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Revised History of HIV in Kenya – Part III – Chronology


I mentioned some historical factors in Part II, so I’ve put together a timeline for Kenya’s epidemic, which seems appropriate in a history, especially a quick and dirty one. Some of the factors involved in HIV epidemic spread date back to the beginning of the century (or the beginning of humanity in the case of population). The table only lists some factors that have played, or are said to have played, a significant role; others will crop up later.

HIV Timeline Kenya

[Click on image to expand]

These factors would not have made it in any way inevitable that HIV would spread rapidly in certain places, more slowly in others and hardly at all in a few. That’s not what I’m arguing here. But there is an exception, a factor which doesn’t yet appear in the above table. Unsafe healthcare facilities to which the majority of a population has access render outbreaks of certain diseases more likely, and probably facilitate the exponential growth of some of those diseases more efficiently than any other factor possibly could. This is not true for HIV alone (or even MRSA in wealthy countries). TB can spread in health facilities (though deep mines are likely to be far more notorious in this instance), as seen in the case of Tugela Ferry in South Africa. Hepatitis C (and B) has often been spread widely through public health programs, such as in Egypt. Ebola is also very easily spread this way, and early accounts from some outbreaks are fairly explicit about this. Many of the people infected in the current outbreak are healthcare personnel. Many more were likely to have been infected by contact with other infected people in health facilities, perhaps even through contact with doctors and nurses (either because the doctors or nurses were infected or because their protective clothing was contaminated). Unsafe healthcare, as mentioned in Part II, is said to have ‘kickstarted’ the HIV epidemic. But conditions in healthcare facilities in African hospitals are appalling, so unsafe that the UN warns its employees not to use them. Tourists are warned to avoid injections and other procedures, even to carry their own injecting equipment. It’s only Africans themselves who are urged to go to health facilities and public health programs, without any warnings about unsafe practices or risks.

What is inevitable is that, if there is ever an outbreak of a disease that can be spread through unsafe healthcare, it will result in a serious epidemic in countries where conditions in healthcare facilities are unsafe. Such outbreaks have been documented in the case of HIV in Libya, Kazakhstan, Kyrgyzstan, Romania and other countries. But the possibility of such outbreaks in sub-Saharan African health facilities has not been investigated. Or, if such an occurrence has been investigated, the findings have never been published.

So there were political, economic, environmental, ecological, demographic and various other factors in play long before HIV first reached Kenya, said to be some time in the 1950s. They are briefly mentioned in the above table because they need to be explained, which requires some historical detail (more than a superficial account is beyond the scope of this post). Therefore, I shall jump to the end of the colonial period right now and address remaining issues another time.

The first 10 or 15 years of independence saw a lot of progress in Kenya, especially in education and healthcare. Spending increased to provide these and other services for everyone, rather than the select few who would have had access to them before independence. The relative prosperity of this period was short lived. Global and more local economic and political events in the 1970s and 1980s would have already begun to interrupt progress. But the need to accept loans from the World Bank and the IMF, which had strict ‘austerity’ conditions attached to them, spelled the end of improved access to health and education, cuts in all public spending, wage freezes, spiraling unemployment and a severely reduced public sector, including health and education, which are among the biggest employers.

In 1978 Moi took over from Kenyatta, the first president after independence, and was happy to comply with the stringent conditions demanded by these international financial institutions through their structural adjustment policies, as long as it meant he could get his hands on a lot of money. He remained president for 26 years, during which time the population went from 16 million to about double that figure, while health, education, infrastructure and other sectors were held, nominally, at around 1980s levels, although these sectors declined rapidly during the Moi regime.

This is where the story becomes surprising (if you think it’s all about sex). HIV had been around for a few decades, albeit unnoticed. But it spread rapidly from some time in the 80s and prevalence probably peaked in the late 90s, at 10 or 11%. Very high death rates, peaking in the early to mid 2000s, helped ensure that prevalence was halved by 2012 or 2013, according to the latest figures (although that’s 5% of a population that is increasing at over 2.5% per annum). But why would HIV prevalence decline when the worst effects of structural adjustment policies were being felt, from early in the 1990s onward, as it appears from my (admittedly rough) chronology? The annual rate of new infections, incidence, is said to have peaked in the early 90s, which would account for a peak in prevalence a few years later, and a subsequent drop. But we associate increased levels of spending on health, education, infrastructure and the like on development, better education, and better levels of health. How could the epidemic appear to be receding at precisely this time? The country had done nothing to deserve improvement in any area of health, let alone HIV, which Moi refused to acknowledge for most of his term of office.

When I wrote the brief account of HIV in Kenya five years ago, I was still busy questioning some of the completely unexpected findings I had uncovered for my dissertation, most or all of which the HIV industry was already aware. Why were wealthier people often more likely to be infected? Why were urban dwelling people also more likely? Why were ‘unsafe’ sexual behaviors often little more associated with HIV transmission than an absence of such behaviors, or the presence of ‘safe’ sexual behaviors? In Kenya, almost all development indicators were at their lowest in the Northeastern province, but HIV prevalence was also lowest there. Condom use was minimal, fertility rates were high even for Kenya, gender inequality was high, polygamy was common, as was female genital mutilation, intergenerational sex and marriage (large differences in age between partners, usually older men and younger women) were far more common than anywhere else in the country, and many people had little knowledge of HIV.

The list continues. Population was growing rapidly in some of these areas, several were undergoing urbanization (or something similar) and population density was increasing in others. Shortly after I started studying HIV it was clear to me that it couldn’t possibly be all about heterosexual behavior, I just didn’t know what could account for very high prevalence figures in some places and low figures in others. Upon visiting Kenya in 2002, when everyone told me about ‘traditional’ practices and all manner of factors that resulted in high rates of HIV transmission, they were also talking about how ‘abstaining’ (a word I associated with religion), ‘faithfulness’ (a word I associated with courtly love) and ‘condomizing’, a word I didn’t associate with anything at all, were resulting in declining prevalence figures. How could this be, and weren’t high death rates already explaining these drops in prevalence?

Obliged to exclude certain modes of HIV transmission from my dissertation to keep it focused and within size restrictions, I was advised to lose sections on non-sexual HIV transmission. It took me a about a year to get back to that, but when I did, all the previously unexpected findings started to make sense: I was sure that HIV wasn’t solely transmitted through sex, I just didn’t know that the HIV industry had been so strenuously denying the proportion that unsafe healthcare, cosmetic and traditional practices had been contributing in the past, and were still, obviously, contributing. It became clear that the industry somehow resembled an old boy network infused with a kind of freemasonry, a fair amount of evangelical zeal, and a good helping of neo-eugenicism acquired from some of the big NGOs that got in on the HIV act early on.

HIV is transmitted through heterosexual sex, that’s not in question. But people in Northeastern province don’t have much access to healthcare, infrastructure, education or many other benefits, and that is what may have protected people living in that province from HIV. In contrast, people living close to better developed infrastructures, people in cities (especially Nairobi, Mombasa and Kisumu), wealthier people and people living closest to health facilities may have, where conditions in health facilities were not adequate, faced very high risks. They are not ‘at risk’ populations, so much as ‘populations put at risk’ by the institutions that persuade them to avail of their services but can’t always provide these services safely. There are, indeed, certain behaviors that increase the risk of being infected with HIV, but they are not all sexual behaviors, they are not all individual behaviors and they are not all the behaviors of poor, uneducated, powerless people, either.

It’s not that health, education and infrastructure are not benefits, they are. Kenyans and people of all underdeveloped countries need more healthcare, more education and more (appropriate) infrastructure, lots more than they have ever had. But unsafe healthcare can be a lot worse than no healthcare. When structural adjustment policies reduced access to the benefits of health, education and others, they may also have reduced the exposure of most people in Kenya to an important, but rarely discussed, HIV risk.

An estimated 1.6 million people are living with HIV today, but that’s a relatively small percentage of the population. HIV prevalence in countries with far better and more equitable access to health facilities, such as Botswana, is among the highest three in the world. The HIV region where the epidemic is said to have begun, with relatively poor infrastructure, also has a far less serious epidemic than the southern region. Where road networks are almost entirely absent, such as in the Northeastern province of Kenya (and some countries in low prevalence North Africa), there are few health facilities, and access to these facilities is low. But along Kenya’s best road networks (which are certainly nothing to boast about) HIV prevalence is higher. The best health facilities are not found in isolated areas, of course. But nor are the best health facilities likely to have been safe places in the 1980s and 1990s. Some of them are still unsafe, we just don’t know how unsafe, and exactly what proportion of HIV is transmitted through unsafe healthcare.

Infrastructure alone didn’t result in rapid transmission of HIV, much of that was built during the colonial period. Nor did the existence of health facilities, or even public health programs, guarantee that a HIV epidemic would be severe. But increased access to health facilities where safety standards sometimes (often?) fell below par might explain the huge increases in HIV prevalence that occurred inside very short periods. People outside of the HIV industry would wonder how a virus that is difficult to transmit through heterosexual sex could appear ti occur in ‘explosive’ outbreaks, with prevalence doubling in less than a year. The industry would assure them that ‘Africans’ clearly engage in levels of unsafe sex that is beyond what any non-Africans could manage. Those whose prejudices already matched those of the HIV institutions accepted this explanation. Anyone who continued to question such a racist view of HIV was accused of denialism and shunned by their professional colleagues (unless they didn’t have any professional colleagues, or a profession).

Much of the evidence collected over the last 30 years, even evidence collected by the HIV industry itself, points to a rule of thumb: you can not work out levels of sexual behavior from HIV prevalence; and you can not work out HIV prevalence from levels of sexual behavior. But the HIV industry, outrageously, insist that high HIV prevalence in African countries is evidence for high rates of ‘unsafe’ sexual behavior, and  that high rates of sexual behavior ‘explain’ or predict high rates of transmission.

When I turned my attention to non-sexual HIV transmission I came by a small group of people who are still questioning the orthodoxy, as they had been doing for many years. Some have retired, others don’t depend on HIV related funding for their work, most are doing it for free. There are those who had been involved in HIV related work, and they are either ignored or treated with contempt for even talking about unsafe healthcare, or anything else that makes the sexual behavior paradigm look like the institutional racism that it is. The mere mention of some names involved can end a conversation, or elicit  no more than a peremptory gesture, which is the only evidence the HIV industry has yet been able to muster against the possibility that non-sexual modes of transmission may make a significant contribution to the most severe HIV epidemics in Africa.

In Kenya, people will still tell you about how much ‘Africans’ love sex. If you ask why prevalence in Homa Bay, bordering on Lake Victoria, is 135 times higher than it is in Wajir, not far from the border with Somalia (though not very close to anything else worth speaking of), they will say that people around Lake Victoria love sex. Beyond that, they have no credible explanation. Every now and again there’s a flurry of activity around some issue that attracts the media’s attention and this can crop up in conversations. For example, in 2002 some people were still talking about ‘devil worship’, for which a well publicized commission was set up, and which never published the results of its inquiries. But HIV stories drowned out even stories as titillating as devil worship. People around Lake Victoria will tell you with great relish about the sexual behaviors of fishermen, ‘barmaids’, transport personnel, Ugandans, Luos (the predominant tribe around Lake Victoria) and various other groups that have at various times been held up for scrutiny by the HIV industry and, as a result, thoroughly stigmatized.

HIV has been in Kenya since just after the middle of the 20th century and it was recognized from the early 1980s. It has spread around the country, though very unevenly, perhaps over a period of 40 years. The HIV industry has convinced Kenyans that it is individual sexual behavior that ‘spreads’ HIV. But transmission rates declined before any effort was made to address the epidemic, something the HIV industry are unable to explain. So the epidemic is still very much alive, and unexplained by the orthodox story. Kenyans still don’t know what is driving the epidemic, therefore they don’t know how to prevent it from continuing.

There’s more, a lot more. Hopefully I’ll have time soon.

Lessons from three previous Ebola outbreaks


Newspapers, web, and TV have been delivering a crescendo of reports and comments on West Africa’s Ebola epidemic. A lot of what is available for public consumption scares people who are not at risk. At the same time, people at risk are not getting adequate advice from official sources to make informed decisions about how to protect themselves and their loved ones.

In this situation, it’s useful to take a look back at three well-studied and well-reported Ebola outbreaks: the first two recognized outbreaks in 1976 in Sudan and Zaire (currently Democratic Republic of the Congo) and a later outbreak in Kikwit, Zaire, in 1995. Official committees of experts studied each of these outbreaks and reported what they found in the Bulletin of the World Health Organization in 1978 and in the Journal of Infectious Diseases in 1999.

Nzara and Maridi, Sudan, 1976

The first recognized Ebola outbreak began in Southern Sudan in late June 1976 and ended in November 1976. A WHO/International Team coordinated a detailed and thorough investigation of the outbreak, reporting 284 cases and 151 deaths. Information and quotes in this and following paragraphs are from: Bulletin of the World Health Organization, 1978, pp 247-270, available at: http://whqlibdoc.who.int/bulletin/1978/Vol56-No2/ (accessed 2 August 2014).

The outbreak in Southern Sudan was traced to infections among workers at a cotton factory in Nzara town beginning in late June. The source of the virus is suspected to be bats or other animals living in the factory. During the outbreak, 9 factory workers got ill with Ebola (p 253); most subsequent infections came from household contact. “The outbreak in Nzara died out spontaneously” (p 254) after 31 deaths. Before the Nzara outbreak ended, cases from Nzara spread Ebola to two other communities, Tembura and Maridi. In Tembura, a woman from Nzara introduced Ebola that killed three close contacts; that was the end of it in Tembura. In Maridi, Ebola spread from two people from Nzara treated at Maridi’s hospital, which “served both as the focus and the amplifier of the infection” (p 252). Transmissions in Maridi lead to 116 deaths. Several patients from Maridi went for treatment in Juba, resulting in one additional infection and death among Juba’s hospital staff.

“The difference between the Nzara and the Maridi outbreaks is best exemplified by examining the focus where patients most probably became infected. Few patients (26%) were even hospitalized in Nzara, and they seldom stayed more than a few days, but in Maridi almost three-quarters of the patients were hospitalized, and often for more than two weeks. As a result, Maridi hospital was a common source of infection (46% of cases), whereas the Nzara hospital was not (3% of cases)…” (p 253).

A WHO/International Study Team arrived in Maridi towards the end of the epidemic and stayed to the end. The Study Team recruited surveillance teams to scout for cases in communities around Maridi. “A large number of cases of active infection were soon discovered; each was reported to the Sudanese officials and an ambulance accompanied by a Public Health Officer was sent to the house. Patients were persuaded to enter the isolation wards at the hospital” (p 250). Significantly, Public Health Officers did not force suspected cases to go to the hospital: “Some refused, and in these cases relatives were warned of the grave risks, and advised to restrict close contact with the patient, and to limit it to only one close relative or friend. Protective clothing was offered but usually refused.”

Yambuku, Zaire, 1976

The first recognized case reported symptoms on 1 September. The last death occurred just over two months later on 5 November 1976. An International Commission managed a detailed and thorough investigation of the outbreak, reporting 318 cases and 280 deaths. The information in this and following paragraphs is from the Bulletin of the World Health Organization, 1978, pp 271-293, available at: http://whqlibdoc.who.int/bulletin/1978/Vol56-No2/ (accessed 2 August 2014).

“The index case in this outbreak had onset of symptoms on 1 September 1976, five days after receiving an injection of chloroquine for presumptive malaria at the outpatient clinic at Yambuku Mission Hospital… [A]lmost all subsequent cases had either received injections at the hospital or had had close contact with another case. Most of these occurred during the first four weeks of the epidemic, after which time the hospital was closed, 11 of the 17 staff members having died of the disease…” (p 271).

“Five syringes and needles were issued to the nursing staff [at the Yambuku Mission Hospital] each morning for use at the outpatient department [with an average of 200-400 outpatients each day], the prenatal clinic, and the inpatient wards [with 120 beds]. These syringes and needles were apparently not sterilized between their use on different patients but rinsed in a pan of warm water. At the end of the day they were sometimes boiled” (p 273).

“The epidemic reached a peak during the fourth week, at which time the YMH [Yambuku Mission Hospital] was closed [on 3 October], then it receded over the next four weeks” (p 279). “[I]t seems likely that closure of YMH [Yambuku Mission Hospital] was the single event of greatest importance in the eventual termination of the outbreak” (p 280). The last recognized transmission occurred in late October.

The International Commission organized surveillance for cases in communities around Yambuku. “Suspect cases were not closely examined, but medicines were given to them and arrangements were made for their isolation in the village… [P]hysicians were sent to follow up suspect cases…” (p 276). Notably, surveillance teams did not force or even urge suspect cases to go to hospital. In any case, the outbreak in and near Yambuku had already died out on its own, with the last probable case dying on 5 November, four days before surveillance began on 9 November (p 277).

The International Commission collected and reported data on transmission from cases to family members. In 146 families with one or more cases acquired from outside the family, 1,103 family members were exposed, of which 62 (5.6%) got sick with Ebola (p 282). In other words, there was less than a 50% chance a case would infect a family member (146 cases, or more if any family had more than one case, infected a total of 62 family members). Thus, once the hospital closed, each case infected on average less than one family member, so the epidemic died out on its own.

Kikwit, Zaire, 1999

An International Scientific Commission investigated an Ebola outbreak in Kikwit, DRC, a large, sprawling town with a population reported at 200,000-400,000 at the time of the outbreak. The investigation identified 315 cases between 6 January and 16 July; out of 310 cases with adequate information, 250 died. Information in this and subsequent paragraphs is from a 1999 special issue of the Journal of Infectious Diseases, available at: http://jid.oxfordjournals.org/content/179/Supplement_1 (accessed 3 August).

During the Kikwit outbreak, 80% of case patients were hospitalized to treat their Ebola illness (page S82). However, hospitalization did not interrupt contacts between family members and case patients (p S88): “As in much of Africa, the families of inpatients are responsible for providing food and many other aspects of patient care, such as cleaning bedpans and washing soiled clothing and linens. Often family members arrange to sleep on the hospital ward [even sharing the patient’s bed; p S90] to assure continued care through the night.”

A study of secondary infections among 173 household members of 27 case patients found 28 secondary infections in 15 households (7 had >1 secondary case). “The exposure that was most strongly predictive of risk for secondary transmission was direct physical contact with the ill family member, either at home in the early phase of illness or during the hospitalization” (p S89). The 28 secondary cases occurred in 95 household members who had touched the case patient during early or late illness; whereas none of 78 household members who had not touched the patient at that time got sick, even though many slept in the same room, shared meals, or touched the patient before illness (p S89).

“There was an additional risk associated with a variety of exposures to patients in the terminal stages of illness, such as sharing a hospital bed or hospital meals and touching the cadaver” (p S90). “[T]he use of barrier precautions by household members and standard universal precautions in hospitals would have prevented the majority of infections and deaths…” (p S91).

During case surveillance in and around Kikwit town (p S78), “persons who met the case definition…were instructed to seek medical evaluation and possible hospitalization at Kikwit General Hospital…” However, this was not forced; if the sick person chose to stay home, family members “were educated on how to reduce their risk of infection…. Nurses previously trained in the sentinel clinics also visited household of probable case-patients to distribute protective materials (eg, a pair of gloves, soap, and wash basin) as needed and to reinforce educational messages about risks of transmission and symptoms suggesting disease in subsequent family members.” During surveillance outside Kikwit (p S78-S79), “Probable case-patients were confined in their households, instructions for care were given, and basic protective equipment was provided to the primary care givers.”

Lessons for West Africa, 2014

Based on reports from previous epidemics, here are several recommendations. The first is for people at risk to protect themselves. The second is for public health managers to deal with cases in a way that is acceptable to the community while at the same time ensuring transmission is too low to sustain the outbreak. Stopping the outbreak involves reducing the average transmission from each current case to less than one more case. Both recommendations contribute to that goal.

1. Recommendation to the public: If you are living in a community with Ebola cases, avoid injections, infusions, dental care, manicures, and all other skin-piercing procedures with instruments that might not have been sterilized after previous use. If you do this, and if you stay away from people with suspected Ebola infections, you have virtually no risk to get Ebola.

If someone stays away from sick people and funerals, the only remaining risk to get Ebola is through unrecognized contact with some unknown case. In previous epidemics, acquisition of Ebola from unrecognized contacts with unknown strangers has been confirmed through only one form of contact – blood-to-blood contact when health care workers reuse syringes and needles without sterilization to give injections to one patient after another. Reused, unsterilized skin-piercing equipment can pass Ebola from someone with the virus to complete strangers. If people in communities with Ebola avoid skin-piercing procedures – in hospitals, pharmacies, dental clinics, barbershops, beauty salons, from traditional healers, etc – the risk to get Ebola from some unknown source is near zero. Moreover, the public health risk – that people with Ebola will infect strangers not involved in patient care – will be too low to sustain the outbreak. (If you do go for an injection, manicure, or other skin-piercing procedure, you can ensure instruments used on you are sterile by following advice at: http://dontgetstuck.org/.)

2. Recommendation to public health managers: Accept and accommodate home-based care of suspected and even confirmed cases, if that is what the family wants.

For the sake of effective management of the epidemic, the challenge is to reduce transmission on average from each case to less than one more case. Based on reports from three well-studied outbreaks in 1976 and 1995, caring for an Ebola case at home results on average in less than one new case – that is enough to wind down the epidemic, which is a lot better than what has been achieved so far in West Africa in recent months.

If a suspected case with common symptoms (fever, diarrhea, sore throat) goes to the Ebola ward, what is the chance he or she does not have Ebola? If so, what is the chance he or she will get Ebola from another patient? Without good data showing near zero risk for patients to get Ebola in an Ebola ward, it is reasonable for people to fear and resist going there. And, because getting all cases into isolation wards is not necessary to stop the epidemic (see previous paragraph), there is no good public health excuse for using government coercion to force people to go. Can we expect parents willingly to send children with sore throats to isolation wards?

The risk to family care-givers is, nevertheless, substantial if the suspected case turns out to have Ebola. If families accept the risk, that’s their choice. However, that risk can be reduced by giving care-givers detailed advice about specific risks, providing protective gear, and advising in-house quarantine measures to protect family members and others.

In any case, forcing suspected cases to go to isolation wards is likely to undermine rather than enhance epidemic control. Consider: When people are afraid government will force them or their loved ones to go to an Ebola ward, they may hide sick family members (suspected cases), avoid public health personnel, and seek secret treatment from cooperative doctors or others who may or may not practice barrier nursing or sterilize instruments after use. Thus, the threat of force may well reduce, not enhance, the ability of public health managers to advise and to supervise treatment of cases to prevent onward transmission.

This recommendation to accommodate home-based care agrees with a recent decision by Sierra Leone’s President Ernest Bai Koroma to quarantine sick patients at home, a decision appreciated by Heinz Feldman at the US National Institute of Allergy and Infectious Diseases: “It could be helpful for the government to have powers to isolate and quarantine people and it’s certainly better than what’s been done so far…” See: West African outbreak tops 700 deaths, Associated Press 31 July 2014, available at: http://www.patriotledger.com/article/ZZ/20140731/NEWS/140739987/12662/NEWS (accessed 31 July 2014).

Risks the current outbreak will spread to other countries

Are people living in the US or UK or Australia at risk? No. Just as in Maridi, Sudan, in 1976, the risk is that a patient with Ebola acquired elsewhere will go to a hospital with poor infection control, and that the hospital will amplify the infection, spreading it into the community. This is not going to happen in Europe, the US, or most other countries because hospitals with adequate infection control will not amplify the outbreak.

However, there is a risk that Ebola from West Africa’s ongoing outbreak might spread to other countries in Africa. Wherever HIV, a slow-acting bloodborne virus, transmits through unsafe healthcare, there is a risk that Ebola, with an incubation period of weeks not years, will similarly spread through unsafe healthcare. Most countries in Africa have generalized HIV epidemics, with more women than men infected, and with only small minorities of infections explained by men having sex with men or people injecting illegal drugs. The public health community likes to blame Africa’s generalized epidemics on sex, but no one has been able to find sexual differences between Africa vs. Europe or the US that could explain Africa’s generalized HIV epidemics. What is different is that Africans get more exposures to reused but unsterilized skin-piercing instruments during health care and cosmetic services.

The existence of generalized HIV epidemics in a country is best explained by a lot of HIV transmission through unsafe health care along with some sexual transmission. The fear that Ebola from West Africa might spread to other countries is a realistic concern for countries with generalized HIV epidemics.

South Africa: Don’t Panic About Ebola, We Have Extremely Effective Surveillance Systems


Some may beg to differ with the health minister. While TB is very different from ebola, South Africans will (I hope) recall hearing about an epidemic of multidrug-resistant (MDR) and extensively drug resistant (XDR) TB being transmitted in health facilities in South Africa and surrounding countries, perhaps since the early 2000s. Scaremongering about infectious disease outbreaks doesn’t do anyone any good, but nor does underestimating the ease with which diseases can spread, within a country and internationally.

A three decade HIV pandemic has shown us that surveillance systems on their own are not enough. The XDR/MDR epidemic is very closely connected with the HIV epidemic in South Africa and has been attributed to poor infection control. Countries that wish to control disease spread need strong health systems. However, the reaction to HIV has not been a sustained strengthening of health systems as a whole, but rather a vertical, cherry-picking approach. The result is that most countries in sub-Saharan Africa now have crumbling health systems, massive shortages in skilled health personnel, inadequate equipment and unreliable vital supplies.

Conditions are so dangerous that UNAIDS advises UN personnel not to use health facilities in developing countries, although the institution seems to believe that the same facilities are fine for Africans. Guinea, Liberia and Sierra Leone have relatively low HIV prevalence, whereas the number of HIV positive people in Nigeria could be the second highest in the world; South Africa is home to the highest population of HIV positive people. This has only weakened health systems further.

Nor is there any need to single out South Africa, Nigeria or the three countries that have the worst ebola outbreaks so far. There are Service Provision Assessments and other reports for many African countries showing that basic supplies such as gloves, soap and water, drugs, even injecting and other equipment, are frequently lacking. There are also scores of articles alluding to dangerous conditions, some published many years ago.

The South African health minister, and health ministers in all African countries, would be better off using outbreaks of ebola, MDR and XDR TB, hepatitis and HIV as arguments for investing in health systems that can provide safe health services for everyone, rather than for the rich alone, or for those suffering from headline grabbing diseases. Nosocomial TB in South Africa is thought to have started more than ten years ago, and affects many health facilities, in several countries. Therefore, there have been numerous outbreaks over that period, not just a few isolated instances.

Many of the people who have died of ebola are health professionals and others who are probably more aware of the risks they face than their patients are. Claiming that health systems are fine and that they are able to cope is a betrayal of the work their health professionals are doing. Minister Dr Aaron Motsoaledi should tell the WHO and other international institutions something that is an open secret about healthcare safety in African countries – it is in very urgent need of attention.

Nigeria, Unsafe Healthcare and Bloodborne Virus Epidemics


An article in a Nigerian newspaper highlights the very serious hepatitis epidemic there, with an estimated 20 million people, about 12% of the population, infected with either hepatitis B (HBV) or C (HCV). Although one of the ways HBV can be transmitted, and the way HCV is usually transmitted, is through blood, it is less common to find explanations of why or how people come into contact with someone else’s blood, or how to avoid this.

The Don’t Get Stuck With HIV site gives details of numerous ways you can come into contact with someone else’s blood through healthcare, cosmetic and traditional practices. Healthcare practices include antenatal care, birth control injections and implants, transfusions, child delivery, dental care, donating blood, injections for curative and preventive reasons, catheters, male circumcision and others.

Cosmetic practices include manicures and pedicures, shaving, tattooing, body piercing, use of Botox and other products, performance enhancing drugs and perhaps colonic irrigation. Traditional practices include male and female genital cutting (FGM and MGM), traditional medicine, scarification and various other skin-piercing practices.

The Don’t Get Stuck with HIV site also lists some of the steps you can take to protect yourself from exposure to HIV, HBV, HCV or other bloodborne pathogens, even ebola. The site also links to articles and sources of data about unsafe healthcare, unexplained HIV infections and other indications that risks for bloodborne transmission of various viruses are not always so widely recognized.

As a result, people often don’t know there is a risk and they don’t know how to protect themselves. This is as true of HIV in high prevalence countries with inadequate health services, HBV and HCV in countries where those viruses are common, and even ebola or other haemorrhagic viruses, when such an outbreak occurs. Indeed, ebola epidemics have only occurred in countries where healthcare is known to be unsafe, such as Democratic Republic of Congo, Sudan, Uganda, Guinea, Sierra Leone, Liberia and most recently Nigeria.

Two lengthy reports on healthcare safety in Nigeria have been published in the last few years. The second was a survey using the WHO’s ‘Tool C’, also used for the survey from Philippines mentioned in a recent blog. Bearing in mind the warnings we are currently hearing about ebola, and the warnings we should have been hearing about HIV and hepatitis:

Of the health facilities observed, only 23 (28.8 percent) had soap and running water for cleansing hands, and no facility had alcohol-based hand rub available.

Overall, fewer than half of all injections observed were prepared on a clean surface…

They found that injection providers only washed their hands in 13 percent of cases; none used an alcohol-based hand rub…

Fewer than half of the providers were seen to use water or a clean wet swab to clean the skin before vaccination, therapeutic, and family planning injections…

For vaccination, in 79.7 percent of cases, auto-disable syringes were used.

However, for dental procedures, there were two observations where providers used sterilizable syringes, and of these two, one of them also used a sterilizable needle…

18.7 percent had a needle left in the diaphragm of a multi-dose vial.

When glass ampoules were used during vaccination, the providers used a clean barrier in 1 of the 11 vaccination injections observed. Providers used a clean barrier in the only such dental injection observed, 3 of 11 family planning injections, and 4 of 43 therapeutic injections observed (9.3 percent).

Providers generally used standard disposable needles and syringes (70 percent) for phlebotomy procedures, and lancets for procedures requiring lancing (78.6 percent). Providers were rarely seen to use safety devices such as auto-disable and retractable syringes…

62.6 percent of procedures were prepared on a clean, dedicated table or tray where contamination of the equipment with blood, body fluids, or dirty swabs was unlikely (in 42 out of 67 hospitals and 20 out of 32 lower-level facilities).

[for blood draws and intravenous procedures] Overall, providers washed their hands with soap and running water in only 2 of the 99 observations.

Data collectors observed that patients shared a bed or stretcher with another patient in 17.6 percent of IV infusions. This was also the case for 4.5 percent of IV injection patients.

Data collectors observed that in 69.3 percent of cases, the provider used a clean gauze pad and gently applied pressure to the puncture site to stop bleeding after the procedure.

Only 10.5 percent of providers cleaned their hands with soap and water or an alcohol-based hand rub following the observed procedures. In the 35 cases in which there was blood or body fluid contamination in the work area, the area was cleaned with disinfectant in 20 percent of observations (see Table 14).

During interviews, five percent of providers (11 out of 217) reported that they used sterilizable needles in injections, phlebotomies, IV injections, or infusions. Of the 5 out of 187 supervisors who reported use of sterilizable syringes and needles, three said that fuel was always available to run the sterilizer, while the remaining two reported that fuel had been unavailable for less than one month at some point.

Half of the 80 health facilities had infectious waste (non-sharps) outside of an appropriate container.”

This list includes only some of the risks to patients. There is also a section on risks to the provider, risks to other health staff, such as waste handlers, and risks to the community. Nigeria is unlikely to have the worst health facility conditions in Africa and there are many areas of healthcare safety requiring urgent attention.

When news reports about ebola constantly emphasize things like eating bushmeat and ‘traditional’ practices at funerals, think of the kind of conditions that can be found in Nigerian hospitals even when healthcare personnel are aware that an inspection is taking place. When reports about hepatitis concentrate on intravenous drug use and other illicit practices, and when reports about HIV seem to be almost entirely about sexual behavior, conditions in health and cosmetic facilities and contexts where traditional practices take place must also be relevant.