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Guardian Ebola Coverage: More Journalism, Less Journalese, Please

Comments Off on Guardian Ebola Coverage: More Journalism, Less Journalese, Please Posted by on October 15, 2014

My last post cited an article from the English Guardian claiming that a two year old boy had been bitten by a fruit bat and thus became ‘patient zero’ for the current ebola epidemic in West Africa. Since then, the newspaper has rewritten the paragraph to read:

“In December last year, near the village of Meliandou in southern Guinea, two-year-old Emile may have come into contact with one of the fruit bats that fly through west Africa’s skies, often gathering at dusk to roost in trees.”

‘May have come into contact with’ is a lot better than what Clar Ni Chonghaile wrote previously, but the article still confidently claims that this two year old boy is ‘patient zero’. An article in the New England Journal of Medicine shows that this confidence is mislpaced:

“Potential reservoirs of [ebola], fruit bats […] are present in large parts of West Africa. Therefore, it is possible that [ebola] has circulated undetected in this region for some time. The emergence of the virus in Guinea highlights the risk of [ebola] outbreaks in the whole West African subregion.”

An infectious disease doctor at CDC goes further: [these] two kids were likely early cases of the outbreak but not the first cases.

My criticism of Ni Chonghaile is not that she is wrong about bats or patient zero, but that she infers some kind of certainty where there are at best hypotheses, and at worst pure speculation. I accept fully that epidemiology is often like that, therefore I object to the use of ‘fruit bats’ and ‘funeral practices’ as explanations when these are probably a very small part of the story.

Although it is not my purpose to check ‘facts’ in the article, I would also say that timing is very important; it matters a great deal when the first suspected case was reported, whether they survived, when the next case was reported, etc. So it is worth pointing out that Ni Chonghaile also gets the dates wrong: the symptoms started for the first suspected case on December 2, not December 26; he died four days later. [Correction: the NEJM article gives two possible dates, one in early December and the other in late December, with consequent changes in the possible dates of infection of other suspected cases.]

But the most important thing that Ni Chonghaile and others writing on the subject fail to discuss is the possibility that unsafe healthcare is likely to have played a considerable role in transmitting ebola. Infection from healthcare worker to patient, as well as from patient to healthcare worker, are very likely, so is infection from patient to patient. What about reused syringes, needles and other equipment? Even reused gloves?

Naturally, the Guardian and other media outlets decry conditions in health facilities in African countries in the abstract. But concrete evidence that unsafe healthcare may have been responsible for transmitting HIV, hepatitis, TB and other diseases in the past, and may still be responsible, doesn’t seem to impinge very much on their ostensibly enlightened consciousness.

Eliminating contact with bats, funeral rites and a handful of other exotic phenomena will not, have not, stopped the epidemic. Sure, a bat (or some other animal) may have started the current outbreak, but how has it been sustained since then (whenever that may have happened)? This is not at all about blame, but about tracing how each infection occurred and eliminating that mode of transmission.

These trivial ‘certainties’ deflect attention from a host of uncertainties, but also from the unspoken suspicion that the current approach itself is not working, that protocols may be incomplete, that the proposed solution may be part of the problem. It should not be beyond a journalist to question things that seem to be relevant, but are currently being ignored. Or perhaps I expect too much from them?

AIDS, blood, ebola, HIV, iatrogenic, nosocomial

Patient Zero, Perfect Storms and Other Comforting Epidemic Metaphors

1 Comment Posted by on October 13, 2014

The English Guardian reports: “In December last year, near the village of Meliandou in southern Guinea, two-year-old Emile was bitten by one of the fruit bats that fly through west Africa’s skies, often gathering at dusk to roost in trees.” In fact, as the article goes on to make (partially) clear, this is just one hypothesis out of many.

The ‘first’ person infected in the current outbreak may or may not have come into direct contact with a bat, or some other animal; or the outbreak may have occurred in a health facility, rather than in ‘the bush’; the term ‘Patient Zero’ is suitably dramatic for articles about disasters set in exotic locations, but has distracted attention from how people continue to be infected with ebola.

It’s comforting to think that African two year olds are a lot less likely to be bitten by bats now that the scientists, medics and disaster workers have moved in; perhaps African parents will even give up or modify their unsafe bat-hunting habits and take people to hospital if they are thought to be sick, and cease to take vaguely defined risks of being infected at funerals.

Meanwhile, when a healthcare worker in Texas is infected with ebola, being one of the many people who nursed ebola victim Thomas Duncan, a ‘breach of protocol’ is immediately suspected. Another hypothesis, of course (although it leaves out the possibility that the protocol has failed to take into account some additional mode of transmission).

Compare this to an earlier blog post: when 86 people who have no identifiable risks for the virus are infected with hepatitis C in the US, expensive investigations are carried out into possible breaches of infection control processes in the health facilities that the victims attended.

Yet, when millions of Africans who have no identifiable risks for the virus are infected with HIV, an entire industry develops around the prejudiced view that Africans engage in huge amounts of unsafe sex. No investigations are carried out into conditions in health facilities, although various reports show that infection control processes are seriously lacking.

Of course, there was no ebola protocol in West Africa back in December of last year. But all the more reason, then, to investigate health facilities. What kind of infection control processes were in place then, and are now? Subsequent findings suggest that there are severe shortages in trained personnel, supplies and beds, etc, similar to those noted in other African countries.

Rational explanations in western countries, but metaphors and non-rational backstories in Africa. Spacesuits, because it is an exotic virus from a different planet, brave westerners, but only poor and uneducated Africans.

It just seems a bit suspicious that ebola (and HIV and other diseases) are spread through the ignorance and carelessness of victims in African countries, but through a ‘breach of protocol’ in the US. Health facilities are such dangerous places in African countries that it is surprising authorities insisted on rounding up those suspected of being infected with ebola and marching them off to a clinic in the first place.

But that approach may now be challenged if this article in the New York Times is at all correct. It says that officials have admitted defeat and that they are going to “help families tend to patients at home”. About time too. This could be a major turning point if it is taken to its logical conclusion (if logic if given a role, for a change).

As David Gisselquist has pointed out on this site, people are not being asked about possible infection through through healthcare procedures they may have received in the recent past. Gisselquist has been arguing that people should be warned about healthcare risks, treated with respect and fully supported if they decide to care for ebola patients at home.

Long before the current ebola outbreak occurred it was already common practice for healthcare professionals to say as little as possible about lack of safety in facilities, resulting in HIV, hepatitis, TB and other diseases being transmitted through various procedures, such as injections with reused syringes and needles, unsterilized equipment, reused gloves and other materials. This needs to change, as the ebola outbreak shows (and as the hepatitis and HIV epidemics have been demonstrating for several decades).

In the US there are possible insurance claims, professional negligence inquiries, outbreak investigations, protocols to be rewritten, with some of these phenomena possibly being mentioned in the mainstream media from time to time. Oh, and perhaps some much loved mongrels to be euthanized.

But in Africa the media will continue with its customary approach: treat the people as an exotic, primitive species, to be pitied for their funeral practices and ‘bush meat’ hunting, their reluctance to go to a hospital (implied to reflect a suspicion of modern or ‘western’ things or people), etc. There will be lots more ‘ebola orphans’, two year old Emiles, ministering angels in spacesuits and the like.

It’s as if this completely unforseeable ‘perfect storm’ (a metaphor also favored by the media when writing about HIV) took away Patient Zero, and the rest of the outbreak was down to a combination of other ineluctable processes. But, whereas a perfect storm is a rare combination of factors, unsafe healthcare has been around for decades.

The current ebola outbreak is a symptom of decades of unsafe healthcare; it is nothing like a ‘perfect storm’. Two year old Emile, ebola’s putative patient zero, is as far from being the index case as Gaëtan Dugas was for the HIV epidemic. Stopping ebola requires an admission that unsafe healthcare spreads disease and allows isolated outbreaks to become pandemics. Apologies if the truth is far too prosaic to sell newspapers.

AIDS, blood, ebola, HIV, iatrogenic, nosocomial , ,

Amnesty International South Africa: Right to Healthcare Futile Unless it’s Safe Healthcare

1 Comment Posted by on October 10, 2014

When I was writing yesterday’s blog post I didn’t realize that the Amnesty International report I referred to had already been published. It’s called ‘Struggle for Maternal Health: Barriers to Antenatal Care in South Africa‘. It is quite extraordinary that such a lengthy report about maternal health can fail to mention safety, unsafe healthcare, healthcare transmitted infections and the like.

But the report puts the cards on the table on page 21: “Heterosexual sexual intercourse is the main cause of HIV transmission in South Africa.” The South African ‘National Strategic Plan’ is cited in support of this contention, and that document doesn’t really support the claim at all, although it’s clear that it comes from the usual documents from the usual normative agencies.

Normative agencies such as UNAIDS, WHO and others make guesstimates of the proportion of HIV transmission that can be attributed to male to male sex, intravenous drug use, commercial sex work and various heterosexual ‘groups’ (who are never very clearly defined). The minute figure that remains, 1-2%, is attributed to healthcare transmission of HIV.

But as yesterday’s blog (and other data on the Don’t Get Stuck With HIV site and blog) show, there are numerous types of healthcare transmission of HIV, including antenatal care, invasive forms of contraception, blood tests, donations and transfusions, child delivery, injections, surgery and many others.

Amnesty and others go on about stigma, the need for privacy, lack of information and poor public transport for pregnant women. But the stigma is not very surprising: if a HIV negative man constantly hears that the virus is primarily transmitted through heterosexual sex and that his wife is HIV positive, or that his child is, he is not being irrational in believing that his wife has been having sex with someone else.

Rather, he is misinformed. Misinformed by the likes of UNAIDS, WHO and, it seems, Amnesty International. Neither the woman nor the man are told that HIV may have been transmitted through some non-sexual route, perhaps even through unsafe healthcare. This is an especially important mode of transmission in the case of HIV positive infants whose mothers are negative, or HIV positive mothers whose partners are negative.

The closest Amnesty International’s report gets to the issue of unsafe healthcare is where they recommend “[paying] particular attention to the need to develop, resource and implement programmes to address the underlying determinants of health that promote safe pregnancies and deliveries.” [my italics] But there is little or nothing in the body of the report indicating that unsafe healthcare may be an underlying determinant in much of the morbidity and mortality among women, infants and children.

The report does talk to healthcare users and providers and there are some useful findings. People are not given clear, complete or even accurate information a lot of the time. Healthcare workers often lie or withhold vital information and they may even be ignorant of certain matters themselves.

Antenatal care provision may be lacking in South Africa, but the country has one of the highest figures for women giving birth in a health facility among all the high HIV prevalence African countries. It also has one of the highest figures for deliveries being attended by a skilled health provider.

In other words, high HIV prevalence countries tend to be those with better antenatal care indicators, rather than worse. Amnesty also reports on transport, but transport infrastructure is more developed in SA and other high HIV prevalence countries than it is in East and central Africa, where HIV prevalence is also lower.

Amnesty International did not seem to question these phenomena, despite the fact that they have noticed that HIV prevalence is high in SA, especially in the areas they did their research (KwaZulu Natal and Mpumalanga), also that maternal morbidity and mortality are much higher among HIV positive than HIV negative women.

Had they questioned the often cited but never demonstrated reflex ‘heterosexual intercourse is the main cause of HIV transmission’, they might also have tried to find out if health professionals may be hiding behind patient confidentiality and privacy and deliberately avoiding testing partners of HIV positive women because they wouldn’t want anyone to suspect that unsafe healthcare can be responsible for transmitting HIV.

These both look like conflicts of interest for healthcare providers, between informing HIV positive people how they or those they care for may have been infected and avoiding the suspicion that unsafe healthcare can result in transmission of HIV, hepatitis, bacterial infections and other pathogens (including TB, ebola and anything else going around in hospitals).

South African’s constitution holds that healthcare should be of ‘good quality’ and that citizens have the right to the highest attainable standard of health. Unless health facilities are safe places, increasing access to healthcare may be counterproductive and expose people to avoidable illness and injury. Unless healthcare personnel are enabled to provide safe healthcare, training and retraining them may be similarly counterproductive.

A well funded and experienced human rights NGO such as Amnesty International must go beyond the corporate mythmaking of normative agencies, the views of people constantly bombarded with misinformation and prejudice about HIV transmission, and health professionals who are either ignorant about healthcare transmission or who wish to protect their profession from suspicion of infecting patients.

AIDS, ebola, HIV, iatrogenic, nosocomial

Healthcare Transmitted HIV: Informed Consent and Conflict of Interest

1 Comment Posted by on October 9, 2014

Research in Mozambique, Swaziland and Kenya has shown that a substantial proportion of HIV positive infants have HIV negative mothers. These infants are likely to have been infected through unsafe healthcare, perhaps reused syringes, needles or other equipment, lack of adherence to infection control procedures, etc.

Amnesty International has launched a campaign to gather information from the public about maternal deaths in Mpumalanga, South Africa. In particular, they are interested in HIV testing, informed consent and whether consent is given voluntarily.

But what kind of ‘information’ are Amnesty collecting? The South African Medical Association’s Ethical and Human Rights Guidelines on HIV and AIDS makes no mention of non-sexual transmission of HIV whatsoever. Is information about the likely source of an infant’s infection not considered to be a vital part of giving informed consent?

Is information about how a mother (or anyone else) may have been infected with HIV not also vital? I would suggest that this information needs to be a standard element in pre- and post-test counselling for everyone, but particularly where the spouse is not HIV positive or where a HIV positive person has no identifiable sexual risks, is not an intravenous drug user, etc.

The Health Professions Council of South Africa’s (HPCSA) Guidelines for Good Practice in Medicine, Dentistry and the Medical Sciences has this to say:

“The risk of transmission of HIV infection in the health care area from patient to patient, patient to health care worker, and from health care worker to patient through inoculation of infected blood or other body fluids has been shown scientifically to be very small. Fears, which are not always based on reality, have thus tended to exaggerate the risks out of all proportion.”

This paragraph is not backed up by any citations and is expressed in language that is out of place in a set of guidelines for health professions; the word ‘scientifically’ is especially incongruous. What does it matter how small a risk of healthcare transmission of HIV is when an infant is HIV positive and the mother and their partner are not? Adults, also, could face healthcare and other non-sexual risks, but are these risks assessed by practitioners who have been told that they are ‘very small’.

The Mozambique research further shows that some HIV positive mothers were likely to have been infected by their HIV positive infants, that HIV negative mothers with HIV positive infants have not been told how their infants may have been infected, that HIV negative mothers have not been told that they can be infected by their HIV positive infants, that some mothers have been allowed to believe that their infant’s HIV positive status is their fault and that some healthcare workers are unable to answer, or even question, these phenomena.

The HPCSA General Ethical Guidelines for the Health Care Professions lists as one of the duties to patients: “Make sure that their personal beliefs do not prejudice their patients’ health care.” Personal beliefs about how the patient may have been infected with HIV, even beliefs based on the HSPCA Guidelines, should not preclude an unprejudiced assessment of both sexual and non-sexual exposure to HIV.

Amnesty International would do well to consider the possible conflicts between the interests of the healthcare professional and the interests of the patient in regard to providing those being tested for HIV with correct and complete information about how the virus is transmitted. When they have finished in South Africa, they may like to extend their investigation to other African countries.

[The Amnesty International report is discussed further in another blog post, October 10 2014]

AIDS, blood, HIV, iatrogenic, nosocomial , , , ,

How is Ebola transmitted in the ongoing West African outbreak?

1 Comment Posted by on October 2, 2014

Getting an answer to the question in the title is crucial for people in countries with ongoing epidemics – to protect themselves they need to know the ways they are most likely to get Ebola. The answer is important for people in other African countries as well – to help them assess the probability the epidemic will reach their country, and to prepare for this possibility.

People outside Africa also need the answer. Politicians and bureaucrats who vote and manage aid funds can make better decisions with a clear account of whether and how what they are paying for is saving lives. Finally, although there is only an outside chance the virus has changed or will change to transmit more efficiently, that small possibility represents big risks to people around the world. We want to know what’s happening.

There are two steps for health aid managers to answer the question in the title. They must:
• Get the answer through surveillance.
• Report what they find to the general public.

As of September 2014, public health experts have not reported the relative contribution of various exposures in transmitting Ebola in the current outbreak. Their failure to do so may be due to missing the first step (ie, they don’t know) or the second (ie, they know but don’t say).

Contact tracing to find the source of infections

The public health response to West Africa’s Ebola epidemic includes a lot of effort to trace contacts of people with Ebola to identify new cases as soon as possible – as soon as they get symptoms. For example, at end-August, “WHO and its partners are on the ground establishing Ebola treatment centres and strengthening capacity for…contact tracing…” (WHO, Ebola virus disease update, 28 August, at: http://www.who.int/csr/don/archive/year/2014/en/).

However, I have found no reports of contact tracing to find where and how people with Ebola got their infections. How to do this is straightforward: Ask people with new Ebola infections if they had touched someone who was sick or if they had attended a funeral in the previous 21 days; touching someone sick or dead with Ebola is a recognized risk. Ask if they got injections, infusions, or any other skin-piercing procedure in the previous 21 days; such procedures are also recognized risks. Then trace contacts and visit and investigate reported health care settings.

If more than a few people with new infections report no contacts with other cases and no skin-piercing procedures, that is cause for concern and, more critically, further investigation. Such unexplained cases could be showing the virus is transmitting in unexpected ways.

John Potterat has been a practitioner and advocate of contract tracing and partner notification as a public health tool to understand and control the spread of infectious diseases. In a recent article on partner notification for HIV in Africa, written before the explosion of West Africa’s Ebola outbreak, Potterat presciently recommends the skills required to diagnose what has allowed that outbreak to grow: “Nurturing public health investigatory (and people and community rela¬tions) skills that one can acquire by conducting PN [partner notification] would be of great service anywhere that new communicable infections or public health emergencies are likely to emerge” (http://www.la-press.com/perspective-on-providing-partner-notification-services-for-hiv-in-sub–article-a4370-abstract).

Telling people what is happening

This second step to answer the question in the title is not automatic. Based on reports from previous Ebola outbreaks, patient-to-patient transmission in health care settings – eg, through injections with contaminated syringes and needles – contributes to expanding outbreaks. Considering the persistent expansion of the ongoing Ebola outbreak in West Africa, it is probable that patient-to-patient transmission plays an important part. If anyone has such information, they have not disclosed it.

In Africa, it has been common practice for ministries of health – encouraged by health aid managers – not to disclose evidence that patients have gotten blood-borne infections such as HIV from unsterile health care procedures. Not warning the public is excused by the assertion that warning might cause more harm than it would prevent: the infections prevented would be outweighed by disease and death due to patients avoiding health care.

Such body count calculations ignore doctors’ ethical obligations. The World Medical Association’s Declaration of Lisbon on the Rights of the Patient avers: “1d. Quality assurance should always be a part of health care… 9. Every person has the right to health education that will assist him/her in making informed choices about…the available health services…” (see: http://www.wma.net/en/30publications/10policies/l4/).

Furthermore, the assertion is based on a misleading mention of only two options – no health care vs. unsafe care. But there is a third option – safe care. Getting to the third option is not, primarily, a matter of money. It costs little or nothing to avoid unnecessary invasive procedures, shift to oral medication, boil instruments, or use plastic disposables. What is lacking is public awareness – lacking due to misinformation by ministries of health and health aid managers.

If ministry officials and/or health aid managers have evidence that people have gotten Ebola infections from health care procedures and settings during the current outbreak, will they tell the public?

Will concern to stop West Africa’s outbreak over-ride public health managers’ unwillingness to warn the public about risks in health care settings? Will the world public’s interest to know if the virus is changing over-ride health aid managers’ unwillingness to acknowledge the contribution of unsafe health care to the current outbreak?

HIV

Whites Only? Investigations Reveal Hospital Transmitted Hepatitis Infections In US

2 Comments Posted by on September 30, 2014

The satirical site The Onion ran the headline ‘Experts: Ebola Vaccine At Least 50 White People Away‘ at the end of July. I’m not citing this article because I think it is funny, but because it raises a shocking point very succinctly, one that must have passed through the minds of many over the past few months.

If such an outbreak were to become established in a wealthy country, mainly inhabited by white people, would it still be raging 9 months later? And what efforts would be made to establish the source of the infections?

There is probably no wealthy country precedent to compare with the sort of epidemics that are frequently found in poor countries, often without even attracting the notice of the western world (or not for very long). But a recent article published in the Mayo Clinic Proceedings outlines the kind of work that went into investigating the infection of 84 people with hepatitis C (HCV) and another 34 with bacterial infections in US hospitals over a 14 year period. In fact, the paper outlines a whole series of investigations, very impressive work, too.

Six healthcare personnel were identified as a result of these many, lengthy and thorough investigations. That’s an average of almost 20 patients infected for each worker. An estimated 30,000 patients were potentially exposed to blood-borne pathogens by these six people. Twenty three different hospitals were involved, in 10 different states. (Naturally, I don’t really know if the victims were all white people; the authors are far too polite to mention such detail.)

A 2009 article entitled ‘Injection drug use, unsafe medical injections, and HIV in Africa: a systematic review‘, by Savanna Reid, estimates that 20 million medical injections contaminated with blood from a patient with HIV are administered every year in Africa. Other research by Yves Hutin, entitled ‘Use of injections in healthcare settings worldwide, 2000: literature review and regional estimates‘, estimates that out of the 17 billion injections administered every year globally, 7 billion of them are unsafe.

So where are the HIV and hepatitis outbreak investigations carried out in African countries? They are not listed in PubMed, unless they are called something else, to throw investigators off the scent. Such an investigation was carried out in Pakistan in 2008, but as it confirmed the worst fears of those who believe that unsafe healthcare is a serious risk it appears to have attracted very little attention (and turned into what looks like a cover-up).

So what do we know about unsafe healthcare in African countries, in the absence of such investigations? We know that infants with HIV negative mothers were probably infected through unsafe healthcare in Mozambique, and some of the infants may have gone on to infect their mothers (though it hasn’t been seen fit to explain to these mothers how their infants may have been infected, nor even the likely source of their own infection).

We know that people who have received medical injections in Kenya and several other countries are several times more likely to be HIV positive than those who have not. We know that women who have sex only with other women in Namibia and other southern African countries have been infected and that their non-sexual risks have not been investigated. We know that many people found to be infected with HIV in most African countries have said they have not had sex, or that they have not had sex with a HIV positive person, or that they have only engaged in safe sex [earlier version corrected].

In fact, there are numerous instances of HIV outbreaks in African countries, and probably other diseases, which have very likely been caused by unsafe healthcare, reused syringes and other equipment, failure to comply with infection procedures, etc. But none of them have been investigated. Instead, there are vast quantities of data shoved into mathematical ‘models’, showing that HIV is almost always transmitted through heterosexual behavior in African countries (this being just one example).

Completely untrue, but in accordance with the ‘promiscuous African’ myth, which has a long history in the medical (and eugenics) literature. The authors of such papers systematically ignore empirical data and fail to investigate outbreaks, they assume that African people themselves are either seriously mistaken about their sexual history or just tell lies, and they go unchallenged by their fellow academics and even peer reviewers, who have the luxury of remaining anonymous, but seemingly prefer to toe the party line.

No doubt these mathematical models are great examples of academic prowess and rigor, that stand up to the highest levels of scrutiny. But they are no substitute for the kind of investigations that have been carried out into what is thought to be a mere tip of the iceberg in hospital transmitted hepatitis and bacterial infections in the US. However brilliant these models are in the field of epidemiology, they are the work of people who care nothing about their fellow human beings in African countries.

Why do these highly qualified academics care so little about poor black people and, apparently, so much about people more likely to be wealthy and white? Is it academic vanity, money, some kind of animalistic competitive instinct, or a combination of these? The challenge to all these clever academics, who can publish their work in the most prestigious journals and be cited in the cream of the western media, is to go to the same lengths investigating and stopping HIV (and ebola, HCV and other diseases) in African countries as they do in parts of the US before the epidemic spreads any further.

AIDS, HIV, iatrogenic, nosocomial , , , , , ,

UNAIDS, Beckham and Sidibe: Right Words; Wrong Oriface

Comments Off on UNAIDS, Beckham and Sidibe: Right Words; Wrong Oriface Posted by on September 28, 2014

Every year, more than 1.5 million people are newly infected with HIV, the vast majority of them black Africans, with a lot more women than men being infected. Meanwhile, UNAIDS continues to insist that the virus is spread almost entirely through ‘unsafe’ sexual behavior in African countries, though nowhere else in the world. HIV via unsafe healthcare, they insist, almost never happens in countries with the worst healthcare systems in the world.

The institutional racism and sexism exemplified by UNAIDS, the broader UN, the World Bank, charitable foundations and other parties results in huge levels of transmission of a virus that is difficult to transmit through heterosexual sex; transmission through unsafe healthcare remains completely ignored, even denied, by what has become a massive HIV industry.

These institutionally racist and sexist stances also result in the implication that most of the people infected with HIV are highly ‘promiscuous’, careless, uncaring, stupid, and whatever other negative qualities the media happens to have been fed about HIV positive Africans at any given time.

There is no mainstream media coverage of these instances of institutional racism and sexism, no online campaigns to have UNAIDS abolished, no celebrity photo shoots with publicity obsessed naifs being paraded before an adoring (or despising) public, no newspaper articles, neither tabloid nor broadsheet.

Where are the academic articles by those whose entire time is spent, allegedly, examining and analyzing such phenomena and advising those putting together policies that should go towards reducing the transmission of serious diseases like HIV? Which academics are condemning the institutional racism and sexism that has continued, unabated, since HIV became a lucrative headline-grabbing disease in the late 1980s?

There’s plenty of media coverage of some ex-singer that UNAIDS hoped could belt out a few well rehearsed lines in front of a camera (and a sneering Michel Sidibe). A child actress did a better job of memorizing and spewing out the right lines and buzzwords, with the right facial expressions and body language, so she got some publicity too.

An exhibition that sounded (to some) like it would ‘insult’ black people, even though most of the people taking part in it were black South Africans, was banned because a few people managed to drum up a crowd of ‘insulted’ people who had never seen the exhibition. Though insulted by something they had never seen, they remain uninsulted by the continued treatment of black Africans as sex obsessed disease vectors; protestors scream about ‘objectification’, but fail to recognize it in the flesh.

Ultimately, what Victoria Beckham was saying was no more ridiculous than what UNAIDS and other institutions repeat endlessly. She’s just not very good at UN-speak; her mentors haven’t worked on her hard enough; give it time and she too will be able to trott out the same bullshit as the smirking head of UNAIDS does.

No one was infected with HIV by Beckham’s speech and, unlike the usual UNAIDS blather, it wasn’t even articulate enough to be considered racist or sexist. No black people were injured by an exhibition that never happened at the Barbican. The only ones insulted will be the ones who were told that the event was far too shocking for their poor delicate little selves. The truth, clearly, is far too dangerous for ordinary people to handle. Nice to know that the notion of a ‘protectorate’ has not died out completely.

HIV , , , ,

Intersection between HIV and Ebola in Africa

1 Comment Posted by on September 23, 2014

A long history of unsafe health care

During the 20th century and continuing, millions of Africans have gotten blood-borne infections, including tetanus, hepatitis B, hepatitis C, HIV, and Ebola, from unsafe healthcare. With some exceptions, the health aid community’s response has been to deny that health care accounts for more than minorities of blood-borne infections. Instead of fixing unsafe procedures, the health aid community’s repeated response has been to promote solutions involving more invasive procedures.

For example, women and infants in Africa were observed to get tetanus infections from unsterile and contaminated instruments during childbirth. The health aid community responded with tetanus vaccinations – arranging for young women to get as many as five more injections, and for babies to be injected at birth. Vaccinations protect mothers and babies from tetanus, but because additional injections are not reliably sterile, an unknown number get other blood-borne infections.

Across much of Africa in the late 20th century, 70%-95% of adults had been infected with hepatitis B at some time in their lives, while 7%-15% had continuing (chronic) infections. Most chronic infections came from exposures during infancy or early childhood. Studies in Africa reported as many as 50% of children infected before their 5th birthday. The health aid community denied an important role for unsterile health care. Instead of making sure children received safe care, the health aid community introduced another injected vaccine to protect them from hepatitis B. Vaccinations currently protect many Africans from hepatitis B but increase their risk for other blood-borne infections.

Enter HIV. Recent mainstream research traces the origin of the world’s HIV epidemic to colonial health care programs spreading a rare HIV infection (from an otherwise self-limiting outbreak, likely beginning from a chimp butchered for bush meat) to thousands of Africans through unsterile injections for sleeping sickness, yaws, and suspected sexual infections. A lot of evidence suggests blood-borne transmission continues to drive Africa’s peculiar HIV epidemics. Unlike epidemics in almost all countries outside Africa, women in Africa are infected more often than men. Outside Africa, HIV is rare except in adults who inject illegal drugs and men who have sex with men; whereas in much of Eastern and Southern Africa, as many as 20%-50% of adults, most with conservative sex lives and often an HIV-negative spouse, can expect to get HIV during their lifetime.

Missing an opportunity to find and fix unsafe health care

In 1988, Russia investigated an unexplained HIV infection in a child with an HIV-negative mother – thereby uncovering and stopping a chain of transmission through unsterile procedures in 13 hospitals that spread HIV from one to 265 children in 15 months. Several years later, tests in four African cities (Kampala, Kigali, Lusaka, and Dar es Salaam) on 5,593 inpatient children and their mothers found 61 children (1.1%) to be HIV-positive with HIV-negative mothers. Instead of initiating investigations, WHO staff blithely and incredibly concluded “the risk of…patient-to-patient transmission of HIV among children in health care settings is low” (p. 85, 1992-1993 Progress Report, Global Programme on AIDS).

The health aid community has spent billions on HIV prevention messages for Africans focusing almost exclusively on sexual risks. Such messages, with their roots in European and American racial prejudices, smear all Africans – including millions of HIV-positive married women with HIV-negative husbands – with suspicions of uncontrolled sexual behavior.

Although the health aid community has done its best to ignore HIV from unsafe health care in Africa, the US Congress has not only been aware of the problem, but has also made available billions of dollars to fix it. In 2003, the US Congress pressed USAID and CDC to spend $300 million allocated for HIV prevention to improve injection safety and blood safety, primarily in Africa. In 2008, when Congress approved $48 billion for HIV aid, primarily for Africa (see: http://www.pepfar.gov/documents/organization/108294.pdf), it asked the President to develop a 5-year strategy, including (page 8): “(C) promoting universal precautions in formal and informal health care settings; (D) educating the public to recognize and to avoid risks to contract HIV through blood exposures during formal and informal health care and cosmetic services; (E) investigating suspected nosocomial infections to identify and stop further nosocomial transmission…”

At the same time, Congress (page 39) asked the US Global AIDS Coordinator to submit an annual report assessing impact on “capacity to identify, investigate, and stop nosocomial transmission of infectious diseases, including HIV and tuberculosis…” Regrettably, during 2008-13, USAID and CDC spent nothing on outbreak investigations in Africa or to warn the public about blood-borne risks. Instead, USAID and CDC promoted more invasive procedures – male circumcision in unreliably sterile conditions – to reduce HIV infections.

Ebola shines a spot-light to unsafe health care

In 2014, West Africa’s Ebola outbreak exposed unsafe health care systems. Health aid managers were quick to acknowledge that health staff are at risk – this was impossible to deny as more than 100 doctors and nurses died. On the other hand, health aid managers have been silent about patients getting Ebola from unsafe health care.

Health aid managers have for decades been able to get away with a head-in-the-sand response to HIV from unsafe health care. This has been possible because HIV infections from health care are relatively easy to ignore – most victims don’t recognize their infections, which are silent for years. Even when unsafe health care fuels atrocious HIV epidemics, health aid managers have been able to divert attention, adding insult to injury, by blaming infections on victims’ supposed sexual misbehaviors.

With Ebola as with HIV, health aid managers are faced with the choice between warning the public to be wary of skin-piercing health care procedures or staying silent about the risk and thereby allowing preventable infections. With HIV, health aid managers’ have chosen to deny problems, even at the cost of millions of unnecessary infections. With Ebola, however, health aid managers may not have that option. People who see family members, friends, and neighbors get Ebola within days after health care procedures may demand action to find and stop unsafe health care procedures.

If West Africa’s current Ebola outbreak gets people to see and stop reuse of unsterile instruments in health care, the beneficial consequences of the current outbreak – fewer HIV and other blood-borne infections – could far outweigh its current terrible human costs.

HIV

To stop Ebola: Tell people about bloodborne risks and treat them with respect

1 Comment Posted by on September 21, 2014

With recent US and WHO statements and commitments, the health aid community is escalating the war on Ebola in West Africa. That’s good news. But I’m still worried. Escalation does not necessarily lead to success, especially if health aid managers escalate failed strategies. Two errors in the response to date have been:
• Not warning the public about risks to get Ebola during invasive health care. This error may well be the principle cause of the continuing increase in numbers of infections.
• Not respecting patients’ rights to choose where to be treated. This error breeds public distrust, undermining cooperation. A strategy to stop Ebola that does not rely on and respect the public is like trying to clean up a puddle with a hammer. The health aid community should switch to towels – to a softer approach.

Based on experience from past outbreaks, as soon as health aid managers fix these errors, we can expect a sharp fall in numbers of new infections, with the outbreak ending in a matter of weeks to months. To fix these errors, public health programs should:

1. Warn people that injections, infusions, and other skin-piercing procedures can spread Ebola, and to avoid such procedures as much as possible

An important observation from earlier outbreaks is that Ebola transmission in health care settings amplifies what is otherwise a self-limiting outbreak. Transmission during home-based care, even with some dangerous funerals, has not been enough to sustain an outbreak. Aside from what happens in the community, preventing any additional (“excess”) transmissions in health care settings has been enough to stop previous Ebola outbreaks.

Most transmissions in health care settings fall into two categories – transmissions from patients to health care workers, and patient-to-patient transmissions. In the current West African outbreak, health aid managers have addressed doctors’ and nurses’ risks to get Ebola from patients by providing protective gear such as gloves and aprons. However, health aid managers have been silent about patient-to-patient transmission, especially through reuse of unsterilized skin-piercing equipment for injections, infusions, and other procedures. This “oversight” may be the error that allows continuing “excess” transmissions in health care settings to amplify what would otherwise be a receding outbreak.

The urbanization of the current outbreak makes it especially important to warn the public to avoid invasive procedures with unreliably sterile instruments. In rural areas, where most Ebola outbreaks have been observed to date, options for invasive procedures are limited. But in towns and cities, where many who are infected with Ebola currently live, people can get injections, infusions, and other skin-piercing procedures from scores of enterprising healers in formal and informal sectors, including pharmacists, private clinics, quacks, etc.

How to stop “excess” patient-to-patient transmissions during invasive procedures? In theory, public health managers could assure that health care is safe by educating and supervising doctors and nurses. However, health care in the affected countries in West Africa was not safe for patients even before the current Ebola outbreak. With the outbreak further stressing the system and reducing available staff, health care is even less safe than in “normal” conditions. To stop transmission of Ebola during invasive procedures, there is no option except warning the public. That is also the only ethical option.

2. Demonstrate respect for the public by letting people choose where to be treated and by acknowledging risks in health care settings, including Ebola isolation wards

The World Medical Association’s Declaration of Lisbon on the Rights of the Patient (available at: http://www.wma.net/en/30publications/10policies/l4/) presents guidelines for doctors to respect patients. According to article 3: “The patient has the right to self-determination, to make free decisions regarding himself/herself… A mentally competent adult patient has the right to give or withhold consent to any diagnostic procedure or therapy…” such as, for example, entering an Ebola isolation ward vs. taking treatment at home.

Ebola response teams in West Africa have violated patients’ rights by coercing them to enter isolation wards. When health agencies allow Ebola suspects and even cases to choose treatment at home, it frees money and staff to give better treatment to remaining inpatients and to improve community outreach. Based on previous outbreaks, home treatment results on average in less than one new infection for each current case – which is all that is required to stop the epidemic.

Giving suspected cases and their families the option to treat at home will defuse tension between health care personnel and the general public. Healing this rift is essential to allow public health authorities to gain accurate information about the epidemic. People who are not afraid are more likely to talk.

HIV

Revised History of HIV in Kenya – Part VII – Health Facilities

Comments Off on Revised History of HIV in Kenya – Part VII – Health Facilities Posted by on September 7, 2014

Part VI explored the possibility that family planning and Sexually Transmitted Infection (STI) services may have been provided in health facilities that would later be deemed unsafe in the context of HIV, involving reuse of syringes and other equipment with inadequate or no sterilization. Many determinants have been identified for STIs throughout the twentieth century, all over the world. They include poverty, poor education, unemployment, ‘promiscuity’ (Meheus, 1974), low prevalence of contraception and others. STI prevalence tended to be higher among men than women, high in both urban and rural areas, higher among unmarried than married people (Hopcraft, 1973) and fairly evenly distributed around a country such as Kenya. In contrast, HIV is more likely to be associated with relative wealth, better education, employment, proximity to roads and other infrastructure, higher use of contraception, urban dwelling, marriage and others. More women than men are infected, associations with sexual behavior considered unsafe are often not very strong and prevalence is unevenly distributed, with a few hotspots in Kenya and many ‘coldspots’. One might logically conclude that, while HIV can be transmitted sexually, it is often transmitted in other ways, and that is why patterns of infection for HIV differ so much from patterns of infection for other STIs.

However, there are important overlaps in these patterns of STI and HIV infection. For example, HIV prevalence was found to have reached 4% among Nairobi sex workers in 1981 and increased to 61% by 1985; this was established by retrospectively testing stored blood samples (Piot P, 1987). Females infected with non-HIV STIs in the past were generally found to be engaged in sex work or had a partner who had visited a sex worker. Prevalence of STIs was often high in certain occupational groups, such as transport workers, soldiers and those employed in extractive industries. As a result, these and other groups had long been targeted by STI eradication programs; sex workers had also been targeted by various family planning initiatives. This suggests that those facing high risks for infection with STIs, or assumed to face high risks, may have had increased non-sexual risk of being infected with HIV once that virus began to spread (having established itself several decades before). Although HIV prevalence went up to 81% among sex workers in Nairobi, it peaked in 1986 and declined steadily for nearly 20 years without any reasonable explanation being found for this trajectory (Kimani J, 2008). Oddly enough, neither Piot et al nor Kimani et al consider the very strong possibility that sex workers (and members of other targeted groups) were systematically infected with HIV through unsafe healthcare until this risk was eventually recognized (or perhaps changes in practices reduced the risk of transmission without anyone noticing the impact this was having on healthcare transmission until much later?).

In the early 80s, no precautions had been taken to prevent the transmission of blood-borne viruses such as HIV in health facilities, as the virus had only just been discovered. Throughout the 80s, as it became apparent that health facility transmission was (or could become) a significant risk, certain measures were taken to improve safety. But the changes would not have been adequate to eliminate transmission altogether. In the 90s, as mentioned in Part III, access to health facilities declined, which may have inadvertently protected many people from infection; HIV incidence in the general population peaked some time in the 90s, at a time when visitor numbers to health facilities would have been falling as a result of increasing poverty, the introduction of ‘user fees’, cuts in service provision and other factors. Sex workers and others thought to be ‘promiscuous’ must have faced a very high risk of being infected with HIV in STI and family planning facilities, although the risk must have decreased considerably some time in the 80s and continued to decline, without ever being completely eliminated.

As for those not considered to be so ‘promiscuous’, they would also have faced high risks in general health facilities. Family planning and STI facilities were often integrated into general healthcare services. Women attending antenatal care (ANC) services and giving birth may have faced higher risk than others (aside from sex workers and other groups targeted by STI and family planning programs). This makes it less surprising that very high HIV rates were found in ANC clinics from the late 80s onwards. HIV prevalence is often highest among women of childbearing age. While these same women may (or may not) be more sexually active that others among whom HIV prevalence is lower, they clearly face increased non-sexual risk of infection with HIV at ANC clinics that are not particularly safe. Family planning services were promoted widely, often aggressively promoted, and not just to those thought to be ‘promiscuous’. Family planning, ANC, contraception and even general health services tend to be more accessible and more utilized in urban areas, by wealthier, better educated people (Hopcraft, 1973), the very groups found to be more likely to be infected with HIV. So people with HIV are more likely to have faced various non-sexual risks, whatever about their sexual risks. Why do UNAIDS and the HIV industry seem only to consider their sexual risks? Piot et al and Kimani et al are not exceptional in completely ignoring the possibility of massive levels of healthcare transmission of HIV; the entire industry has grown out of denying that unsafe healthcare could have played a part in transmitting a virus that is a lot less efficiently transmitted through heterosexual sex.

For a long time in Kenya (and other developing countries), family planning had been seen as a means of ‘promoting economic development’, as well as ‘improving maternal and child health’. It wasn’t just highly intrusive and aggressively promoted because it was seen as beneficial to Kenyans and other Africans, but also because it was seen as a means of reducing population growth and averting an eventual global shortage of food, water and vital resources. In the same way that preventing and treating diseases in developing countries was a way of ensuring a ready supply of cheap labor in resource rich countries, family planning was seen as a way of controlling birth rates and population increases beyond what was needed for labor. For many NGOs operating in African countries now, family planning is development; and ‘maternal and child health’ consists of, pretty much, family planning. It is seen as something of a truism that maternal and child deaths can be reduced most readily by reducing fertility rather than, say, improving conditions in hospitals and elsewhere.

A 1973 paper reveals something about conditions in STI clinics in Uganda (Arya, 1973). For a start, it is pointed out that over 90% of the population lives in rural areas. Therefore, most of the population’s health needs are catered for by rural health centers, dispensaries and other minor facilities, staffed mainly by auxiliaries, rather than by more highly trained professionals. Whether it is because STIs were common or because the colonial and post-colonial administrations were exceptionally interested in them, Arya argues that “venereal disease played an important role in the organization of the medical services in Uganda in the beginning of this century.” Mulago Hospital, started in the second decade of the 20th century as an STI clinic, became and remains the largest referral hospital in the country. This is similar to Kenya, with specialist STI services being available in Mombasa and Nairobi for many decades. Health expenditure is low, estimated at around one dollar per year per person in the mid 70s, but basic health services were provided free of charge. Arya alludes to the lack of success of most STI programs, in both developing and rich countries, in bringing these diseases under control; he suggests that there are other diseases that may be in more urgent need of attention. Arya also notes that private practitioners provide STI services, mainly in larger towns, and that the quality of these services is unknown.

Arya published a paper in 1976 about the role of medical auxiliaries in STI control in developing countries (Arya & Bennett, 1976). In common with some other authors, Arya and colleague draw attention to the high disease burden faced by developing countries, coupled with the scarce resources, human, financial and material. These are particularly acute in rural areas, where most people live, but where well qualified professionals are reluctant to work. The authors also feel that STI services are mismanaged to the extent that they may be causing more problems than they are solving, with high prevalence resulting from “inadequate treatment, improper treatment or no treatment at all”. They mention high treatment default rates, find the contribution of private practitioners to STI control ‘questionable’ and conclude that the overall quality of services is poor. Diagnoses were unreliable (Burney, 1976), patients were receiving repeated injections of small doses of penicillin, which increased resistance, etc. Another paper notes the injection of large volumes of penicillin in some countries, which is likely to have involved the use of glass syringes and reusable needles in those days (Meheus, 1974). Contact tracing was generally beyond the capacity of STI service providers. Arya and Bennett recommend that medical auxiliaries specialize in STIs and that their training includes “knowledge of the local socio-cultural factors which largely determine traditional sexual mores” and note that STI patterns “differ from those in the western nations and may even vary from one area to another within a country”.

The papers cited above and in Part VI give a few insights into what things were like in terms of STI programs in Kenya and Uganda in the 1970s. Many of those said to be dying of ‘slim disease’ in Uganda in the early 1980s could have been infected with HIV as long as ten years before. If the rate of new infections peaked in the late 1980s, transmission would have been increasing throughout the 1970s, reaching its peak in the late 1970s. Why incidence peaked and then declined is another story. It may have had something to do with the 1978-1979 war with Tanzania (wars tend to be periods of low HIV transmission (Gisselquist, 2004)), the civil war from 1981-1986 or, much more likely, a combination of factors. Incidence began to increase a few years later in Kenya, perhaps in the mid 1970s, reaching a peak in the early 1990s, as discussed elsewhere. However, incidence started to increase earlier among certain groups, such as sex workers, transport workers and others who, significantly, had been targeted by STI eradication programs for decades. Incidence also would have peaked and begun to decline earlier in these groups.

Conditions in Kenyan health facilities in the 1970s, especially those providing STI and family planning services, were poor. If a blood-borne virus were to establish itself in one or more of these facilities, there would have been plenty of scope for it to be transmitted widely, not just among populations aggressively targeted by various health programs, but also among those requiring other health services, such as antenatal care. The risks of widespread transmission of HIV in health facilities were not recognized for a number of years and many more years had passed before any of these risks were addressed (some have yet to be addressed). But western HIV awareness campaigns were hijacked long ago by various parties who wished to present the virus as one transmitted almost entirely through ‘promiscuity’, and who wished to deny the possibility of transmission in health facilities. Because most of those infected in African countries were heterosexual, a different story about transmission needed to be created. Unfortunately, the same campaigns and strategies were exported from wealthy countries, where transmission was almost entirely a result of male to male sex or intravenous drug use. These campaigns were supremely unsuccessful in Kenya, but this was blamed on the failure of individuals to change their sexual behavior, rather than on any non-sexual mode of transmission.

If HIV transmission in health facilities and through other non-sexual modes continues, the virus will not be eradicated. More poignantly, if health facility transmission had been addressed in the 1980s, when it was realized that this was a very efficient mode of transmission, the virus would never have infected so many people. Some of the worst epidemics in the world only got going in the late 1980s or early 1990s, such as Zimbabwe, Botswana, South Africa, Swaziland, Mozambique and others. Many of the biggest players (bureaucrats, politicians, publicists, academics, industrialists, etc) currently driving the HIV industry have been in the business since the 1980s. Must Kenyans and other Africans wait till these ‘experts’ are gradually replaced by more enlightened personages? It is to be hoped that new generations of practitioners are not obliged to choose between adopting the deeply engrained institutional prejudices of their profession, or accepting the status of ‘dissident’ or ‘denialist’, unable to publish, teach or even present their views to the industry.

 

REFERENCES:

 

Arya, O. (1973). Changing patterns in the organization of the venereal diseases and treponematoses service in Uganda. Brit. J. vener. Dis, 134-138.

Arya, O., & Bennett, F. (1976). Role of the medical auxiliary in the control of sexually transmitted disease in a developing country. Brit. J. vener. Dis., 116-121.

Burney, P. (1976). Some aspects of sexually transmitted disease in Swaziland. Brit. J. vener. Dis., 412-414.

Gisselquist, D. (2004). Impact of long-term civil disorders and wars on the trajectory of HIV epidemics in sub-Saharan Africa. SAHARA J., 114-27.

Hopcraft, M. V. (1973). Genital infections in developing countries: experience in a family planning clinic. Bulletin of the World Health Organization, 581-586.

Kimani J, K. R.-A. (2008). Reduced rates of HIV acquisition during unprotected sex by Kenyan female sex workers predating population declines in HIV prevalence. AIDS, 131-7.

Meheus, A. D. (1974). Prevalence of gonorrhoea in prostitutes in a Central African town. Brit. J. vener. Dis., 50-52.

Pepin, J. (2011). The Origins of AIDS. Cambridge : Cambridge University Press.

Piot P, P. F.-A. (1987). Retrospective seroepidemiology of AIDS virus infection in Nairobi populations. J Infect Dis, 1108-12.

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