but there are proposals to put even more people on drugs and the sustainability of these proposals is highly questionable.
  
  At present, people whose HIV infection has reached a particular stage are usually put on antiretroviral drugs (ARV). Perhaps about half the HIV positive Kenyans who have reached this stage are currently receiving treatment. Pregnant women who are infected with HIV are put on a short course of ARVs and this results in most babies growing up HIV negative. Less frequently, people who may have been accidentally infected with HIV can be given a short course of ARV treatment called post exposure prophylaxis (PEP).
  
  But there are proposals to roll out ARV drugs to more and more people. For example, it was proposed just over a year ago to test everyone, or as many people as possible, and to put anyone found to be HIV positive on ARVs. If this could be done, the number of people on treatment would go up several hundred percent.
  
  Another proposal is to roll out what is called pre-exposure prophylaxis (PrEP). This would involve putting HIV negative people on ARVs in the hope that this would protect them from becoming infected. The target of this kind of programme would be those seen to be most at risk of contracting HIV. This could involve sex workers, men who have sex with men, prisoners, intravenous drug users and perhaps the clients of sex workers, people who have many parters and people who have concurrent sexual partners, relationships that overlap with other relationships.
  
  The number of people who would be targeted would be hard to estimate. How many men who have sex with men are there in Kenya? Is it five percent of the population or 10 percent (2-4 million)? Men who have sex with men are hardly going to identify themselves in the current homophobic climate anyway. An obvious target of PrEP is people who are HIV negative but are in a relationship of some kind with someone who is HIV positive, called discordant relationships. This could number some 350000 people.
  
  Similarly for sex workers, how many are there? Is it hundreds of thousands and does that include people who occasionally engage in sex work or who don't consider themselves to be sex workers? And what about identifying their clients, how many million would there be? Is it really feasible to identify those most at risk of becoming infected with HIV? The recently published modes of transmission survey shows that, for years, HIV programming has been seriously misdirected and also that those who are most at risk is a very mixed and constantly changing group.
  
  There are questions about the possible effectiveness of PrEP but there must also be questions about the feasibility of identifying all the people who could benefit from it, given the numbers of people who are infected with HIV and the numbers of people who are in danger of becoming infected. If resistance is a problem at current levels of ARV rollout, what kind of problem would it be if ARVs were rolled out to all people at risk or thought to be at risk of contracting or of transmitting HIV?
  
  All the uses of ARV run the risk of resistance. Those who are HIV positive and on ARVs are at risk, but so are the women who receive short courses of ARVs to prevent mother to child transmission, so are those who receive post exposure prophylaxis, so are those who receive pre exposure prophylaxis. With resistance comes increased sickness and death unless second line treatment is rolled out. And second line treatment means increases in cost of several hundred percent. Again, questions about sustainability arise.
  
  The question of whether we can treat our way out of the HIV epidemic is constantly raised but the answer is unclear. I would suggest that the answer is no and that even efforts at preventing the spread of HIV should steer clear as much as possible from technical fixes, such as ARV drugs. Drug treatment of HIV, let alone drug prevention, may not be sustainable and is already seriously affecting the amount of money available for preventing HIV transmission.
  
  Instead of the almost inconceivable amounts of money being proposed to pay for drugs for treatment and prevention, far lower sums of money could be spent on improving the overall health, education and welfare of Kenyans and of those in other high HIV prevalence countries. It is immoral to continue pretending that there is a technical fix just around the corner and that everything will be OK. As long as we continue to look for technical fixes and ignore the lives of people in underdeveloped countries, people will continue to become sick and to die from treatable and/or preventable conditions.

• Uganda Won't Allow Mere Principles to Compromise Foreign Aid

  Posted: January 15, 2010, 8:55 pm by Simon

  Uganda's President Museveni is not known for being forbearing or fair minded, especially when it comes to men who have sex with men (or, presumably, women who have sex with women). But he has decided to distance himself from David Bahati's bill, which proposes the death penalty for certain offenses relating to homosexual behaviour and prison sentences for others who fail to report homosexual behaviour. It even proposes life imprisonment for persons engaging in same sex relationships.
  
  This is not an instance of Museveni suddenly becoming softhearted, either. There are existing Ugandan laws against homosexuality with very long prison sentences. The country that claims to have had so much success in fighting the HIV epidemic continues to fail some of the people most at risk of becoming infected with HIV and of infecting others. Bahati's bill was certainly heading in the wrong direction but Museveni needs to do a lot more than oppose the work of a power crazed bigot.
  
  Sadly, the Bahati bill had a lot of popular support in Uganda. Other East African countries have similarly punitive laws and there was the fear that if Uganda passed such a law, other countries would follow. It's frightening that most African countries outlaw homosexuality but even more frightening when you hear about the level of persecution homosexuals and those suspected of being homosexuals must put up with from the public, professionals, officers of the law and just about anyone else.
  
  Museveni is said to have been reacting to international protests, especially from countries from which large amounts of donor money come. He mentions pressure from Canadian, American and British leaders and refers to the bill as a 'foreign policy issue', which it clearly is not. It's good that Museveni has decided to question the bill, but it would be more heartening to hear that he had some objection to persecution of and discrimination against homosexuals.
  
  However, earlier on in the debate, people like Bahati said the country should forgo some foreign aid if donors objected. The debate has moved on a little and there was probably never any danger of Uganda refusing foreign aid. Their HIV efforts, and those of most high prevalence African countries, are almost totally dependent on foreign donations. But even some of the American fascist evangelists who originally supported the bill have now started to criticize it.
  
  The best we can hope for right now is for Museveni to succeed in persuading Bahati to withdraw the bill or in persuading people not to support it. That would put Uganda back in the position it is in now with regard to homosexuality. That's not good, but it could be worse. But more pressure is needed, like the pressure against the Bahati bill, in order to ensure that the rights of homosexuals and other minority groups are recognised.
  
  All the talk about Ugandan's and other Africans being so Christian, right minded, conservative and the rest is just so much posturing when you view it alongside people's attitudes towards those who are seen as somehow different. There's something scary about a religion whose adherents seem to behave in ways that are directly contrary to the religion's preachings.
  
  To the Ugandans and other Africans who argue that homosexuality is an export from the West, it could be pointed out that the sort of double standards that allow avowed Christians to persecute their fellow human beings may actually be the worrying export from the West. These double standards are doing and will continue to do a lot of damage; unlike homosexuality, which has always existed in all known human societies, including African ones.
  
  And Museveni has the cheek to talk about not compromising the country's 'principles', while at the same time taking into account 'foreign policy interests', presumably referring to hundreds of millions of dollars of aid money. Yes, it would be totally unchristian to do otherwise.

• Kenya Makes a Start in Addressing the HIV Epidemic

  Posted: January 14, 2010, 12:23 am by Simon

  For the first time, I have come across an official Kenyan Government publication relating to HIV that is readable, credible and well thought out. Their survey entitled'HIV Prevention Response and Modes of Transmission Analysis' is available now (despite being dated March 2009). It address many of the worries about Kenya's HIV epidemic that have only been briefly mentioned before, but never adequately dealt with.
  
  For example, it questions the fact that a far larger percentage of HIV spending goes on treatment and care than on reducing transmission; it questions the fact that HIV prevention programmes are top down and the same everywhere, even though the HIV epidemic affects areas very differently; it questions the fact that much of the HIV prevention spending seems to go to those who are not most at risk of being infected with or of transmitting HIV; many of those who are most at risk or in need of specific prevention programming receive little or none.
  
  At last, the fact that there are men who have sex with men in Kenya and that they contribute to the epidemic is admitted and it is concluded that they need to be targetted. A recent report (too recent for this survey) shows that men who have sex with men live in all provinces and in urban and rural areas. It also shows that the clients of male sex workers providing services for other men are predominantly Kenyan. Previously, it was said that men having sex with men was a foreign phenomenon and that it mostly occurred along the coast.
  
  Indeed, HIV transmission by men who have sex with men may be even higher than estimated by the Modes of Transmission Survey. But it's good that the issue is being discussed, rather than denied or ignored. The paper also admits that much of the money that goes into prevention goes towards interventions that have not been shown to have any impact on transmission. It admits that specific interventions may not have had much impact yet, even though some indicators are positive. It acknowledges that programmes and services are concentrated in areas where the need is not greatest.
  
  So, people who are most at risk of becoming infected and of infecting others, such as men who have sex with men, commercial sex workers (and those who engage in any kind of transactional sex), intravenous drug users, long distance drivers, members of the fishing community and others are being acknowledged as being in need of prevention services. Let's hope that will be translated into the provision of these services. This survey is a very important step in Kenya's approach to HIV prevention.
  
  But before some of these groups can be targeted, there are other problems that need to be addressed. It is illegal for men to have sex with men, certain aspects of commercial sex work are illegal and intravenous drug use is illegal. Members of these groups are rightly afraid to identify themselves and to risk being identified because they are the victims of persecution by members of the public, clients, professionals, police and others. But the survey mentions these issues and makes recommendations relating to them.
  
  It remains to be seen whether any of the improvements recommended by this survey are made by the current government. But reading this survey gives me hope because maybe now there are some people in a position to do something who are willing to even discuss phenomena that have so long been ignored.

• We Don't Need Evidence that Health, Education and Other Social Services Are Good

  Posted: January 13, 2010, 9:11 pm by Simon

  You might think that HIV prevention interventions have some bearing on the context in which they are implemented. For example, you might think that interventions to persuade people to have fewer partners are concentrated in areas where it has been shown that people have many sexual partners. Or you might think that about interventions to persuade people to avoid concurrent relationships, sexual relationships with more than one person at a time.
  
  But in fact, interventions are mostly the same wherever you go, whether it's a developed country or an underdeveloped one. The little research that has been done into sexual behaviour suggests that in some places people have far more lifetime sexual partners than in others and even that in some places people have more concurrent sexual relationships. But no research shows that areas where people have more sexual partners or more concurrent sexual relationships actually correspond closely with areas of high HIV prevalence.
  
  It's just an assumption that if HIV prevalence is high, people there much have more sex, more partners and more concurrent relationships. Some of the research that has been done clearly demonstrates that areas with high levels of HIV have lower levels of multiple partnerships and concurrent partnerships. It also demonstrates that areas with high levels of multiple partnerships and concurrent partnerships have lower rates of HIV. Clearly, unsafe sex is unsafe, wherever it occurs and however, but specific prevention programmes would need to be clear about what kind of 'unsafe' sexual behaviour, precisely, is occurring and how to change that.
  
  But HIV prevention interventions are more likely to be dreamed up by those with political, religious or commercial interests, in complete isolation from anything that could be called evidence. And so far, they have almost all worked equally badly, whether it's in South Africa, which has the highest number of people living with HIV in the world or the US, which has the highest HIV prevalence in the developed world. These failures are not because of lack of available evidence about what would work and what would not work, though there is a lack of evidence. The failure is because HIV prevention funding has been seen as a matter of 'morals', petty politics and a good way to make some money.
  
  If these circumstances were to change, what hope would there be that the high rates of HIV transmission in many countries of the world could be reduced? The issue of concurrent partners is hotly debated by the foremost academics in the field. But what these people don't disagree on is whether condoms work. There is no evidence that condoms don't work, though they are not 100% efficient. There is only a prejudice against the use of condoms because people who use condoms are having sex. But if people weren't having sex there would be no HIV pandemic.
  
  I have never heard an academic, or anyone else, arguing that education, health education and sexual health education are bad and producing evidence to support their arguments. I have only heard bigoted politicians and religious leaders who seem to know little and care less about what their country's children know about sex and sexuality. Over and over again, it has been shown that children who know about sex and sexuality are more likely to delay their first sexual experience and to take precautions against unplanned pregnancy, HIV and other sexually transmitted infections.
  
  Research into sexual behaviour is not just scarce, it's hard to do and the results are rightly hotly debated. But we don't need to wait for this difficult and costly research to be completed to aim to cut the transmission of HIV. It would be immoral to wait for this research. We know now that people have sex and they need sex education and contraception. They need health services, especially sexual and reproductive health services. The majority of new cases of HIV transmission in developing countries are still sexually transmitted, so to those who say HIV prevention is difficult or that evidence is lacking: this is not completely true.
  
  Sure, there are controversies and there is research that badly needs to be done. But ignoring the efficacy of condoms, education, health and other social services in cutting the transmission is not only wrong, it is also disingenuous. Access to education, health and other social services are human rights so no 'evidence' is needed for these areas to be funded straight away. And while we're considering these human rights, we could also take a look at gender imbalances of all kinds, but especially relating to employment, family law, inheritance and marital power imbalances.
  
  High HIV prevalence relates to the broad determinants of sexual and other types of behaviour, to the overall conditions in which people live, to their levels of health, education, wealth and many other things. HIV prevention has mainly concentrated on individual sexual behaviour and this is one of the things that makes reducing HIV transmission appear to be so intractable.
  
  As the authors of a paper published in The Lancet over three years ago conclude: "No general approach to sexual-health promotion will work everywhere, and no single-component intervention will work anywhere. We need to know not only whether interventions work, but why and how they do so in particular social contexts. Comprehensive behavioural interventions are needed that take account of the social context, attempt to modify social norms to support uptake and maintenance of behaviour change, and tackle the structural factors that contribute to risky sexual behaviour."

• How Long Can We Continue to Ignore Those Who Are Still HIV Negative?

  Posted: January 12, 2010, 11:48 pm by Simon

  I was back in Mogotio with Ribbon of Hope today, weeding the watermelon beds in our latest shamba (smallholding). There were eight of us there today, three who were getting paid for the work. Others will get payment in kind. I have to be honest, I managed to do a few hard hours under the hot equatorial sun but I had to give up at lunchtime and I'm now stiff and sore. And there was at least two thirds of the field left to weed when I left!
  
  But it's good to see the project get off the ground because it will provide some casual employment in an area that sees little work and it will provide some good food crops at low prices at a time when food prices are particularly high. In the next few months the shamba will require a lot of looking after, weeding, irrigating and security. There will be plenty of people willing to do some of that work.
  
  Mogotio is only about 30 kilometers out of Nakuru, so it is by no means the most isolated place you'll find. But it feels isolated. There are very few NGOs that ever visit the place and I haven't been able to find out about anything they do. I saw a World Vision four wheel drive but none of the community leaders I asked could say what the organisation does there. UNHCR has been active in the area recently because hundreds were displaced by the heavy El Nino rains. There are over one hundred white UNHCR tents just outside the village, but that's an exception.
  
  The area is almost entirely dominated by the sisal industry. There are a few factories, most of which don't operate very much. There is little money to be made by growing sisal and people who live in these areas don't make much of that money anyway, it's mostly made by the estate owner, who lives in Nairobi and rarely visits the area. Some of the people who work for or have worked for the factories are owed wages going back many years. Every now and again they get some money, but just a fraction of what they are owed.
  
  Like a lot of parts of Kenya, HIV is widespread here but it receives little attention. Most NGOs are based in the cities and bigger towns. They work in or close to wealthy suburbs and rarely leave those areas for long. When they do, it's like a state visit, a convoy of huge, air conditioned, white, oversized vehicles, stirring up the dust and little else. HIV spreads more slowly in rural areas and that may be one of the reasons that less attention is paid to them than to urban areas. However, the majority of Kenyans, over 80%, live in rural areas.
  
  And many more people in rural areas don't go to school or don't go to school very much, many don't have access to mainstream media, they don't have access to health or other social services and they have little or no connection with the benefits of the cities and towns. They are more isolated than their distance can explain. Every now and again something comes their way, probably not much, then the project or organisation leaves and loses touch.
  
  But even some of these isolated areas have access to some HIV testing and counseling facilities and even the HIV drugs that most people are supposed to receive for free. They usually don't have access to any other kind of drugs and they are lucky if they can stay healthy, but it's a start. But treating more and more HIV positive people every year has little impact on reducing HIV transmission. Many more people become infected for every one person who gets treatment.
  
  And HIV prevention really is a strange animal. In all the time HIV has been around, few methods of HIV prevention have been developed. A fraction of the money that goes into HIV goes towards prevention, less than 25% in Kenya. About half of that goes on prevention of mother to child transmission and the 12% that's left is spent on rather dubious projects that are known to be of little or no benefit.
  
  A series of findings were presented at the 2006 Aids Conference that demonstrated that most kinds of HIV prevention programmes have a very small effect, some have a negative effect and the majority don't do anything. Consider the list: Voluntary Counseling and Testing, Condom Social Marketing, Mass Media, Abstinence-Based Interventions, Peer Education, Family Planning Counseling for HIV-Infected Women, Needle Exchange Programs, and the Effect of HIV Treatment on Risk Behavior.
  
  The only one in the above list that has proved itself is needle exchange programmes. These have been known to be effective for a long time but they are strongly disapproved of by many funders, especially US funders, who feel that they increase drug use. They don't increase drug use, they reduce it and they have an impact on HIV transmission. But such programmes are of little relevance in Kenya as a whole and of virtually no relevance in a place like Mogotio.
  
  The majority of HIV infections in Kenya come from heterosexual intercourse. A sizeable percentage comes from male to male intercourse. A debatable, possibly high percentage, comes from medical treatment, such as injections. But in rural areas, like Mogotio, people are in need of good education, health services, ordinary health services, not vertical interventions that treat HIV (or something else) alone, basic social services, infrastructure and things like that. There is no mystery about HIV transmission that makes its reduction intractable. People need a reasonable standard of living, they need security in their lives, especially food security, they need work, for which they get paid; just basic things that people in developed countries take for granted.
  
  Yet more and more money continues to be poured into programmes that are unlikely to work or even ones that have been demonstrated not to work. In the case of Mogotio, of course, they don't even get these programmes most of the time. Money intended for the constituency appears to get stuck elsewhere and people are forced to plod along without even the most basic of their rights being realized. As long as people have so many problems in their lives and so little to aspire to, HIV will continue to be low on their list of priorities. If HIV is low on their list of priorities, even effective prevention programmes, if effective programmes exist, are destined to fail.

• Ribbon of Hope's Mogotio Shamba

  Posted: January 11, 2010, 8:23 pm by Simon

  
  
  Photo: Beans, almost ready to harvest.
  
  Today was a good day for Ribbon of Hope in Nakuru. We went to the Mogotio shamba (smallholding) to see how everything was growing. Much of the one and a half acre plot is planted with beans that were put down a few months ago. It was hard work planting them because they are packed in close together. It was harder work irrigating the crop through the dry months, but it was worth is as the field became lush and green. Now the beans are almost ready to harvest in the next couple of weeks, as long as the heavy rains don't destroy them. The rains have already beaten some of the crop into the ground but we'll hope for the best.
  
  
  
  Photo: Amaranth, almost shoulder height.
  
  And there are other crops in the field, also almost ready to harvest. There's coriander, kale, amaranth, tomatoes and spinach. These were planted later than the beans, but they are growing quickly because of the heavy rains. Earlier crops that were planted, such as onions, green peppers and kunde have more or less peaked and are declining now, but they were worth the effort, especially the green peppers.
  
  
  
  Photo: In the foreground, coriander and some members of Ribbon of Hope.
  
  The idea of growing these common foods is that local people will do the work and they will then sell the produce or buy it at low prices. About five or six people have been involved in producing all this food so they will now be able to use it themselves, sell it to friends or sell it in the market. It's surprisingly reasonable to rent land in this part of Kenya and surprisingly expensive to buy land. Unfortunately, it's hard to keep up the work and provide security and the like on rented land and this has been an uphill struggle from the start. But again, we hope for the best.
  
  
  
  Photo: A fine looking bed of kale or 'sukuma wiki', as it's called here.
  
  We have rented another plot of land, also a bit over an acre, in a field nearby. This is also close to the river and so should be easy enough to irrigate. It is now completely planted with watermelon plants. It took a short time to plant the whole field but it will take a lot of work to look after this valuable crop. For now, there's not much to see in the field, a few spots of green. Actually, too many spots of green and we have to weed the whole thing tomorrow. But in a few weeks time the field should be covered in melon vines and in a few months, a beautiful and fragrant crop.
  
  
  
  Photo: A recently planted field of watermelon.
  
  Ribbon of Hope has other shambas but this one has been the most successful, so far. This is probably because the same people come to do the work, week in, week out. Other shambas don't always receive the same dedication, though they should work out, eventually.
  
  In addition to producing onions, green peppers and kunde, this shamba produced a fantastic crop of butternut squash last year. Ribbon has been able to invest in a petrol pump and, later on, a foot pump. The petrol pump is great but it does cost a lot to run and also it seems to suffer from a lot of engine problems. The foot pump is a great addition and uses no fuel (!) but we haven't had it long enough to really say how good it is. It just feels nice to have a pump that doesn't require petrol, given the disadvantages of having to use fossil fuels, as if we were fossils ourselves.
  
  
  
  Photo: Tomatoes, filling up nicely as a result of the El Nino rains.
  
  It's a bit early to say how cost effective these small economic interventions are. The amount of money spent is not huge but it remains to be seen how good the harvest is and if there is a good market for the various produce. Undoubtedly, such projects increase self-reliance considerably, even where they don't produce much. But in the long run, we would like to be able to increase the number of such projects and have more successful harvests than unsuccessful ones. I'll post up any further news and progress as and when.

• PSI: Throwing Bad Money After Bad

  Posted: January 10, 2010, 7:50 pm by Simon

  At one time, the leading paradigm of development was the control of population, the belief that poor countries would develop if they would only have fewer children. One of the foremost organizations persuading people to use condoms and employ other family planning techniques was Population Services International (PSI). They were not very successful and family planning and reproductive health in developing countries is still woeful, despite large sums of money being thrown at these problems.
  
  PSI is still a powerful organization with lots of money to throw at the problems of development. But now, much of their money goes into HIV, where they (along with various other powerful and rich organizations) have also been relatively unsuccessful. PSI's aim is to use the 'power of marketing' to persuade people to change their sexual behaviour and use condoms and other modern contraceptive methods.
  
  Strangely enough, PSI don't seem to know that the road up is also the road down, that contraception to prevent unplanned pregnancy can also prevent sexually transmitted infections (STI), such as HIV. The goal of reducing unplanned pregnancy was lost in the scramble to persuade people to change their sexual behaviour to avoid being infected with HIV (never mind about other STIs). However, many HIV positive women having babies did not plan to get pregnant in the first place. And the whole issue of sexual activity and reproduction has become so confused that people are apt to concentrate on one thing, such as unplanned pregnancy, and completely ignore two other important considerations: HIV and other STIs.
  
  Not that long ago, it was reported that many women would prefer to run the risk of contracting HIV than that of getting pregnant. They would have unprotected sex with a partner, often a person they didn't know very well, then they would resort to emergency contraception (EC). This EC is not appropriate as a general contraceptive and it does not protect from HIV or other STIs.
  
  Why would people be willing to take this risk? Is it because they simply don't see contracting HIV as a very high risk? They could be right, they may be more likely to become pregnant than to contract HIV or some other STI, but the risk is still there and the odds go against them the longer they continue to have unprotected sex. Actually, the chances of becoming pregnant also become higher the longer they continue to use EC as a substitute for more appropriate contraception.
  
  I'm singling out PSI because they have been big fans of marketing EC in developing countries and because of their dependence on marketing. Marketing may well be appropriate in the commercial world, where everything has to seem cooler or newer or better than what went before. But contraception, family planning, reproductive health and things like that are not good because they are cool or funky or with it, they are good because they work.
  
  If PSI have been successful at marketing EC, they have done so irresponsibly. After all their decades in developing countries they should know by now that what people need is good basic education, good basic health services and good sexual health services, particularly for women and girls. Fancy (and expensive) marketing is not a substitute for proper education and health. The message has now been fluffed, so that people have all sorts of muddled ideas about contraception, sexualy behaviour, pregnancy and anything else organizations like PSI have been involved in.
  
  If organizations like PSI are really interested in people's health and welfare, they should pay a little less attention to marketing expensive products and services and spend some time advocating for the levels of health and education spending that countries like Kenya really need. Contraception such as condoms is not cool, it's vital for people to be able to live their lives without risking serious disease or unplanned pregnancy.
  
  People, adults and children alike, just don't know enough about HIV, reproductive or sexual health. There is no amount of advertising and campaigning that will give them access to the information, services and products they need to ensure their sexual and reproductive health. HIV, and even high levels of unplanned pregnancies, are not emergencies. They are part of everyday life and a factor of how little has been done to improve people's health and education over the past few decades.
  
  Contraception of any kind is useless without adequate levels of spending on education and health, especially those relating to sexual and reproductive health.

• The Odds Are Not Stacked Enough in Our Favour, Say Big Pharma

  Posted: January 9, 2010, 7:06 pm by Simon

  The 'Counterfeit Act' signed by the Kenyan government last year is being challenged as unconstitutional, violating the right to health. This act was not really necessary because it was already an offense to make and distribute fake goods and there are already officials whose job it is to enforce existing laws.
  
  In fact, the act seems to have been cobbled together and rushed through parliament at the behest of big industry, especially big pharma. The last thing they would want is competition, except where the odds are well stacked in their favour. So they whinged to the government (a process called lobbying in some countries) about how things were so unfair and the government kindly came up with a piece of legislation that fails to distinguish between fake goods and generic goods.
  
  As a result, generic versions of drugs destined for Kenya have been held up in various countries on the grounds that they may not be legally distributed in Kenya. This is great for big pharma, they never wanted generic versions of drugs to be produced unless they themselves produced them, at inflated prices. But they were forced to reduce their prices when producers won the right to produce generics and big pharma have been fighting them ever since.
  
  GlaxoSmithKline has come up with the expedient of reducing a few well known products, such as some of their antibiotics, to try to undercut generic versions. However, they don't seem to understand the concept of undercutting: their prices need to be lower. They have reduced their prices, sure, but they are still far more expensive than generic versions. What they are offering are hardly loss leaders, rather some kind of token gesture, to which journalists give the expected publicity and praise. And it's still not even certain if the reductions will be passed on to consumers.
  
  The result of Kenya's self-serving piece of legislation is that there is widespread confusion about pharmaceutical products. People really have no way of knowing what is fake and what is not. The fact that something has a well known manufacturer's name on it does not guarantee that it is not fake. But if it is genuine, you are still robbed of the extra cost that going for the branded product involves.
  
  People are just not able to afford many of the branded products. Slight reductions here and there, or even substantial reductions, miss this point. What is never so clear is what people have to sacrifice if they do go for the expensive branded product. But that's of little interest to organisations like GlaxoSmithKline or to the journalists who flock to report on whatever titillating rubbish is being reported on by all other journalists.
  
  I'm glad to hear this despicable act is being challenged and hope those opposing it succeed. Because other countries, such as Uganda, are considering similar acts, no doubt in response to lobbyists for big pharma and other industry interests.

• Will PEPFAR Become a Fund for Health?

  Posted: January 8, 2010, 8:39 pm by Simon

  It sounds as if PEPFAR (President's Emergency Fund for Aids Relief) is about to change a bit under the Obama administration. These changes are all long overdue. For a start, Aids is no longer to be seen as an emergency. It wasn't an emergency before PEPFAR started, so this is good to hear.
  
  The 'exceptionalisation' of Aids, treating it as if it is a disease that is separate from health in general, should have its own institutions and funding, is to disappear. Again, this move is long overdue, but still welcome. Hopefully, it will mean that some of the huge sums that have been raised for Aids will be spent on health services. Those who think Aids issues will lose out needn't worry, people with Aids also have general health needs. So everyone will gain.
  
  The head of PEPFAR, Eric Goosby, is at last questioning the sustainability of putting everyone who is HIV positive on drugs that they will need for the rest of their lives. Of course, HIV positive people should be treated, but with far more people becoming newly infected for every one put on treatment, something really has to be done to reduce the number of new infections as well.
  
  So HIV prevention should return to the agenda. The question is, what kind of prevention programmes will be funded by PEPFAR? In the past, prevention has included little but lecturing people on their sexual behaviour. There are few prevention programmes that have had much impact on HIV transmission. Of course, most well funded programmes will tell you that they have been very successful and show evidence that whatever mindless drivel they repeated to all and sundry can be trotted out at the ring of a bell, or whatever.
  
  But rates of HIV transmission remain high in many countries, including the US, despite these questionable programmes. Does PEPFAR have anything new to bring to the table? If they don't, it would be good to hear that they are willing to talk about using condoms and employing other harm reduction approaches to HIV. For example, clean needle and syringe distribution and greater advocacy and support for sex workers, men who have sex with men and other vulnerable populations.
  
  Another change proposed is that PEPFAR funds go to governments rather than, primarily, to NGOs. While it's true that NGOs may not have done very well in many cases, I'm not sure about the wisdom of handing large amounts of money to governments. Kenya has had a particularly bad history when it comes to administrating large amounts of money intended for HIV treatment, care and prevention (or any kind of funding). Time and time again, investigations have found administration of funds wanting, only for the money to flow in again once the row has died down. PEPFAR recently announced a doubling in Aids funding, amounting to 2.7 billion dollars over the next five years.(A Ugandan writer also worries about these changes ito PEPFAR.)
  
  Disbursements of US aid for HIV don't relate to a country's need. The HIV epidemic in Kenya is by no means the worst in Africa, even in Sub-Saharan Africa but they are one of the top recipients of funding. No, disbursements seem to depend more on how cozy a country's relationship is with the US and for Kenya, the relationship has been very cozy since independence. Perhaps questions about how much of that money actually benefits people with HIV are irrelevant to PEPFAR, as long as cozy relationships remain, who knows? But let's hope the changes take place and my fears are not realised.

• Apologies for Lack of Posting

  Posted: December 27, 2009, 2:41 pm by Simon

  I haven't given up but I am in a place where I don't have much opportunity to use the internet. I will be back at work in early January and should have ample opportunity then. I wish readers a good holiday.

• Aids Denialism Doesn't Make the Disease Go Away

  Posted: December 14, 2009, 11:22 pm by Simon

  There are many controversies surrounding HIV, development in general and various other things. So, writing a blog about these can attract some controversial remarks, in theory. In practice, I have received some comments but few that are controversial. When remarks have little or nothing to do with what I have posted, I delete them. If the post is clearly just an attempt to attract attention to some site, product, issue, service or person, I am also likely to delete them.
  
  But a comment I received today, anonymous of course, purported to be about my most recent posting, which discusses levels of HIV transmission from unsafe medical practices. 'Anonymous' may have thought that in questioning certain aspects of HIV funding and the like, I am aligning myself with certain Aids sceptics, who deny that HIV causes Aids, or whatever. Whether this anonymous contributor represents AliveandWell.org or not is irrelevant; I do not agree with what the site stands for and I would not wish to have anything to do with a group of people whose only aim seems to be to further muddy these already turbid waters.
  
  My approach to HIV in Kenya has been that of a general scientist. My interest is in the overall conditions in Kenya and how they changed as HIV arrived, spread and continues to spread. Therefore, I look at history, economics, social practices, lifestyles and many other things, in addition to medical and social science aspects of the virus. I do not have the scientific expertise to address all the details of the AliveandWell site. There are plenty of people who can do that, if they deem the content of the site worth the effort.
  
  As for the idea that HIV and Aids were 'invented' by some wealthy people so they could make money (or even take over the world), I have never heard anything that could make such a hypothesis the least bit plausible. No doubt the AliveandWell site is teeming with such evidence, but I think I have more worthwhile things to spend my time on.
  
  Some of the numerous 'experts' cited on the site may well have a great deal of expertise, I really can't say. Certainly, some of them seem to have lots of letters after their name. But people can make up qualifications, or pay for them. And plenty of well qualified people come out with utter rubbish that can be used by whoever wishes to shore up some rant that they like to call 'theory' or 'hypothesis'.
  
  The anonymous poster says AliveandWell advocates 'scepticism' around HIV but the site is the work of a group of Aids denialists who encourage the use of 'alternative therapies' for HIV positive people. HIV positive people would be well advised to consider the fate of the woman who started the site, Christine Maggiore, who died of Aids, along with her infant daughter. Maggiore refused antiretroviral treatment for herself and for her daughter.
  
  To adopt the stance that Maggiore and her followers recommend is not scepticism, it is idiocy. Some adults may wish to adopt such a stance, which is regrettable. But there is no justification for imposing such idiocy on people who are unable to defend themselves. There is enough disinformation about HIV/Aids in developing countries already without this sort of deception being peddled and I hope people who visit AliveandWell see the site for what it is.
  
  Those are my thoughts on your wonderings, Anonymous.

• Don't Have Sex and Don't Go to the Hospital

  Posted: December 12, 2009, 3:26 pm by Simon

  Over the past twenty years or so, there have been a few papers pointing out that HIV transmission through unsafe medical practices, especially in Sub Saharan African countries, may be higher than previously thought. These papers don't seem to have had much impact and when modes of HIV transmission surveys have analyzed the part that such practices might have played in the current HIV pandemic, they have usually reported that heterosexual transmission is the most common, followed by things like male to male sex, intravenous drug use, commercial sex work, etc.
  
  The possibility of unsafe medical practices playing a large part in HIV transmission is being raised again, though it is hotly disputed by some. But given the amount of guesswork involved in estimating HIV prevalence in high prevalence countries, it would not be surprising if the figures were open to question. If it were established that HIV was regularly transmitted through medical practices, it would certainly dent the widely held belief that HIV can be fought purely by trying to control people's sexual behaviour.
  
  I and some others have long opposed the view that sexual behaviour alone can adequately explain the massive rates of HIV transmission in certain countries, compared to the relatively small rates in other countries. This is not to deny that sexual behaviour is an important factor in HIV transmission, just to question the idea that certain people in certain African countries have more sex or have more partners or whatever, than people in other countries around the world.
  
  But unsafe medical practices would be unsurprising in a country that spends so little on health, a country that has so few properly trained medical personnel, so few hospitals, a country where the vast majority of people can't afford to go to a health professional when they are ill and who may often be better advised not to go at all.
  
  The cries of those who claim that massive funding for HIV treatment and care is justified may be well founded, I don't know. But one thing is for sure: in the time that HIV treatment has been well funded, hospitals and clinics have not improved noticeably, rather, they have disimproved. Staff numbers have fallen. Disease rates have risen. All the indicators suggest that the disimprovements in health that started in the 1980s, before Aids had had much impact, have continued right up to the present, high Aids funding levels notwithstanding.
  
  So, as the anti circumcision lobby might say, this is not a good time to start mass male circumcision programmes. There may never be a good time, the case for mass male circumcision is still unconvincing, but no one in their right mind would opt for an operation on their penis or the penis of their child or relative until health services have been improved. People need to be confident that they will get better in hospital, not worse. Children in Swaziland whose mothers are HIV negative and who had attended hospitals and clinics a lot were found to be most likely to be HIV positive. Similar studies have been carried out in other African countries.
  
  Whether you are going to a clinic or hospital for HIV related services or anything else, you are in danger of suffering from unsafe medical practices. The health service in Kenya is on its knees. Expensive HIV treatment or circumcision programmes either need to have their own infrastructure built from the ground up, which seems highly inefficient, or they have to wait until health services are built up in their entirety.
  
  Kenyan's are still waiting for their health service to be rebuilt. The circumcision programmes have stalled, thankfully, some would say. And the HIV treatment campaigns are seriously hampered by the condition of the country's health services. Indeed, antiretroviral treatment is probably also hampered by the low levels of health in the population, but who is going to notice that? There just aren't enough health professionals to bear witness to the chaos that exists.
  
  The whole issue is a reminder of how little is known about the true nature of different HIV epidemics in different countries. Many of the figures that are used to shape the various approaches to the disease are pure guesswork and interpretations are often strongly shaped by influences that have little to do with science or even reason, for example politics, religions and 'morality'.
  
  A sensible conclusion to draw from warnings about the safety of medical procedures would be to spend more money on health infrastructure and especially on training more health personnel. More money is probably need for HIV specifically, but it will be money thrown down the drain until health infrastructure has been improved.

• The One Trick Pony That Can't Defy Gravity

  Posted: December 10, 2009, 3:57 pm by Simon

  When debates become polarized there can be a danger that neither side can accurately characterize the view of their opponent. Thus, Gregg Gonsalves of the International Treatment Preparedness Coalition characterizes a particular view as the 'Aids backlash' and lumps together a number of views that may not even be held by any particular person or group. He characterizes the backlash thus:
  
  The belief that "the fight against AIDS has misdirected our energies towards broader goals in health and development; the provision of antiretroviral therapy is a folly, it's too expensive and isn't worth the money to continue its expansion; efforts against AIDS are destroying health systems and promoting unnecessary deaths from other simpler-to-treat diseases and conditions such as childhood diarrhea".
  
  Personally I think there is probably not enough money put into the fight against Aids and that much of that money is not being used very well. In particular, I think too little of the money is being spent on prevention and almost all of that is not being used very well. True, it took some time for the international community to face the threat that Aids presented but when they did face it, they came up with a level of funding that has never been matched by campaigns against other diseases or disease groups (such as sexually transmitted infections, water borne diseases, etc).
  
  I don't think the provision of antiretroviral therapy (ART) is a folly and I don't think people who hold the sort of sceptical view I've expressed in the last paragraph necessarily do either. The fact that there are many more people becoming infected than there are being put on ART is not an argument to reduce ART programmes, rather, it is an argument for finding out why HIV prevention is being ignored and rectifying this situation urgently. There is little point in spending nothing on people until they become infected with an incurable illness if something could be done to prevent them from becoming infected.
  
  But also, there is little point in treating people for HIV and leaving them to die of something else. There are many preventable and treatable diseases that are killing people, including people who are HIV positive. I think that this is, in part, because of poor health facilities and services and an acute shortage of personnel. But also, there is a lack of funding that goes back several decades.
  
  I am in complete agreement with Gonsalves when he points out that poor health services are not a result of the Aids pandemic. This is clearly true in Kenya and many other developing countries, where poor health services date back to the early 1980s, when Aids existed but hadn't been identified and certainly hadn't even begun to wreak the havoc that came later. Aids didn't help these ailing health services and certainly decimated the health workforce, as well as the workforce as a whole. But in short, Aids was just another nail in the coffin for public services in general, not just health.
  
  I sympathize with Gonsalves to some extent, but when is money going to be spent on HIV prevention programmes that work, as opposed to programmes that promote purely political (including religious and pseudo-religious) ends? When is money going to be spent on the things that concern the most people, the many diseases and social problems that most people face? I needn't list the diseases or even the problems, Gonsalves would be more aware of them than most.
  
  Some of the people that Gonsalves may gloss over as the 'Aids backlash' wonder how HIV positive people will benefit from a one trick pony health programme that can give them ART but nothing much else, perhaps not even the food they need to be able to take the antiretroviral drugs. They wonder why HIV positive people with certain diseases are more worthy of treatment than those who are dying of the very same easily preventable and treatable diseases. They wonder why those who are at risk of becoming infected with HIV are not entitled to very much, but if they become infected, they may receive a great deal.
  
  But, more importantly, I think: what kind of HIV programmes can be implemented successfully in countries that have inadequate health services, along with poor standards of education, hardly any social services, very little infrastructure, lack of political leadership, governance, legal systems and levels of equality that would be required for these very expensive programmes to work? Even one trick ponies can't work without any solid foundation, as the Aids one trick pony amply demonstrates.

• Foundations for HIV Prevention

  Posted: December 4, 2009, 3:06 pm by Simon

  I rarely come across articles criticizing HIV prevention programmes for their lack of success, but apparently a contributor to the Social Aspects of HIV/AIDS Research Alliance conference this year draws attention to the fact that many 'prevention' interventions were implemented without ever being tried. He may have gone on to say that ones that were tried and found to be useless continue to attract most prevention funding, but I wasn't at the conference.
  
  Professor Geoff Setswe is right that HIV took some time to be recognised and had already infected many people before the most appropriate methods of preventing its spread had been investigated. But more than 25 years later, prevention programmes continue to be rolled out that are untested or that are tested but found to have little or no benefit. But no one is counting bodies when there is money to be made.
  
  It's easy to blame health and other social problems on the global economic crisis now, but that wasn't the problem just over a year ago. In Kenya, since the 1980s, one excuse after another has been blamed on the lack of progress in education, health and other areas. If it wasn't economic, it was oil or food or political or environmental and if it wasn't a crisis it was a disaster. The HIV pandemic itself is just one of those many 'disasters' or 'crises'.
  
  But poor health in Kenya is not a disaster, nor is it a short term crisis. Health services have been reduced in Kenya at least since the early 1980s, when the Moi government depended on loans from international financial institutions to prop up his form of democracy. These institutions funded him in return for his agreement to cut spending on social services and the public sector in general. It seems unlikely he or his colleagues (who overlap considerably with the present administration) were particularly worried about the idea of reducing public spending.
  
  Health service spending in Kenya is now minimal (as are spending on education and other social services). Health infrastructure needs to be built from the ground up, more or less. Most people don't go to hospitals or clinics and many who do fare worse than they would have if they had stayed at home. It's little wonder that HIV was transmitted rapidly in Kenya during the 1980s and continues to spread today, despite the hundreds of millions of dollars spent on the disease. There are still far more people being newly infected than receiving treatment, though a lot more money is spent on treatment.
  
  Fine, Professor Setswe, clinical trials are not always appropriate for testing social and behavioural interventions. But are clinical trials needed to show that starving people need food, that those suffering from malnutrition need proper nourishment, that poor people need support, that sick people, whatever they are suffering from, need medical attention, that those without adequate supplies of water die of thirst or water borne diseases? And the list goes on. Those who pigheadedly continue to talk about how difficult HIV is to prevent seem to be uninterested in what those in high HIV prevalence countries really suffer from.
  
  HIV is a real disease. Those suffering from it need treatment and care. Those who are in danger of becoming infected need to be protected from it or to be enabled to protect themselves from it. But most people will get up in the morning and have food, water, work, school fees, day to day health and many other things on their minds. And in all the time that HIV has been around, these other concerns have been largely deprived of attention and funding.
  
  Finally, mass male circumcision is mentioned as a possible HIV prevention method that is supported by a lot of evidence but has been held up for various reasons. Perhaps one of the reasons that circumcision has been held up is because health services in Kenya and other countries who were tricked by those same international financial institutions have been reduced to the extent that it is not possible to roll out any kind of mass health programme. Some of the HIV programmes that were rolled out failed because infrastructure, education, health and many other areas have been so underfunded for so long.
  
  The same article mentions a Dr Ntanganira, who says that "We know what works". But the article doesn't say what works, unfortunately.

• The Aids Industry Sure Knows How to Blow its Own Trumpet

  Posted: December 1, 2009, 10:07 pm by Simon

  Yesterday was World Aids Day again and in Kenya you couldn't miss the copious amounts of advertising, bunting, leafleting, t-shirts, sun visors and other paraphernalia of the industry. High and not so high officials were out in strength to collect their per diem, without which, presumably, nothing important could happen. There were the mobile testing clinics in areas that already have static testing clinics and millions and millions of condoms distributed.
  
  For all it's faults, the Aids industry has published some figures that certainly look good. Botswana, which has one of the worst HIV epidemics in the world, has the highest percentage in any African country of people on antiretroviral therapy (ART), the highest rates of HIV testing and the highest number of women on ART to prevent mother to child transmission (PMTCT). They also have the third highest percentage of children on ART.
  
  Over several decades, the campaigns to recognise the rights of HIV positive people to receive treatment have been successful in a lot of countries. In many developing countries, a sizable percentage of HIV positive people in need of treatment are on treatment. In the West, very few babies born to HIV positive mothers are themselves HIV positive. Indeed, the percentage of HIV positive babies born to HIV positive mothers is declining in a number of developing countries too and should be relatively low by now in a country like Botswana, where such a high percentage of HIV positive mothers are receiving PMTCT.
  
  But rights seem to be most commonly recognised for those who are already infected with HIV. If you read various developing country HIV strategic plans (which are curiously similar, despite the epidemics being very different in quality), you will notice that the word 'rights' is rarely used except in relation to HIV positive people, mainly in relation to access to treatment. The rights of those who are not yet HIV positive, and that's most people, are rarely mentioned. Yet they have a right to the things that will ensure that they remain HIV negative.
  
  Of course, it is hard to quantify the effects of the various HIV prevention programmes that have been rolled out in Kenya and other African countryies. Most of them were run by wealthy organisations who could afford the 'research' and publicity that would make them look very successful. The reality is that very little is known about preventing HIV and, beneath the hype, few programmes have been truly successful.
  
  I would be the first one to admit that the very idea of cutting HIV transmission is fraught with difficulties. Many things have been tried, some of them perhaps even well thought out. But in the end, there is very little money to be made out of prevention and therefore very little money put into it. Condom distribution is an exception, but where there is little or no health or science education, let alone sexual and reproductive health education, condoms haven't really taken off that well. You may have heard otherwise but there are good commercial reasons for that.
  
  The problem with the majority of the prevention programmes that have received some of the relatively small amount of money that is available for HIV prevention is abstinence. Most programmes relied on the idea that if people would just abstain from sex, they would not be likely to be infected. The more liberal advocated abstinence until marriage, until it was noticed that more and more people are becoming infected by their spouse. But various programmes were cobbled together that, one way or another, advocated abstinence or what amounts to abstinence. People didn't abstain and most of them won't. This is not something peculiar about developing countries. Abstinence campaigns have failed where ever they have been tried.
  
  The reason I mention the rights of people who are HIV negative is that many of them will, sooner or later, become infected with HIV because one or several of their rights are presently being denied. People, whether adults, children, male or female, have a right to health and a right to treatment when they are sick. Yet more people in Kenya and other developing countries are dying of easily treatable and curable diseases than are dying of Aids.
  
  Children have a right to a decent education and part of that should include levels of health and science education that should give them the prerequisites to attain enough understanding of sex, sexuality and reproductive health to avoid becoming infected with HIV or other sexually transmitted diseases and to avoid unplanned pregnancies. In a word, people need education to lead healthy lives.
  
  People have a right to a decent standard of living for themselves and their children, they have a right to adequate food and nutrition, they have a right to good standards of governance and security, water, sanitation, infrastructure and many other things. They have a right to a legal system that protects them from harm and persecution and the like. Women need to be given the same rights as men, in the workplace, in the economy, in education, in health and everywhere else. Men who have sex with men, intravenous drug users and commercial sex workers need their rights protected.
  
  It is the denial of the sorts of rights mentioned above, along with various other rights, that leaves people vulnerable to becoming infected with HIV and suffering many other serious consequences. People in developing countries who are suffering from HIV now, and those who have died of it, were likely denied one or several of their rights. HIV is not transmitted in isolation from people's circumstances, from the conditions in which they live and work.
  
  Those who are HIV positive and those who are HIV negative are equally entitled to their rights, though skewed funding for Aids would suggest that this is not the case. In order to avoid transmitting HIV to others and in order to remain HIV negative, everybody's rights need to be protected. In short, everyone is entitled to these rights and without them, the treatment and care programmes for people who are HIV positive will be, to a large extent, in vain; the half hearted prevention efforts will also be in vain.
  
  Prevention has proved to be a slippery fish. But treatment and care for one disease in isolation from all the other things people can and do suffer from has also been less successful than it should have been. There is little point in treating one incurable disease and ignoring the many others that are more easily treatable and often even curable. But that is what's happening. The Aids industry is just too rich and powerful to allow people to know that.

• 'Religiosity' and Levels of Social Capital

  Posted: November 30, 2009, 12:39 am by Simon

  The work continues with Ribbon of Hope Self Help Group, Nakuru, in Kenya's Rift Valley. We have ongoing projects producing basic foods such as vegetables and staples, dairy cattle and hens, etc. And we are still hoping to spread the word about ways of saving money by using solar cookers and home made fuel briquettes for cooking and various other techniques. Any project that costs very little or nothing will be considered as long as it is appropriate for people in this area and as long as it is sustainable and not destructive or damaging in any way.
  
  As usual, some people are cooperative and hard working, otherwise, there would be no point in an organisation such as Ribbon of Hope. But sometimes it seems as if there are as many obstructive people as there are constructive people and it can be hard not to dwell on them. Especially when they so often win out and destroy projects that would have worked well without their interference. Today, we had the experience of trying to find out why some people abandoned their basic accounting and record keeping several months ago and now seem both unable and unwilling to say how they have been running their organisation.
  
  It would be unreasonable to expect everyone to be equally successful in their endeavours and it is natural for some people to get involved initially, only to step back later and contribute less than before. But, much though I'd like to think that there are more cooperative than destructive people here, the evidence suggests that this is not true. I'm sure there are all sorts of possible explanations and I would be the first to admit that the people we work with live under all sorts of stresses and pressures that can make them a bit desperate. But I'm not going to make excuses for some of the things I've seen and heard about. I'll just hope that in the long run there are more positives than negatives and that Ribbon of Hope manages to attract serious contributors rather than time and resource wasting people.
  
  There is a very interesting 'index' called The Legatum Prosperity Index, which aims to look at prosperity beyond the one dimensional Gross Domestic Product (GDP) favoured by so many economic analyses. The index looks at various economic figures, politics and governance, education, health, security, personal freedom and social capital. The whole index seems skewed by what are almost exclusively Western values but it's still an interesting exercise and their report is well worth the read.
  
  Kenya doesn't come out very well, scoring 95 overall out of 104 countries for which there was adequate data available. This is not to say that Kenya's data is particularly reliable but let's give it the benefit of the doubt. The country receives a pretty low score for almost all the various indexes and rankings available. Economically, the country is weak in many ways and is particularly dependent on raw materials. Education, health, governance, personal freedom and security rankings are very poor. Surprisingly, the country is said to have well developed democratic institutions.
  
  But the real shocker for me is that the country is ranked 25th for its level of social capital; 'most Kenyans find others to be reliable and some actively volunteer or help strangers'. Sadly, some people who 'volunteer' only do so for what they can get out of it. Apparently Kenya's social capital score is 'boosted by exceptionally high levels of religiosity'. Well, that's certainly no surprise. But many of the people who profess the loudest to be Christian, Saved, Born Again or whatever else are the ones who never miss an opportunity to get something by deceit.
  
  I think this element of the Prosperity Index begs the question about whether high levels of religiosity is an indication that Kenya is strong on social capital. The police and other officials who require a standard bribe in order to do what is just their job are often as ostentatiously religious as anyone else. An official who tried to get a 50 dollar bribe out of me asked me to pray for him when he found I wasn't going to pay. The people who dress up for church on Sundays overlap with the mob that crowded around a young homeless boy to beat him for some offence, real or imagined. This sort of mob rule, usually aimed at very vulnerable people, such as elderly people branded as 'witches' or homeless people branded as thieves, is very common. Some of the 'volunteers' I have met never miss an opportunity to mention their love for Jesus but nor do they miss an opportunity to get something that is intended for sick and dying people.
  
  This is not an attempt to bash the 'religious' people of Kenya or of any other country, just a question about what kind of connection there is between 'high levels of religiosity' and high levels of social capital. Reluctant as I am to come to this conclusion, I would say that social capital is one of the things that Kenya is most sorely lacking in. And this lack of social capital has had, and continues to have, a profound influence on high levels of HIV, sexually transmitted infections (STI), unplanned pregnancies, stigma, discrimination and probably many other problems.

• Superweeds: What Doesn't Kill Them Makes Them Stronger

  Posted: November 29, 2009, 7:04 pm by Simon

  One of the big promises of the industry that produces genetically engineered (GE) crops is that they will allow farmers to use less pesticide, thereby saving money and reducing negative impacts on the environment. But a recent paper shows that these claims don't stand up to scrutiny. On the contrary, pesticide use has increased almost every year in the thirteen years that GE crops have been planted on a large scale in the US.
  
  Crops such as cotton, corn and soybean are genetically engineered in order to withstand a particular type of pesticide. That pesticide is sprayed over a large area and kills everything but the crop. That's the theory, anyhow. So the industry has spent a lot of money trying to rubbish the claims that eventually weeds would evolve that would be resistant to the glyphosate herbicide that needs to be used in increasing amounts on GE crops; these have been dubbed 'superweeds'. But such weeds have evolved and they keep evolving to resist higher levels of glyphosate and anything else farmers try to do to keep them under control.
  
  This glyphosate is a pollutant that degrades land and contaminates water. Its serious effects on the environment, on conventional agriculture and on animals, domestic and wild, have been demonstrated many times but they have also been shown to cause health problems in humans. Reproductive, birth and neurological problems have been linked with exposure to pesticides.
  
  Those using GE crops are not permitted to collect seeds to plant the following year and are compelled to buy seeds every year from the GE industry, in addition to the pesticides and the increasing amounts of herbicide. But farmers who try to buy conventional corn, soybean and cotton seeds find that there are few stocks available. Almost all these important crops have been taken over or contaminated by GE versions in the US.
  
  And this industry wants us to believe that GE crops are the future for developing countries? Producers of GE crops in the US now have to spend so much money controlling resistant weeds that it is eating into their profits. Coupled with the costs of pesticides, it won't be long before there will be no profit at all. And the industry's claims about the increased yields from GE crops have never been demonstrated either. Yields are affected by resistant weed infestations, of course, but the yields have been no better than those of conventional crops. Sometimes they have been a lot lower.
  
  In developing countries, where conditions are far from ideal, the chances of farmers even getting normal yields from GE crops are slim. And as the costs go up farmers will be unable to continue and will be forced to try to return to conventional crops. But their land and the land of those around them will, by then, be contaminated, as will seed crops. Their land, and even land close by that never bought into GE crops, will continue to produce weeds that are resistant to pesticides and the crops will be contaminated with GE strains for many years, if not decades.
  
  It's ironic that this supposedly great technological achievement has now resulted in US farmers having to employ people to pull up weeds by hand. But this will not be an option for people in developing countries. They will not be able to withstand the pressures of increasing costs along with falling yields and GE crops will be a disaster for them, even more so than it is for industrialised countries. Monsanto and Syngenta are the main offenders mentioned in this report, names that will be familiar to those who have followed the GE industry to date. Their plan is to produce more pesticide and to produce stronger versions. That should help a lot.

• Self Destructiveness Seems Like a Strange Quality in a Church

  Posted: November 27, 2009, 1:06 am by Simon

  I've had time to read UNAIDS's 2009 HIV Epidemic Update and it's interesting, but perplexing in many ways. Take, for example, the issue of unprotected sex with multiple partners. As a result of research into different modes of transmission and their relative importance in different countries, it was found that Kenya has a particular problem with people having unprotected sex with several different partners.
  
  This didn't come as a big shock, of course. Many people, all over the world, have unprotected sex with several different partners. But the risk of transmitting or being infected with HIV is much higher in a country with high prevalence of HIV and certain other sexually transmitted infections (STI). And Kenya is such a country, with 7-8% HIV prevalence, high prevalence of STIs known to make one more susceptible to transmitting and contracting HIV (such as herpes simplex virus), very poor education and health services and an attitude towards condom use that is, I suspect, strongly influenced by conservative religion and politics.
  
  The shocking thing is how many people are willing to take such risks with their sexual partners while refusing to use condoms, coupled with the fact that tens if not hundreds of millions of dollars have been spent on HIV prevention campaigns that advocate the use of condoms. A recent campaign by the extremely wealthy, powerful and conservative Population Services International (PSI) aims at stopping relationships on the side or multiple relationships. The campaign mentions condoms too but concentrates on stopping the relationships.
  
  The trouble is that after many years of some parties campaigning for safer sex, others have been campaigning for no sex at all or no sex except inside marriage. The volume of this sort of campaigning is high and usually advocates against the use of condoms or suggests condom use only in difficult circumstances (such as where one's partner is already infected with HIV). Aside from the fact that in Kenya, Uganda and other countries, the chances of becoming infected by one's marital partner is higher than becoming infected by a casual partner, many people are not married, are no longer married or have not, as yet, been able to get married. So lecturing them about abstaining till marriage can be a rather pointless exercise.
  
  One of the apparent results of all these campaigns that have a pseudo-moral political and religious agenda is that people have internalised the message about not using condoms but they haven't given up having sex with a number of different people. Many of the people who engage in multiple partnerships are married, so they are in danger of infecting their partner or being infected by their partner. And yet the religious and political zealots keep ranting on about condoms and how they are not the solution.
  
  The Catholic pope is quite right when he says that HIV cannot be overcome by relying exclusively or primarily on the distribution of condoms. They need to be used, all the time, and properly in order to reduce the transmission of HIV. He may also be right about the importance of conjugal fidelity, but conjugal fidelity appears to be rather rare, perhaps more so among those married in the Catholic church than in many others. As for sexual abstinence, it appears to be rare in the Catholic church and is not even a foregone conclusion among those who profess to have taken a vow of chastity.
  
  If we lived in the sort of world the pope is talking about, where everyone did only what they were supposed to do with regard to sexual behaviour, there would be no need for condoms or many of the other things that he and his ilk object to so strongly. But then, nor would there be HIV or other sexually transmitted infections. Maybe people shouldn't have sex except within marriage and for the purpose of procreation, according to some moral code. But people have sex, defecate, eat, drink, sleep and play.
  
  According to the moral code of some people, having sex or exercising many other forms of human behaviour are not, in themselves, moral or immoral. Which is not to say it is not wrong to have sex with one person when you are in a relationship with someone who thinks that they are your only partner, for example. But the pope sees having sex outside the strict bounds of Catholic teaching as absolutely wrong. And using a condom to avoid an unplanned pregnancy or to protect oneself from HIV or any other STI is also wrong. Yet, in a world where people only had sex within those strict bounds, it would seem strange to even have to make a pronouncement about contraception.
  
  Maybe the pope will keep going on about abstinence until marriage and the evils of contraception. If he does, all the worse for the Catholics who choose to listen to him. And I'm talking about the Catholics who live in this world, in Africa in particular. Because a lot of them don't seem willing to take all of his advice, preferring to select the bits they like and leaving out the bits they don't like. The pope is surprisingly influential and as a result of his influence, HIV continues to spread rapidly in Kenya and other countries. It infects innocent people, through various means, young and old people, religious and non-religious people and especially people who have sex. And that's most people, as far as I know.

• Celebrate World Aids Day By Dismantling UNAIDS

  Posted: November 25, 2009, 1:40 am by Simon

  UNAIDS has never been shy about producing long and colourful documents about HIV/Aids and in the last couple of days they have released two; the Outlook Report 2010 takes a look back and compares the HIV pandemic of today with that of the mid 1990s; the second document is the yearly AIDS Epidemic Update, which I haven't had the strength to read yet.
  
  The Outlook Report, like many of the various articles commenting on one or other of the reports, sometimes takes a rosy view of how the international community and the AIDS community have dealt with the pandemic. In the sense that things have moved on, and finding that you are HIV positive no longer has the significance it once had, they are right. We have come a long way in treating what was once an untreatable illness that would lead to a certain and very unpleasant death.
  
  But the worrying thing is how the Outlook Report, like many UNAIDS and other reports in the past, talk about the importance of HIV prevention. It has been obvious that HIV prevention is so important that the amount of HIV money spent on it needs to be increased considerably. But the amount has gone down and the prevention programmes that get most of the money have little or no effect and have never had much effect.
  
  Defenders of the disproportionate amount spent on treatment and care of HIV positive people are fond of pointing out that this shouldn't be an either/or debate. True, it shouldn't, both treatment and care on the one hand and prevention on the other should receive more funding than they presently receive and the funding should be more equitably divided. Treatment and care contribute a certain amount to HIV prevention but they are not the same as prevention and they will never contribute more than a certain amount. That's why there are five new infections for every two people put on antiretroviral treatment.
  
  The report goes on to allude to the work that has been done to show that prevention programmes, such as they are, fail to target those most at risk in populations. Most of the money is spent on populations as a whole and very little on, for example, men who have sex with men, commercial sex workers, intravenous drug users, prison populations, fishing communities around Lake Victoria, mining communities and various others, who are very often at risk because of their occupation or lifestyle.
  
  The report seems aware that HIV transmission is not primarily about individual behaviour and that there are different kinds of HIV epidemic in different countries and that some people are more at risk than others. It even seems cognizant of the fact that it is the circumstances in which people live that makes them more or less likely to become infected with HIV. But it hasn't made the leap to realizing that in some countries, especially developing countries, most people live in such circumstances. Not everyone is at equal risk of becoming infected but most people live in conditions that mean they are already at high risk of becoming infected or that they will one day be at high risk of becoming infected.
  
  That makes it sound like HIV prevention is unlikely to ever have much success, but the opposite is true. Treatment and care have been to a large extent dominated by commercial interests. Products, processes and services have been developed, many by those who are in a position to profit from them. But prevention has been dominated by the party-political and pseudo-moral debates of political and religious leaders. Their aim is to further their own agenda, which are far from being concerned about millions of people becoming sick and dying.
  
  Raising awareness about HIV, sexually transmitted infections, sexual health, reproductive health and anything else is good and will go a long way towards protecting people from a number of dangers. But good overall health, healthcare, nutrition, food security, education, infrastructure and many other benefits would give people the maximum protection, not just from HIV, but from other illnesses and ills.
  
  And this brings us to another often repeated pronouncement made by various senior HIV/Aids experts. They like to deny that HIV funding has distorted health and development funding and disrupted more general programmes that aimed to benefit societies as a whole. HIV/Aids funding is not too high, it needs to be higher. But there needs to be a similar move to spend the money more equitably. HIV will not be eradicated without health services, education and other social services, no matter how much money is thrown at it.
  
  So, spending money on all other areas of development will also contribute to the fight against HIV/Aids. But continuing to spend disproportionate amounts on HIV/Aids will not benefit the many other development issues that have been hijacked by numerous commercial and political interests. HIV treatment and care is just one of many health issues that the world faces but HIV prevention is about health, not disease. Therefore it has far broader significance and affects far more people than one single disease. In fact, it affects everyone.
  
  Ultimately a self-serving and very expensive organisation, UNAIDS needs to be reabsorbed back into the overall agenda of public health, or some agenda that encompasses the health of everyone, not the sickness of a few. This is not to say that HIV positive people should not be entitled to treatment or care. Rather, they and all other sick people should be entitled to treatment and care. But people who are not sick should be enabled to stay that way. UNAIDS is good at diverting a lot of money for people once they are HIV positive but this is denying the right of HIV negative people to stay that way.

• Stop Thief, There's More!

  Posted: November 24, 2009, 12:43 am by Simon

  At present, Tanzania is Africa's third largest producer of gold but may be set to become the largest. Gold mines towards the North of the country, formerly mined by Tanzanian artisanal miners, have for a long time been making a handful of foreign mining companies very rich. But recently, gold that is still being mined by Tanzanian artisanal miners in the South of the country has attracted the interest of a handful of foreign mining companies, who can expect this to make them very rich.
  
  It's interesting how this is a 'discovery' because, as far as Tanzanian artisanal miners are concerned, they discovered the gold. It's their livelihood and not a very good one at that. But it's better than the nothing they will be left with once the big gold extractors move in. Typically, big gold miners employ a few thousand people, compared to the hundreds of thousands that will be displaced.
  
  Time and time again, such gold 'discoveries' have been trumpeted as great news for Tanzania (or Kenya or Uganda or where ever). But Tanzanians should be well aware of how much they have profited from their vast mineral resources. Or rather, they should be aware that they have been systematically impoverished because of their vast mineral resources. Uganda has had a recent opportunity to find out how gold 'discoveries' affect ordinary people and even Kenya will have an opportunity soon, as gold has also been 'discovered' in the Kenyan Mara region.
  
  The American company buying a large but very cheap interest in these recently 'discovered' gold deposits will be given all the usual benefits of non-existent oversight, few taxes, if any, minute royalty payments, most of which they will probably renege on, somehow, and the freedom to exploit Tanzania's rather loose employment and other human rights protections. In return, Tanzania will experience a large increase in unemployment and a loss of resources that will never be compensated for; Tanzania being, already, one of the poorest countries in the world.
  
  Oddly enough, there is also a recent article about safety in small mines in Tanzania. This issue is not often reported on, although the issue of safety in large mines is even less reported on. Not because large mining interests have a great safety record, they just spend more on publicity. The secrecy that surrounds big mining in Tanzania and other developing countries doesn't come cheap. Only the employees do that. It's true that safety in smaller mines has been neglected by the government for a long time but that's no excuse for giving the Americans, the South Africans and the Canadians carte blanche to plunder the country's gold. I'm just assuming the appearance of these two articles at around the same time is not a coincidence.
  
  To be fair, many mining employees earn better than average wages, though nothing to write home about. But this doesn't make up for the fact that for every one employed there could have been ten or twenty put out of a job. Nor does it excuse the mind boggling, tax free salaries that the non-Tanzanian employees get (which are usually kept secret). And it certainly doesn't make up for the fact that the country is highly dependent on foreign aid, not because it is poor, but because everything it has of value is stolen with the connivance of senior statespeople and businesspeople, Tanzanian and non-Tanzanian alike.
  
  Critics of large scale theft of gold from developing countries recommend that donor countries, international institutions and the like champion the interests of countries such as Tanzania. Well, the World Bank, the International Monetary Fund (IMF), America, Britain, Canada and many others who could be championing the interests of development are too busy fighting for the other side. The lack of regulation in Tanzania and other developing countries mainly emanates from the so-called international institutions, whose focus always appears rather national.
  
  And America, Britain and Canada may well be big donors. But the amount of money they give in aid donations is very small compared to the amount they pilfer. I don't think it's reasonable to expect thieves to just put their hands up, so it's up to the Tanzanian people, through their government, to fight this one out. It remains to be seen whether they will continue to hand over their future or whether they will demand a more equitable way of managing their resources. So far they have behaved like a person confronted by someone raping their wife and offering the rapist their mothers and children.

• Sex Workers Need Support, Not Condemnation

  Posted: November 19, 2009, 12:50 am by Simon

  Malawi's aim to give sex workers an alternative to sex work is a step in the right direction and it's certainly better than the finger wagging and moralising that passes for policy in Kenya and other African countries. Sex workers will be offered low-interest loans to start small businesses and in return they will be expected to give up sex work.
  
  But a serious problem with this approach on its own is that most small businesses fail. There is a limit to the proportion of a population that can depend on small businesses for their income. And if there are too many small businesses, even the ones that don't fail do badly.
  
  Besides, it's not just sex workers and currently unemployed people that want access to microcredit, especially to set up small businesses. Many people are just about getting by, earning tiny amounts of money some of the time and turning up to work every day in the hope of earning enough to pay the next day's fare to work.
  
  A lot of people you talk to, especially in professions such as beauty therapy and hairdressing, for example, say that their ambition is to either make or borrow enough money to set up a small business, a salon or something that is more dependable than an employer who may not even pay up the pittance that is owed.
  
  And when people have access to credit, too many of them seem to go for the very businesses that have already flooded the market. Selling second hand clothes is something of a euphemism among sex workers because there are so many people doing it, a lot have to resort to commercial sex work to make enough to survive. Many sex workers that I have met are trained in hairdressing, beauty therapy or hotel and catering in one of the numerous colleges (or rather dubious quality) that you see in even the smallest towns.
  
  Commercial sex workers, subsistence workers, homeless people, indeed, any poor or vulnerable people, face a number of problems. Not having enough money to survive is just one problem in what can be a long chain of circumstances. This substantial group of people is not exclusively female, but it is predominantly female.
  
  Girls are less likely to go to school, less likely to have adequate school attendance, less likely to complete primary education, less likely to go on to or complete secondary education and in the end, they are unlikely to have enough education to compete for the small number of jobs that are open to females. Even those who do well at school are unlikely to get a job that pays a reasonable income and this is particularly true of females.
  
  Many girls with too little education are probably poor and even if their family has some money, it is more likely to be spent on boys. So if a girl or woman decides to get some training or vocational education, finding enough money is one of the biggest problems. Commercial sex work is far better paid than any of the other options available. It would be interesting to know how many girls and women raised the money to go to hairdressing or beauty therapy school through sex work only to end up supplementing the meagre income they subsequently earn by returning to sex work.
  
  There are two points that need to be highlighted here: firstly, older women, those in their thirties and forties, are in the most urgent need of finding alternatives to sex work. For them, sex work doesn't have the many dangers that it has for younger women. Older women have to compete with younger women by resorting to more risky sexual practices and by working for less, which means they have to find more clients. But for many older women, it's just not possible for them to get clients any more. Worse still, the sex industry is currently flooded with sex workers.
  
  The second point is that commercial sex workers themselves need protection. No amount of grant money for small businesses is going to result in sex work disappearing off the face of the earth. On the contrary, if the process of enticing women away from sex work is successful, the price of commercial sex will increase. Unless governments can also banish poverty and unemployment, sex work will become an even more attractive option because the price it attracts will go up.
  
  In Kenya, sex work itself is not against the law. Living on immoral earnings is against the law and some of the people who make most out of the earnings of sex workers include the police. They persecute sex workers and get a steady income from them and because police have so much power, most sex workers are too scared to be arrested or changed. They pay up, thinking that the alternative could be a lot worse.
  
  And they are right. Sex workers face regular threats, such as beatings, arrests, rape and persecution. Although this is not always at the hands of the police, sex workers are not protected by the police or anyone else. As the aim of enticing sex workers away from commercial sex is partly to reduce the transmission of HIV, they Malawian government will also need to take measures to protect the rights of women, whether they are involved in sex work or not.
  
  In Kenya, good education about reproductive, sexual health and even health in general are rare, especially for those who don't even receive a decent level of education of any kind. Health services, including reproductive and sexual health are under funded and effectively unavailable to most people, including those who are most in need.
  
  Malawi and other countries with high HIV prevalence need to prioritize business training, low-interest loans and alternative sources of income for women who want to give up sex work, who are likely to be able to leave sex work and who will be able to make a better living by leaving sex work. Eradicating commercial sex completely will take a lot longer.
  
  Those who will continue to have to resort to commercial sex work need the protection of the law, they need to be protected from the excesses of the police and other officials and they need to be protected from the many people and bodies who treat them like criminals when they are more likely to be victims of crime and corruption. If sex workers have access to social and health services and their rights are protected, this will go a long way towards reducing the spread of HIV.
  
  Moralizing and finger wagging will continue to have little impact. The Kenyan plan to do a survey of commercial sex workers and other vulnerable people will be futile if people have no protection from the sort of prejudice and discrimination that has been whipped up by the moralizers and finger waggers. The current constitution makes no plans to provide such protection, so such changes are still a long way off.
  
  The Malawian government is to be applauded but they and other governments need to deal with the human rights issues that are involved in commercial sex work, such as poverty, vulnerability, corruption, prejudice and extreme violence. It’s not commercial sex work per se that results in high rates of HIV transmission. It’s the living and working conditions faced by those who have to resort to commercial sex work.

• When Water is Scarce, Develop Hydroelectric Power Installations

  Posted: November 17, 2009, 9:55 pm by Simon

  It hardly comes as a surprise, but electricity prices in Kenya are increasing because of unreliable rainfall patterns. Unwisely, Kenya depends to a large extent on hydroelectric power. So when there is a prolonged drought power is in short supply. Expensive, inefficient and highly polluting emergency power is generated using fossil fuels to make up some of the shortfall.
  
  Hydroelectric dams have been built in developing countries for many decades. This may have seemed like a good idea a long time ago, although it is more likely to have appealed to the Western engineering companies and others who reaped substantial profits from the building of these installations. But the multiple disadvantages of hydroelectric power are now widely recognized, disadvantages including inefficiency, expense and irreversible environmental damage.
  
  For the moment, I'll leave aside the (albeit important) question of who is profiting from the production of emergency power over such a long period of time, which makes it seem less of an emergency and more like plain stupidity. But the cost increases for electricity, said to be about 60% over the past six months, are being passed on to hard pressed consumers. This is particularly galling in a country where only a minority of households have an electricity supply.
  
  Already, well over half of Kenya's power is, ostensibly, generated by hydroelectric installations. This suggests a surprising overdependence in a country that has several viable alternatives. But there are now plans to build a new dam in Coastal Province (where most of the country's hydroelectric power is produced) to provide domestic water supplies, irrigation and electricity. Tens of millions of dollars will be spent on something that is unlikely to work very well and will have serious adverse impacts. The money is coming from the Chinese government and, while water infrastructure is badly needed, another huge dam hardly seems like the best approach given the history of such projects in developing countries.
  
  Kenya could produce enough electricity for all its citizens using sustainable and relatively cheap sources, such as wind, solar and geothermal. There are good reasons for keeping water supply and irrigation separate from electricity generation because hydroelectric power is not just inadvisable, it's also quite unnecessary in Kenya. Touting the project as being a solution to water shortages doesn't explain why such a large amount of money is being spent on it. We are not told what the Chinese government is getting in return. Oil and other natural resources, probably.

• Deciding Who Gets to Eat and Who Gets to Starve

  Posted: November 15, 2009, 8:37 pm by Simon

  A curious feature of some of the big famines in history is that the countries experiencing the famine were not necessarily short of food. Likely as not, the majority of people were very poor and did not have the money to buy food, but food was being produced and exported.
  
  Many millions of people in a number of developing countries currently face food shortages, malnutrition and probably famine at a time when the world is producing record crops. The Food and Agriculture Organisation (FAO) estimates that 2008 saw the highest recorded cereal crop production figure ever. It is predicted that 2009 will see the second highest figure.
  
  Wikipedia is a great source of information but their bald statement that "[f]amine is caused by a human overpopulation relative to the available food supply" is in need of qualification. It is estimated that as many as 10 million Kenyans face serious food shortages, but this is not clearly because the country is overpopulated. There are several other significant pressures on food production and access to food.
  
  For example, many people are extremely poor, have always been poor and have little prospect of ever becoming less poor. Food prices have been driven up over the past few years by market speculation and by the use of productive land for growing biofuels. So poorer people, who could barely afford enough food before these trends began, are now facing starvation.
  
  Other pressures include droughts, often followed by serious floods, which result in poor harvests and destroy large tracts of arable land. There was also widespread unrest in Kenya in 2008 and people abandoned their land. A number of these internally displaced persons (IDP; the Kenyan government is not keen on releasing figures for just how many are still displaced) now have little means to feed themselves and no chance of returning to where they came from. And the majority of people have only a tenuous hold on land, renting it from unscrupulous landlords, who can treat tenants as they wish and sell their land at the drop of a hat.
  
  In addition to growing biofuels in Kenya, there are other trends that result in less land being used for affordable food. Land is bought up by natural resource prospectors, such as those in search of oil around Isiolo and those in search of gold in the Mara. This land will not be used to benefit any Kenyans and certainly won't be used to grow food. And much of Kenya's land is used for non food crops or for food products intended for export, such as coffee, tea, flowers, fruit and vegetables. Controversially, a lot of land comprises national parklands, preserved for use by those who can afford to visit it. Most can't.
  
  Despite all these pressures, there is a lot of food being produced in Kenya for export and a lot of arable land available for food production. The reasons people face food shortages and poor nutrition are the same as they have always been: widespread poverty and increasing levels of impoverishment along with rising food prices that mean the poorest will lose out.
  
  When things get really bad and people are dying of starvation, maybe other countries will start shipping in relief food, but this will not improve food security in Kenya. Food security refers to access to food, as well as its production. As with other countries that experienced famines throughout history, resilience will continue to be low, there will be widespread disease, many people will have abandoned rural areas and moved to cities; there will be no remaining seed to grow the next season's crops, no fertilizer, no chance of resisting whatever new pressures arise.
  
  The more I read about famine, the more it seems like a process whereby the rich systematically deny food to the poor in order to increase their profits. But that couldn't be correct, could it?

• Did Someone Say 'Final Solution'?

  Posted: November 14, 2009, 2:00 am by Simon

  I have read various articles about the proposal to carry out a 'gay census' in Kenya. But none of them shed any light on why the Kenyan government should suddenly be interested in identifying some of those most at risk of being infected with and of transmitting HIV. The best way to make gay people feel they are not being singled out is to make HIV and sexual health services available to all, without prejudice.
  
  In fact, the proposal is not just to single out men who have sex with men (MSM). The proposal also aims to identify commercial sex workers (CSW) and intravenous drug users (IDU). That's hardly going to make members of these groups feel any better. They all have several things in common: they are all doing something considered to be illegal. They are also the subject of prejudice, discrimination and condemnation by political and religious leaders.
  
  Men who have sex with men, commercial sex workers and intravenous drug users need access to sexual health services. They also need access to more general health services, the protection of the law from persecution by members of the public and by the police. But programmes involving what is often referred to as 'harm reduction' are not popular in Kenya. The possibility of decriminalising sex between people of the same gender, commercial sex work or even intravenous drug use is not even being discussed right now.
  
  So what strikes me as most suspicious about the call to carry out this gay census, or census of people who are most at risk from HIV, is that it is being funded by the President's Emergency Plan for Aids Relief (PEPFAR). PEPFAR has always been vehemently opposed to harm reduction measures, such as the use of condoms, needle exchange programmes and other activities that are known to help reduce the spread of HIV and other diseases.
  
  Why would PEPFAR now be interested in funding this particular approach? Are we supposed to believe that the initiative has changed to such an extent that harm reduction is no longer refused funding? And are we also supposed to believe that the Kenyan government has completely reconsidered its earlier views on gay sex, commercial sex work and intravenous drug use?
  
  I suspect the motives behind PEPFAR's decision to fund any kind of 'survey' of some of the most vulnerable people in the country. I suspect the Kenyan government's motives, too. I have heard rumours that a number of powerful people in the US are not completely unrelated to Uganda's current discussions of an effective pogrom against gay people. This is not the way to reduce HIV transmission and it will have numerous other human rights consequences.
  
  Unless many other things are in place that guarantee the safety of people affected by this proposed 'survey', and that will include people who don't actually fall into any of the targeted groups, the whole thing should be abandoned immediately.

• Tomorrow's Disasters Are Preventable Today

  Posted: November 13, 2009, 2:53 am by Simon

  I think most people, if they saw their child playing near a fire or in some other dangerous situation, would do something about it before an accident occurred. They wouldn't just watch and then shell out the money for hospital fees once an accident had occurred. But donor money is usually spent on clearing up after a disaster has hit.
  
  Many children (and quite a number of adults) in developing countries are severely burned because most cooking is done on open fires, close to the ground. Donor money is sometimes forthcoming for the expensive surgery and skin grafts required by people who have suffered burns. But it's not often you come across substantial projects to provide people with alternatives to cooking on open fires, using mainly wood or charcoal.
  
  Burning wood and charcoal accounts for a very large proportion of the carbon emissions from developing countries. Forests are fast disappearing and wood is getting more expensive and less viable as a fuel source. The use of wood and charcoal is part of a massive environemntal disaster. There are cheaper alternatives, such as solar cooking, biogas and the use of fuel briquettes made from combustible materials.
  
  There is a lot to be gained from not burning wood and charcoal. There are the environmental benefits and safety benefits to consider. Also, people in close proximity to wood and charcoal cookers suffer from respiratory problems, one of the top killers in developing countries. Alternative fuels are cheaper, even free. And their use can reduce the time and effort taken to collect wood and produce charcoal.
  
  But rather than see aid money go into proejcts that have these multiple advantages, we continue to direct it to big disasters. The children that suffer terrible burns, that we wish to see treated, shouldn't have to suffer these burns in the first place. The plastic and reconstructive surgeons should be concentrating on people who are not suffering from preventable injuries.
  
  Similarly, money for surgeons and health resources is spent on reconstructing the faces of children affected by noma, which affects children suffering from malnutrition. Food security and proper nutrition would prevent many other illnesses and health conditions, in addition to noma, and would also reduce deaths, especially among infants and young people. Those who don't die from illnesses arising from insufficient food and nutrition still suffer stunted growth and retarded mental development. These are all avoidable.
  
  The current debate about land grabbing in developing countries, where greedy multinationals are buying up huge tracts of land to grow food for rich countries, is an idle exercise if it does not go any way towards reducing this phenomenon substantially. By the time this land has been ravaged by industrial scale farming and contaminated by genetically modified organisms, it will be too late. What is the point knowing now what the consequences will be if we are not going to do anything about it?
  
  Much of the land being grabbed is destined for biofuel production. The ridiculousness of starving people producing crops to fuel the cars of well fed people, far away, seems to be lost on us. We, the people benefitting from the increasing impoverishment of the poor, may be willing to see our governments giving large sums of aid money to starving people in the future, but we don't seem to want to do anything to prevent the circumstances that will eventually leave people starving.
  
  Land grabbing, especially for biofuel production, results in food, water and other vital resources being exported from poor countries to rich countries. If we prevent the land grabbing now, we won't have to send aid money later to the disaster we are so busy creating.

• Widespread Environmental Contamination and Loss of Biodiversity Are 'Externalities' to the GM Industry

  Posted: November 9, 2009, 3:43 pm by Simon

  The Kenyan government has been persuaded that it can 'revive' the country's cotton industry by introducing genetically modified GM cotton varieties. The first thing that springs to mind is the principle reason for the death of cotton industries in Kenya and every other developing country in the world: subsidies for American cotton farmers. It is not possible for poor countries to produce cotton at a price that can compete with the heavily subsidized American cotton, which is why most country's cotton industries failed many years ago.
  
  Of course, these American subsidies are illegal and they are completely antithetical to the country's constant bleating about the importance of free trade. But double standards have never mattered to rich countries and they never will.
  
  There may well be theoretical benefits to GM organisms, such as cotton, it's hard to know. The GM industry has been pumping out inaccurate and misleading data on trials for so long that they probably don't even know what is true and what isn't by now, and probably don't care much, either.
  
  But the problems that will arise if farmers buy into the thirty pieces of GM silver are more obvious, for those who can be bothered about them. The GM producer in question, Monsanto, which has an unrivalled corporate social responsibility record, claims that farmers will save on pesticide costs because they have to spray less frequently. Unfortunately, they will be obliged to pay more for seeds, spray using expensive pesticides produced by Monsanto and the land they spray will be denuded of all species, from the microscopic up. Expensive Monsanto herbicides will do the same for any plant species.
  
  This is a mere externality to Monsanto and probably to the Kenyan government. The fact that the land and water surrounding land planted with this cotton will be contaminated, probably irreversibly, is also an externality and those promoting the introduction of GM cotton even have the cheek (or ignorance) to claim that it will have a positive impact on the environment and the health of those working on cotton plantations.
  
  In addition to the problem of having to buy seed every year from Monsanto, because it's not possible or even permissible to collect seed at the end of the season, it will be difficult for the farmers to get out of the grip of Monsanto, if and when they wish to. Their land and the land around will be contaminated with the GM cotton for generations and even these contaminated crops could be deemed to the be intellectual property of those generous people at Monsanto.
  
  Many of the claims put about by GM hawkers are yet to be backed up by evidence but even they make little effort now to deny that GM crops are unlikely to be of any benefit to small farmers. The vast majority of farmers in Kenya and other developing countries are subsistence farmers who aim to grow enough food to live on and sometimes grow some cash crops to supplement their income. Although various cash crops have long been foisted on small farmers, many have felt the sting of becoming locked into producing things like tea, sisal, coffee, sugar and biofuels, for example, only to find that yields and prices never match up to what they were promised.
  
  Small farmers who buy into GM crops need to ask themselves if they can afford to become locked into yet another non-food crop that will never be truly economical and may leave them worse off than before. Large scale farmers may not experience the same worries, but whole communities in Kenya and other countries need to consider what the potential effects of widespread contaminated land and water may be. They also need to consider the consequences of most of their food production being owned by a multinational that is not even bound by the country's laws.
  
  It's worthwhile for Kenyans to bear in mind that cotton industries in developing countries did not decline because of pests and other problems but because a more powerful country controls the market. This is not likely to change quickly and the Americans are not going to give up the level of control that they have cheated so hard to obtain. Similar remarks apply to other GM crops. GM is not a technology for the poor, it is a technology for the powerful, like many technologies. But of course, it's of less use to the powerful unless the poor believe that they too need GM technology.

• Lack of Sanitary Pads is a Threat to the Health of Kenya as a Whole

  Posted: November 8, 2009, 1:27 pm by Simon

  The hype about how brilliant the introduction of 'free' primary education has been in Kenya continues six years on but the reality is that most parents who couldn't afford primary education before 2003 still can't afford it. The hidden costs are endless and include levies for parent teacher associations, uniforms and overpriced books, equipment, 'extra' tuition, etc. A colleague recently pointed out to me that parents need to pay for their child's desk every year. There must be quite a surplus of desks in schools by now.
  
  While enrollment figures are high for state schools, they have dropped in many private schools and the figures for attendance and completion, even of primary school, are not so brilliant. Numbers of girls completing primary school and going on to secondary school are particularly poor. There are many reasons for girls not completing their education, including the belief that as girls will marry into another family, it is not economical to 'water ones neighbour's fields'.
  
  But a study in Uganda suggests that many girls are dropping out of school as soon as they start menstruating. Schools are not equipped to deal with girls once they start menstruating, apparently. Lack of separate sanitary facilities for girls, and even lack of water, mean that they will often stay at home, either for the duration of their period or even for good.
  
  The extremely high cost of sanitary pads mean that they are inaccessible to many girls. They have to use substitutes or stay at home. To put it in perspective, ten of the cheapest sanitary pads cost more than several days worth of the staple ground maize for a large family. The commonly advertised branded versions cost twice or three times as much and, because one or two of them are sometimes given out as promotional 'gifts', some people think they must always use this version to be really safe.
  
  As well as having to teach sex education without talking about sex, teachers are also in the position where they are usually not trained to include classes about menstruation, either. Teaching about the whole field of sex, sexuality, reproduction, sexual health and sanitation is often considered to lead to immoral behaviour in young people. This can be blamed on taboo or cultural considerations but in fact, it often has more to do with political and religious leadership and funding sources for sex education and education as a whole.
  
  In the end, large numbers of girls with little or no education means that large numbers of children will, in the future, also be brought up with little or no education, knowledge of sex or reproduction or even with the level of empowerment needed to change anything for the better. Continuing gender imbalances mean continuation of the status quo. That's a status quo where much of the population will never be able to attain a decent standard of living, while the more privileged continue to enjoy the great wealth that exists in Kenya (despite the best attempts of colonials, neo-colonials, multinationals and other assorted leeches).
  
  The introduction of 'free' primary education was a little like some of the other initiatives that only aim to tackle one or two headline indicators. (In fact, any of the millennium development goals (MDG) would be additional examples.) School fees were abolished but immediately replaced with costs that mean parents still have to pay de facto fees. There are still far too few teachers and classrooms in many areas to provide decent levels of education.
  
  When it comes to education relating to sex, reproduction, health, sanitation or anything like that, few teachers have been trained to provide these. And there is little to be gained from health and sanitation education when the health and sanitation facilities, even reliable supplies of clean water, are not available to the majority.
  
  Successive governments, along with those who dream up international 'initiatives' don't seem to have noticed that basic needs are basic for the very reason that, without any one of them, people's standard of living is compromised. Children who have little or no food for much of the time will have retarded growth and mental development, poor health and a short life. Lack of sanitary facilities reduce health but this also reduces access to education and the efficacy of education. Basic needs are connected to each other, so you can't just make a list and tick them off as you create an 'initiative' that relates to each one.

• HIV Treatment is Necessary, But Not Sufficient, For Prevention

  Posted: November 6, 2009, 2:29 pm by Simon

  Medicins Sans Frontieres (MSF) has published a report on reduced funding for HIV treatment, from the World Bank's Global Fund and the US Government's President's Emergency Fund for Aids Relief (PEPFAR) in particular. MSF have good reason to be worried.
  
  The pharmaceutical industry successfully lobbied governments and international institutions to pay huge amounts of money for antiretroviral (ARV) drugs that most of the people suffering from HIV/Aids would never be able to afford. In fact, the governments of countries with high rates of HIV/Aids would never be able to afford these drugs, either.
  
  Countries like Kenya have the option to produce generic versions of ARV drugs at a fraction of the price that is currently being paid. But most countries, including Kenya, have chosen not to exercise this right, preferring to enact laws that make it unlikely that the country can produce or even purchase such cheap generic versions. Good relations with the pharmaceutical industry seems to be more important to them than saving the lives of their citizens.
  
  MSF are right, huge ARV rollouts cannot now be stopped without endangering the lives of millions of people who are HIV positive and even people who are, as yet, HIV negative. But rather than arguing for the money to keep coming, in fast increasing amounts, they could concentrate on finding ways of reducing the cost of treatment so that it can continue and even expand.
  
  How much of the billions of dollars of aid money have been spent on building factories to produce drugs that people need in Kenya? I haven't heard of any. Most of the money has been spent in ways that don't go on to produce anything or increase the country's sustainability or self reliance. The funds have mostly been spent as if HIV is just an emergency.
  
  Well, it is something of an emergency, but there are underlying factors that are not part of an emergency. The country has a decaying health service, decaying education sector and a small and decaying infrastructure. People are poor, unhealthy, badly educated and unable to access vital services, such as clean water and proper sanitation. These are the things that face the majority of Kenyans every day, whether they are HIV positive or not.
  
  Money spent on drugs, regardless of the overall condition of health systems is, to a large extent, wasted. Many drugs go out of date before being distributed, they get to people unprepared to take them properly, they are taken by people who are dying of other, easily prevented and treated illnesses, etc. My argument is not that ARVs should not be purchased and distributed and prescribed; it is that there needs to be a proper, accessible health service for all this to happen.
  
  There is not a proper health infrastructure in Kenya, there hasn't been for a long time and increased HIV/Aids funding has not brought about a health infrastructure that serves people's needs. True, there are many clinics and institutions that were not here before HIV/Aids and wouldn't have even appeared. But these mostly deal with HIV/Aids, not other, basic health problems that people face.
  
  My argument is also directed at the emphasis on HIV/Aids treatment over prevention. MSF's Goemaere is right to object to the prevention/treatment 'dichotomy'. Of course treatment has a positive effect on prevention efforts. But it is not enough to try to treat our way out of the epidemic. This is clearly not working and much more needs to be done to prevent new infections. Otherwise, the aim to treat everyone who requires treatment becomes even less attainable and less sustainable that it is right now.
  
  People who are HIV positive need more than just drugs, or even treatment. There are a lot of threats to their health and welfare than HIV. They are dying because they are too far from the hospital, because the hospital is not up to the job of caring for them, because they are entitled to benefits they don't know about or that have been stolen by someone else, because they are poor and isolated and not considered important enough. But there just aren't the services needed to support chronically sick people and these will not just appear because the country is swamped by HIV/Aids (treatment) related institutions and programmes.
  
  Those who are HIV negative need to stay that way and this won't happen by rolling out ARVs, alone. They have needs that are far more important and urgent that the possibility that they may become infected by something that won't kill them for many years. Most won't live for very long anyway, for a huge variety of reasons that are not being addressed right now.
  
  Goemaere recognises the false dichotomy of treatment/prevention, but fails to see that increasing treatment while effectively ignoring prevention will not combat HIV/Aids in the long run. Assuming that HIV treatment will also prevent infections is not enough because it doesn't prevent enough infections and it never will. And treatment will never be as efficient as it should be if health, education, infrastructure and other social services continue to be ignored.

• Lomborg Preaching to the Converted, Again

  Posted: November 4, 2009, 1:16 am by Simon

  As we (Ribbon of Hope) go about, visiting our various clients in and around Nakuru, we see the many and fast changing problems that people here face. Some people get through these problems well enough, others don't. It's always hard to figure out if some make it through because they are better off than others or if they are better off because they are good at getting through problems or if there is a mixture of factors.
  
  The rains have come in some areas. This means that it is time to plant crops. If the right preparations have been made, the crops should grow and if the rains continue, there will be a good harvest. But now the rains are here, are people preparing to harvest rainwater in order to ensure they get through the next drought? Sadly, not many people harvest rainwater. This doesn't appear to be a government priority either. The government even talked about distributing cheap or free seeds and fertilizer but now, there appears to be a shortage of both seeds and fertilizer because, well, er, the government has bought up so much of them. They must have just forgotten to distribute them.
  
  In other areas, the rains have brought too much, too quickly, and have washed away fields, crops, roads, bridges, houses and anything else in their path. Were provisions made for flooding? It appears not. Roads that have been swept away in Coast Province were not flood proof. Floods occur with amazing regularity but flood proofing is an optional extra.
  
  There have been power cuts again recently, despite promises that these would become a thing of the past. The government, it has been claimed, have now got the extra oil they need to make up for the shortfalls in power. Perhaps they will sort it out before the next fuel shortage. But fuel shortages, like floods, droughts, famines and other disasters keep occurring and will continue to occur. They need to be planned for. Last year, politicians were talking knowingly about planning for such disasters but there is little evidence that they have achieved anything yet.
  
  The antics of the 'environmentalist' Bjorn Lomborg are well known to those who are interested in environmental issues but Nairobi appears to have the dubious pleasure of hosting a conference organised by Lomborg's 'think tank', the Copenhagen Consensus Centre.
  
  Strangely enough, Lomborg appears to make a valid point about the need to concentrate on some very cheap, efficient and vital development programmes, such as micro-nutrient deficiencies and intestinal parasite infestations, which affect billions of people. However, there is a need to ensure that these billions of people have access to a balanced diet. The cheapest and most sustainable solution to these problems is not to enhance foods with various supplements and to produce things like vitamin A enriched chewing gum and other headline grabbing stories. There are already plenty of foods rich in vitamin A and other micro-nutrients. It's just that many people are too poor to afford them.
  
  Lomborg also uses the opportunity given by this smokescreen to plug his tired old argument that climate change is not caused by human activities and that we need to adapt to it rather than trying to fight it. If the money and effort spent on denying that climate change is caused by human activities were to be spent on worthwhile causes, such as the ones Lomborg mentions, a lot of good work could have been achieved by now.
  
  Kenya can't afford to risk accepting Lomborg's puny argument. Whether climate change is caused by human activities or not, the government has to put money into sustainable sources of energy for two reasons: first, these sources of energy will still be available for the foreseeable future, unlike fossil fuels; second, the country is not able to afford these expensive and unsustainable sources of energy and they are not able to afford the costs that go with high usage of unsustainable energy sources.
  
  On the other hand, Kenya can afford to invest in wind power (as long as they produce their own generators, rather than buying the ridiculously expensive British ones that the UK government seems hell bent on selling them); they can afford hydrothermal power, solar power, biogas and probably all sorts of other ways of reducing the country's energy bill and the bill for the pollution and environmental damage that has taken place and that continues to take place.
  
  But what is the government doing? Boasting about the possibility of finding oil in the Eastern Province. Billions have been sunk in drilling for oil in Kenya but the point is not that they have diddly squat to show for it. The point is that they don't need to spend all this money on fossil fuels when there are so many alternatives available here.
  
  And the politicians will continue talking about flood proofing now the rains have come and they will surely talk about rainwater harvesting when the rains have gone away. If oil is discovered, they will rake in the money and when the oil has gone they will talk about how long term thinking is required. But I guess you can't blame Lomborg for talking the Kenyan government into stupid energy policies and development agenda. Because people who listen to such arguments seem to want to believe them.
  
  And the bit that Lomborg gets right, that we could achieve a lot by working on micro-nutrient deficiencies and intestinal parasites, has long been recognised. But these are issues that the Kenyan government has little to say about.

• Ribbon of Hope Self Help Group, Nakuru

  Posted: November 3, 2009, 12:05 am by Simon

  Having come all the way to Nakuru to work for an NGO that turned out not to have any projects at present, I was lucky enough to end up working with some people who have a lot going on. Ribbon of Hope is a community based self help organisation. It was initially set up to work with HIV positive people but quickly evolved to support people who are in need of support for whatever reason.
  
  Ribbon of Hope works with local self help groups, advising on and helping with relevant training, sources of finance, income generation schemes and ways of cutting household costs. Members of various local groups are engaged in producing food and other goods and services. Ribbon of Hope has raised the money to rent land and cover the costs of setting up a number of projects. They work closely with the local support groups, ensuring that everything is monitored and controlled adequately and they even go out into the fields to dig, plant and harvest crops.
  
  At present, Ribbon of Hope is trying out new ways of making and saving money, such as solar cookers, fuel briquettes made from organic waste, homemade, reusable sanitary towels and various other techniques. The aim is to find things that are very cheap or completely free and that people with any level of education can avail of. Some people will only want to use the cookers, briquettes and sanitary towels. But others will want to learn how to make them and then sell them on to others.
  
  In addition to these activities, people are involved in more traditional ways of making and saving money, such as growing maize and beans, rearing hens and cows and making jewellery and basketry products. In this way, people who work hard are more or less guaranteed some money, food or other goods. But the additional activities are intended to branch out from things that most self help groups are already doing, and to find some highly sustainable activities that have multiple benefits for those involved. Ribbon of Hope are researching and experimenting with anything that looks like it might help with their work.
  
  It is important to find income generation and cost saving activities that are free or very low cost for two reasons: money is in short supply, pretty much everywhere; but, more importantly, many people in countries like Kenya realise that they need to become more self reliant. Many of the poorer people here have been depending on unsustainable sources of income and support for a long time. They are tired of having to go around to one NGO after another to take advantage of what usually turns out to be a short term hand out to tide them over from one crisis to the next. They don't see Ribbon of Hope as another source of handouts but as a way of getting away from handouts.
  
  In the long term, the poorest people will need to find ways to raise their own living standards. They know that the huge amounts of aid money that come into the country usually end up in the pockets of those who are already well off, politicians, business people, churches and big NGOs. Kenyans have witnessed this over and over again and they don't expect it to change. All that the most active members of these local self help groups need is some initial assistance, in the form of small amounts of money and some good advice. They do the hard work themselves.
  
  Sadly, there are people who are neither productive not supportive. Some are even outrightly destructive. So those who put a lot of work into improving their standard of living also need people to advocate for change, so that they can enjoy the fruits of their hard work. But as they become more self reliant and better able to avoid the effects of those who don't want them to succeed, they should also become better able to advocate for themselves. This function of advocating for and supporting self help groups is one of the most vital roles that Ribbon of Hope plays.
  
  We are interested in hearing from other groups, especially community based groups, who are involved in low cost, sustainable projects that can be implemented regardless of levels of education or skills. In turn, we are happy to tell anyone who is interested about our experiences as we go along. I'll be documenting much of our day to day work on this blog but please feel free to get in touch if you have any questions.

• Reconsider the Proposed 'Census of Gay People'

  Posted: November 1, 2009, 2:04 am by Simon

  Apparently Kenya is going to carry out a census of its gay population. People are expected to volunteer information about their own sexuality and the sexuality of others they believe to be gay. I certainly wouldn't volunteer information about my sexuality or that of others in Kenya. The issue of homosexuality is often met with a tight-lipped silence or a rabid stream of abuse.
  
  The National Aids/STI Control Programme (NASCOP), which intends carrying out the census, claims that it is part of an effort to 'reach out' to the gay community. This may be so, but who will protect people's right to privacy when it comes to their sexuality? Will the police protect gay people or people suspected of being gay from persecution? This seems unlikely, given the police's reputation for being behind many kinds of persecution themselves. Police here are not known for their liberal views or even their love of peace and the rule of law.
  
  All sexually active people should have access to HIV and other sexually transmitted infection (STI) testing facilities, condoms, sexual health education, counselling and other services. But they should also have the protection of the law and this is something that is not presently guaranteed. The way commercial sex workers (CSW), and those suspected of being CSWs or accused of being CSWs, are treated is a case in point.
  
  NASCOP is worried that some people have the mistaken view that gay sex is safer than heterosexual sex, despite the fact that it is far more risky. But heterosexual anal sex is also mistakenly thought to be safer than vaginal sex. All sexually active people, and those who will soon become sexually active, need to know things like this. Men who have sex (MSM) with men may need additional services that other sexually active groups don't need. But groups who are at higher risk of contracting HIV and other STIs, such as MSM, CSWs and intravenous drug users, are all doing something currently against the law or considered to be against the law.
  
  If the very act of trying to bring HIV and related services to gay people is also going to expose them to even greater dangers than they currently face, the whole idea of a 'census of gay people' should be reconsidered. It could be replaced by the provision of services to all people who require them, as and when. It may seem helpful to NASCOP to approach the gay population this way but there are too many flaws in getting people to identify themselves and others as gay in Kenya.

• Prevention Needs to Consist of More than Good Intentions

  Posted: October 28, 2009, 12:26 am by Simon

  To continue a theme that crops up regularly in this blog, an article on AllAfrica.com argues that Kenya needs to invest more in prevention campaigns than curative ones. True enough, but this article is about non-communicable conditions, such as hypertension, diabetes, mental illnesses, asthma and cancer. Health should start with prevention, whether that involves preventing communicable conditions, non-communicable conditions or even accidents such as road traffic accidents, industrial and agricultural accidents or injury and death from criminal acts.
  
  However, realising that prevention is important is one thing, actually doing something about it is another. Take road traffic accidents (RTA), for example. All sorts of shenanigans have been put in place here recently, ostensibly to reduce RTAs. There are police checks and the rest, but what do the police do, exactly? Well, it's no mystery, they take a bribe and wave the driver on. There could be 22 people in a vehicle licensed for 14, bald tires, faulty brakes, out of date insurance or whatever, but as long as the police get their money, no further questions are asked.
  
  In a country where health spending and health infrastructure has been reduced and continues to be reduced since the early 1980s, what exactly are health professionals supposed to do about all these conditions, communicable and non-communicable? The fact that prevention is better and cheaper than cure is irrelevant when there is bugger all money, anyway. But, even where prevention is even felt to be worth the effort, such as with HIV/Aids, are the figures for HIV transmission falling? Certainly not.
  
  There is plenty of talk about preventing HIV but only 30% of HIV funding is allocated to HIV prevention. Most of that (which is probably nowhere near 30% of funding in reality) goes into a lot of mindless bullshit cobbled together by bigoted donors who don't give a damn about whether HIV transmission is really reduced as long as no one offends against their high minded but ultimately self serving interpretations of Christian morality. And it usually is Christian morality.
  
  A report by a Nairobi based institution has come up with some alarming but unsurprising figures on teenagers knowledge of sex and their sexual behaviour. A large percentage of teenagers are having sex but they know little or nothing about safe sex. Unsurprising because they have been taught little or nothing about safe sex. Where has all the tens of millions of dollars intended for HIV prevention gone? It is has gone into not teaching teenagers about safe sex. I don't know how much money can be spent on the non achievement of something; that is in serious need of investigation. But the money is gone and the knowledge is nowhere to be found.
  
  The report goes on to say that 40% of girls and 50% of boys have sex before the are 19, they believe all sorts of rubbish about sex, they fear pregnancy more than HIV, sex education is not taught in most schools, contraception is usually not mentioned (for fear of horrifying donors, politicians and church leaders, who are very sensitive people), half of the girls in a survey had exchanged sex for money, gifts or cash and 47% of the teenagers surveyed either had a child, were pregnant or had undergone an abortion. A separate study finds that 5.5 million girls between 15 and 19 give birth annually in Kenya, that's one eighth of the entire population!
  
  If the calls for investment in preventing disease were to lead to improvements in very basic goods, such as water, sanitation and infrastructure, basic living conditions, primary health, education, gender equality, legal reform and things like that, Kenya would eventually be a lot better off. But it seems more likely that if any money is provided to prevent diseases and improve health, it will be spent on following purely political, commercial and religious agenda. Once those have been attended to, there's rarely any money left for anything else.

• Funding Health is Cheaper than Paying for Disease

  Posted: October 27, 2009, 12:15 am by Simon

  To continue a theme I hit on in my last post, Reuters AlertNet lists lower respiratory infections as the top killer, accounting for more than 4 million deaths in developing countries. HIV/Aids is listed as number two, accounting for three million deaths, although serious under-reporting of HIV deaths must place a question mark over whether HIV/Aids is really number two or number one.
  
  But the number three killer is interesting because malaria is said to be responsible for between one and five million deaths every year. Added to this, diarrhoea, at number four, kills an estimated 2.2 million people every year. So if deaths caused by poor water and sanitation were added up, they could easily be a contender for 'top killer'.
  
  AllAfrica.com are excited at the possibility that diarrhoea may now get as much attention and funding as HIV/Aids. But funding and attention for a specific condition is missing the point. The number of people suffering and dying from diarrhoea is dwarfed by the number who suffer and die from water borne conditions and others that result from lack of decent standards of water and sanitation.
  
  Health is not merely a matter of curing sickness; it is primarily a matter of ensuring that people live in circumstances that will maximise their health. In other words, they need a decent standard of living. Treatment and immunisation are great but they are no substitute for prevention. A lot of disease and death could be much more cheaply prevented by providing people with good water and sanitation.
  
  Similarly, many of the lower respiratory infections that are said to comprise the top killer result from poor living and working conditions. Added together, water borne diseases and lower respiratory infections probably outnumber all other killer diseases in prevalence and mortality. So the effect of improving living and working conditions combined with improving water and sanitation would be profound.
  
  But a health strategy that effectively consists of targeting diseases, or even risk factors, and starting with the biggest, seems to miss the reasons why so many people suffer and die unnecessarily. There isn't a need to target diarrhoea, for example, because it kills more children than HIV/Aids. There is a need to provide people with a standard of living that enables them to avoid all water borne diseases. Lower respiratory infections may be the top killer but simply vaccinating everyone and treating everyone infected will still leave people living in poor conditions.
  
  To use a different example, malaria prevention is not just a matter of distributing bed nets. If you continue to ignore the festering pools of water that you find everywhere, your children will still go out and play in or near them when they wake up. Festering pools of water are not conducive to good overall health. The bed nets are vital in some areas but the risk of both malaria and other water borne diseases can be lowered by an improvement in sanitation and hygiene conditions.
  
  Luckily, the WHO recommendations to which the AllAfrica article refers includes improvements in water and sanitation. But it remains to be seen if the World Bank and the International Monetary Fund (IMF) keep in step with the WHO. Since the early 1980s, these institutions have worked to reduce health, education and infrastructure in developing countries. They have concentrated on dismantling the structures which allow people to live healthy lives.
  
  There's a sense in which health policy and funding seem to concentrate on downstream effects, particular diseases and health conditions, rather than on the upstream determinants of health.

Blah blah blah

Fish cakes

Alas a fish cake.

Yet more fish cakes

Guess what ... yeah ... fish cakes.

The end of the fish cakes