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Category Archives: iatrogenic

Guardians of the Orthodoxy: Writing about Rights and Rites

Comments Off on Guardians of the Orthodoxy: Writing about Rights and Rites Posted by on October 12, 2013

[Cross posted from the Blogtivist site]

Following a facile article in favor of mass male circumcision on the Poz.com site (which I discuss on another blog), where the author went to some lengths to pretend he was not in favor of it, there is an article defending circumcision as a religious rite for Jewish people, with even a single mention of Muslims (at a time when even vaguely pro-Muslim, or non-anti-Muslim, sentiment in the media is particularly unfashionable) in the English Guardian. The title of the Guardian article reads: “A ban on male circumcision would be antisemitic. How could it not be?” The article purports to be a response to the Council of Europe’s ‘comparisons’ of male genital mutilation with female genital mutilation, with the author claiming there is no acronym for the former, suggesting that she has familiarized herself with neither the literature nor the operation.

But enthusiasm for circumcision is not confined to the operation as a religious rite. The big money is behind it as a ‘preventive’ against HIV and several sexually transmitted infections. Starting with adults and teenagers as targets for mass male circumcision campaigns, proponents have long been setting their sights on infants. Never mind the fact that most infants don’t engage in any kind of sexual behavior, least of all a kind that would be claimed to increase the risk of HIV transmission in those who have not been circumcised, not even by the most rabid proponent of the operation. Proponents of circumcision *want* to circumcise everyone, at all costs. What could be easier than starting with Africans, about whom few in the media care very much.

What has the Poz.com argument got to do with the Guardian article? After all, Poz.com is promoting circumcision for its claimed protection against HIV and the Guardian is promoting it as a religious rite. Well, both articles argue for the mainstream, financially sound view, the view that doesn’t fly in the face of current political sentiment and, more importantly, doesn’t fly in the face of important funders and supporters. Poz.com depends on big pharma for its funding, along with some other wealthy institutions. The Guardian does not (entirely), but the Guardian’s Development section is funded by the Gates Foundation. That is higly significant when it comes to circumcision: the Gates Foundation is not just pro-circumcision, it funds one of the three main websites that promote circumcision, the Clearinghouse on Male Circumcision for HIV Prevention (the other two are the WHO and USAID).

In fact, the Foundation has also funded research carried out on African participants, research that is highly questionable, ethically as well as empirically. The Guardian’s article doesn’t appear on their Development section, but the connection with as huge a figure in the realm of circumcision promotion as Bill Gates is of a significance that should not be dismissed lightly. In addition, the Guardian article defends circumcision as a religious rite, but the Poz.com article, by implication, opposes non-circumcision as a cultural right. Ethically and empirically dubious arguments are being shoved down the throats of Africans who do not currently circumcise, by people who do not consider for one moment that others have the right to choose not to circumcise, for cultural reasons. In Kenya, for example, it is for cultural reasons that members of the Luo tribe do not circumcise, and the same goes for many other Africans. It is not because they, like the Europeans, do not believe that the reasons given for mass male circumcision are completely unconvincing (arguments that have changed many times over the decades, except in the fervor with which they are expressed).

Back to Tanya Gold’s arguments in the Guardian. The Council of Europe, astutely enough, used the phrase violation of the physical integrity of the body’ to describe male circumcision. Even defenders of the operation could hardly deny that it violates the physical integrity of the body, could they? After all, that’s the point of it, as a rite and as a putative protection against HIV. Gold doesn’t tell us if she would object if the Council had attempted to suggest that parents be allowed to wait until their boys were old enough to decide whether to be circumcised or not. After all, compromises have been made before. Religious and cultural rites have been modified, even abandoned altogether. Tattooing and body piercing are not banned, but people are not permitted to tattoo and pierce parts of their babies, or even their children. These also violate the physical integrity of the body, although many people believe that they are worth having, for cosmetic or other reasons.

Even Gold is ‘repulsed’ by certain conditions that may surround circumcision, as if these conditions are not common. But most circumcisions are carried out in non-sterile, non-clinical conditions. In fact, like the violation of the physical integrity of the body, this is what makes them a matter of religious or cultural rite, rather than an operation that people can have carried out in a hospital, preferably when they are old enough to decide if they want to have their foreskin removed. Gold is not arguing for these conditions, but she is arguing for the religious right to perform circumcisions, and (perhaps) for the cultural right (or maybe she only considers Jewish circumcision to be worth defending? She is not clear on this.) Would Gold consider allowing parents to wait until their son could decide for himself? We expect those who perform rites and rituals we (in the West) consider repulsive, harmful, etc, to compromise or even abandon those rites and rituals. Why not discuss such a compromise with those who practice circumcision?

Gold objects to calling ritual circumcision a ‘violation of children’s rights’. But if there are exceptions to a law against violation of children’s rights, and violation of the physical integrity of the body in particular, how does this affect other children’s rights, even human rights in general? Can you argue that certain rights should be denied to those infants where parents believe that that would constitute a denial of their own religious rights to circumcise their child? Are human rights not interrelated, interdependent and indivisible: Gold seems to believe that circumcision does not involve violation of the physical integrity of the body, which is ridiculous, though she may prefer a different way of expressing the same thing. But she also seems to believe that circumcising infants is not a violation of their rights, and that banning infant circumcision denies parents their rights. She doesn’t make the distinction between infant circumcision and adult circumcision, but she seems to believe that the Jewish rite necessarily requires that it be carried out on infants.

Sadly, Gold has confined her arguments to the rights of Jewish people and chosen to write about antisemitism, rather than dealing with the broader issues of circumcision, human rights, the right to choose (particularly the right to choose not to circumcise), children’s rights and the like. True, she stuck her neck out by using the word ‘Muslim’ once and had the temerity not to include any other words beloved by journalists and home office officials as an accompaniment to the word ‘Muslim’, but she is clearly not in the business of standing up for what she believes in. It’s almost as if it’s not her job to believe in things. She invokes the typical ‘slippery slope’ argument: if circumcision is a “human rights violation against children… This is a trend – and so of course the next stage is prohibition.” We wouldn’t want to use emotive arguments, would we? There is a “dark marriage between human-rights agitators and racists”, according to Gold.

Which means that in objecting to infant circumcision, either as a religious rite or as a means of ‘preventing’ HIV, I am not just an antisemite, but I am also in bed with racists. I am supporting the “removal of Jews from Europe”. There was me thinking that I was arguing for human rights and against abuses of human rights, especially ones that journalists typically ignore, such as the rights of people who are not wealthy, or powerful, or perhaps people who are not even Guardian readers (who?), although I read the Guardian myself. Gold ends her piece with a sentiment that I would agree with if it were about journalists: “some Jews are always packed in their minds”. But I can’t reassert my credentials as a defender of human rights by accusing a journalist of having views that are formed independently of thought, evidence, logic or humanity; that’s shooting fish in a barrel.

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

What Happens when an ‘Activist’ Site is Bought off by the Multinationals?

3 Comments Posted by on October 2, 2013

The website ‘poz.com’, which is about HIV, but from a US point of view, has a recent article on circumcision by Ben Ryan, who is apparently a journalist. The strapline reads “Major studies support circumcision as prevention in Africa but a small yet vocal group argues the science is flawed. Can circumcision lower U.S. HIV rates?” The question is odd, because the article is not primarily about whether the operation can or can not lower transmission in the US (Ryan seems to suggest the answer is ‘yes’, but in a country where HIV transmission is predominantly among men who have sex with men and intravenous drug users, ‘no’ seems much more likely to be correct). The article is not really about the science either, but rather how that ‘science’ is used. (Even the title, ‘Cut to Fit’, sounds like an ironic reference to the author’s journalistic style.)

Ryan gives a selective review of the ‘science’ as he sees it, listing the major players in circumcision promotion, major in terms of the funding they receive, anyway. But all this is contrasted to an ‘ideological war’, by what Ryan brands as a small group of ‘dissidents’. The fact that many of those who oppose the imposition of mass male circumcision on tens of millions of African men who are not already circumcised, and male infants born to people who would not normally choose circumcision in infancy, are also scientists doesn’t seem relevant. The facts that skepticism is not inherently unscientific and that not all those who oppose mass male circumcision can correctly be referred to as ‘dissidents’ also seem unimportant to Ryan.

Although Ryan enjoys the term ‘intactivist’ to refer to people who oppose mass male circumcision on the grounds that the ‘science’ is highly flawed, this is not a widely used term by opponents. Some, like myself, oppose mass male circumcision on human rights grounds, and on the grounds that insisting on every man conforming to what is an American preference is an outrageous instance of cultural imperialism; but I certainly wouldn’t call myself an intactivist. According to Ryan, those who oppose mass male circumcision are mainly Americans and Europeans, without pointing out that those who promote it are almost all American, and all their funding is from America.

Part of the pretence of ‘giving both sides of the story’ involves interviews with people whom Ryan subtly belittles. One of those interviewed is John Potterat, who has carefully outlined the reasons for skepticism about the ‘scientific’ literature, which is freely available on the Social Science Research Network. According to Ryan and his favored informants, ‘dissidents’ are ‘hampering progress’, ‘spreading misinformation’ and ‘creating skeptics among those who stand to benefit’, the last referring to African people, whose future is being put in jeopardy because of a handful of unscientific people who are not epidemiologists or health scientists, and therefore should not hold an opinion on human rights or cultural imperialism, or so Ryan wants us to believe.

Ryan also interviews Rachel Baggaley, MD, who reassures us that the three million figure the WHO claims have been circumcised under the program sounds very low beside the 20 million originally hoped to ‘benefit’ from the operation because 20 million was an ‘aspirational’ figure; that the WHO had “underestimated the complexities and social sensitivities required to successfully promote the program in certain populations”. Could some of these ‘social sensitivities’ be similar to the views of the people Ryan considers to be a mere fringe of ‘dissent’? What Baggaley is delicately referring to is a dearth of safe health facilities, experienced health personnel and supplies needed to provide mass male circumcision that doesn’t result in a lot of botched operations and a huge increase in hospital transmitted HIV; also, that infuriating barrier to US cultural imperialism: foreigners, non-Americans.

Another ‘dissident’ cited is David Gisselquist, who has spent years publishing articles showing that unsafe healthcare and cosmetic practices may be making a significant contribution to the most serious HIV epidemics in the world, which are all in sub-Saharan Africa. The evidence for various types of non-sexually transmitted HIV is spread over hundreds of papers, written by people from various backgrounds, including public health, medicine, epidemiology and others. Indeed, one of the most important factors in transmitting HIV in African countries is circumcision itself, not just medical circumcisions carried out in unsafe health facilities, but also circumcisions that are carried out for cultural reasons, generally carried out in unhygienic conditions.

While presenting arguments against mass male circumcision in a context that makes them sound futile, Ryan lists the arguments for the program as if they were some kind of holy grail of truth, true for all time, in all places, as true for non-Americans as for Americans. Those pushing for the program keep going on about how similar the results of all the randomized controlled trials were, without this being held up to any kind of questioning; were these crusaders really so lucky, that all three trials came up with almost the same results? Why were the trials carried out in those areas, among those people, with those specific (poorly described) methodologies? Were any other trials carried out that may show the opposite effect? And why are the mass male circumcision programs going ahead in areas where HIV prevalence is already higher among circumcised men than uncircumcised men? What about current programs that are currently suggesting that mass male circumcision programs seem to be increasing HIV transmission, for example in Botswana and Kenya?

Oddly enough, Ryan gives the last word to Baggaley, who now refers to those who oppose the US funded mass circumcision of African men as ‘denialists’. She says they are generally not from high HIV prevalence countries, as if those promoting the program are. Seeing herself as having the perspective of a ‘young man in South Africa’, she finds objections to the operation to be ‘paternalistic’. Evidently she doesn’t see the paternalism in spending billions of US dollars on persuading people to be circumcised by telling them that there are numerous advantages to be enjoyed. How is that different from the various (also US funded) efforts to persuade poor people to be sterilized? How is that different from various syphilis ‘experiments’ carried out on African Americans, or similar ones carried out in Guatemala?

In stark contrast to Ryan’s stance of appearing to be ‘giving both sides of the argument’ while achieving no such thing, Brian D Earp has written a very cogent rebuttal of all the bits and bobs that Ryan thinks of as science. Earp does put his cards on the table: he is not undecided about whether mass male circumcision is a good or bad thing. But neither is Ryan, he just pretends to be. If you are interested in reading solid rebuttals of the arguments of those claiming to be ‘scientists’, and others, it’s worth reading Earp’s article in full. I can not do it any justice by paraphrasing it.

To conclude, branding people as ‘denialists’ or as being ‘unscientific’, even when the point is not a scientific one, or not entirely a matter of science, has a long history. Journalists pretending to be (or thinking that they are?) even handed is also an old trick. So people have to think for themselves: would you do it to someone you love, or would you wait till they were old enough to decide for themselves? And even if your answer is ‘yes’, and you would circumcise your son when he’s still an infant, does that mean tens of millions of African men should be persuaded by the US (and by US funded ‘Kofi Annan’ type figures) to do the same, using a hotch-potch of scare stories, half baked theories and outright lies, all dressed up as some kind of scientific canon, and that tens of millions of African infants should also be circumcised, their parents having been primed using the same body of ‘evidence’?

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

Risk of Blood-borne Viruses from Skin-piercing Beauty Treatments

Comments Off on Risk of Blood-borne Viruses from Skin-piercing Beauty Treatments Posted by on September 26, 2013

In the light of several recent news reports, the Don’t Get Stuck With HIV site has created a new page on possible risks associated with use of skin-piercing products such as Botox and Malanotan. Injection of anabolic steroids and other performance enhancing drugs can carry similar risks, especially if they are administered in an unsterile environment, and/or administered by untrained or inexperienced providers. The UK Government has issued a warning, saying that steroid users are at higher risk of HIV and viral hepatitis. The Don’t Get Stuck With HIV page offers easy to follow advice to people considering such treatments.

Similar information and advice on injections in general is available throughout the Don’t Get Stuck With HIV site; healthcare risks aside from injections are discussed here. There is also information on risks from other cosmetic treatments, such as tattooing, ear and body piercing, manicures and pedicures and hair styling and shaving. However, beauty treatments that pierce the skin may be more risky than some of these other cosmetic treatments because instruments such as needles go deeper below the skin than tattoo needles, for example.

A recent article on the BBC website draws attention to the concerns of a health watchdog about the safety of Botox injections in the UK. They are also questioning the safety of anabolic steroids, tanning agents and dermal fillers. These treatments can be obtained in salons, or they can be self administered. The article warns that sharing equipment can carry a risk of infection with HIV, hepatitis or other blood borne diseases. The UK’s National Institute for Health and Care Excellence (NICE) is currently preparing guidelines on these issues.

Botox is a prescription only drug. However, an Australian news network ran an article late last year about a ‘backyard botox’ clinic, a specific clinic in Western Australia where infection control practices were found to be lacking, highlighting some of the health risks involved. It is said that the risk of infection with blood-borne diseases is small, but nevertheless real. Some practitioners may offer such treatments in the home, where conditions are likely to be unsuitable.

In 2008, the BBC reported that a growing number of people in the UK are injecting themselves with an unlicensed hormonal tanning drug called Melanotan. It is possible that this drug is being sold illegally online, in salons, in gyms and in health and fitness centers.

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

Misinformation from UNAIDS’ flawed Modes of Transmission model

Comments Off on Misinformation from UNAIDS’ flawed Modes of Transmission model Posted by on September 14, 2013

To defeat HIV/AIDS in Africa, UNAIDS recommends: “Know your epidemic.” The best way to do so is to investigate to trace the source of infections – especially in children with HIV-negative mothers, virgins, and married people with HIV-negative spouses and no outside partners.

But that’s not what UNAIDS urges African governments to do. Instead, UNAIDS urges governments to use its Modes of Transmission (MOT) model to estimate numbers of infections from various risks.

But the MOT model contains a glaring error. Because of this error, whoever uses the model ends up estimating far too many infections coming from spouse-to-spouse transmission.

In Uganda, for example, the MOT model estimates that 60,948 married adults got HIV from their spouses during 2008. This is two-thirds of the model’s estimated total new infections from all risks in Uganda in 2008.

The MOT model got this number by supposing that 5.9% of married adults (421,000 adults) were HIV-negative with HIV-positive spouses, and that 14.5% of these spouses at risk got HIV from husbands or wives in 2008 (60,948 = 14.5% x 421,000).

But the number of spouses at risk is far, far less. Uganda’s 2004/5 HIV/AIDS Sero-behavioral Survey reports that 6.2% of husbands and 5.2% of wives were HIV-positive.  But – and this is the important fact the MOT model ignored – most HIV-positive husbands and wives were married to each other. Only 2.8% of wives and 1.8% of husbands were HIV-negative with HIV-positive spouses.

Overall only about 2.3% of married adults (averaging 2.8% of wives and 1.8% of husbands) were HIV-negative with HIV-positive spouses – only 222,000 vs. the 421,000 estimated in the MOT model. If 14.5% of these 222,000 adults got HIV from their spouses in a year, that would account for 32,100 new infections (14.5% x 222,000), far less than the 60,948 estimated in the MOT model.

Why is this important? Because if fewer infections are coming from spouses, how did so many Ugandans get HIV in 2008? In other words, the MOT not only over-estimates HIV from spouses, but also underestimates infections from other risks.

What risks are underestimated? Hold on now! Don’t run away with sexual fantasies about young people and some married adults having too much fun with non-spousal partners. Indulging in racist and stigmatizing sexual fantasies is something too many official AIDS experts like to do. But the evidence does not support such fantasies. The best information on sexual behavior does not come close to explaining Uganda’s epidemic.

Setting aside sexual fantasies, the underestimated risks are more likely to be those that UNAIDS’ staff and other health professionals want to ignore – skin-piercing procedures with unsterile instruments, such as injections, dental care, manicures, etc. This is true not only in Uganda but also in more than 15 other African countries that have used the MOT model to get ridiculous figures on numbers of HIV infections from spouses.

Remember how we began: The best way to “know your epidemic” is to trace infections. Let’s challenge HIV/AIDS researchers — finally — to do their job. Although it’s decades too late, tracing is still needed to find all the important risks and to stop Africa’s generalized HIV/AIDS epidemics.

[Note: This blog summarizes evidence and arguments in: Gisselquist D. UNAIDS’ Modes of Transmission model misinforms HIV prevention efforts in Africa’s generalized epidemics, available at:  http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2315554.]

HIV, iatrogenic, nosocomial , , , , , ,

Mainstream scientists have not explained Africa’s HIV epidemic. Why not?

1 Comment Posted by on August 23, 2013

John Potterat, a senior and well-published international expert on sexually transmitted diseases, has taken part in scientific debates about the relative contribution of sex vs. blood (injections, tattooing, etc) in Africa’s HIV/AIDS epidemics. He’s been frustrated for years. The loudest voices with the most money talking about HIV/AIDS in Africa — UNAIDS, WHO, USAID, Gates, and others — want to blame it all on sex. But they haven’t got the evidence to support what they say and what they want everyone to believe. Why are so many scientists who build their careers on HIV/AIDS in Africa so unscientific, so uncurious, and so careless about what they say and about the evidence?

Earlier this month, John Potterat published a brief but pointed and thoughtful critique of HIV research in Africa. You can download his article free from the SSRN website: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2310200

As a teaser, here’s the Abstract of the article:

The Enigma of HIV Propagation in Africa: Mainstream Thought Has Narrowly Focused on ‘Heterosexual Sex’

John J. Potterat, Independent consultant
August 14, 2013

Abstract:

Introduction: Three decades after the identification of AIDS, epidemiologists still do not fully understand HIV transmission dynamics in sub-Saharan Africa, nor its differential geographic and demographic spread.

Discussion: Despite mounting evidence suggesting a substantial role for nonsexual (puncturing) exposures in HIV transmission, researchers have not systematically investigated its impact on HIV propagation in Africa. Mainstream researchers initially reacted to this idea skeptically, then dismissed it in the short run as apostasy and chose to ignore it in the longer run. This research design flaw has been the Achilles Heel of efforts to explain the rapid propagation of HIV in Africa, a flaw that continues to this day — much to the detriment of scientifically trustworthy interventions.

Conclusion: A science that ignores potentially important modes of transmission, especially when confronted by challenging and respectable evidence, is inadequate and needs remedial attention.

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

Cock-ups happen. Parental Advisory: Read this first – your baby can’t

Comments Off on Cock-ups happen. Parental Advisory: Read this first – your baby can’t Posted by on June 13, 2013

This is a guest blog by Jim Thornton, re-posted from Ripe-Tomato.org. This reposting does not include the disturbing pictures of mutilated baby’s penises. To see the complete posting with pictures, go to: http://ripe-tomato.org/2013/02/16/cock-ups-happen/

The World Health Organisation Manual for Infant Circumcision’s (available at: http://www.who.int/hiv/pub/malecircumcision/manual_infant/en/) sample information sheet for parents (p. 110) is not adequate. Here is the bit on surgical harms:

Complications during male circumcision are rare, being estimated to occur in 1 of every 500 procedures. These complications, which can be severe, include poor cosmetic outcome, bleeding, infection, injury to the penis and the removal of too much or too little skin.

Using “rare” for a 1 in 500 risk, when earlier the benefit of “avoiding the need for circumcision later in life” (about 1 in 2,000) is mentioned without qualification, is biased. The figure also applies to the best series. Less well organised services report rates up to 20%, e.g. Nigeria, available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1560152/?tool=pubmed). Since the manual is for use in developing countries the possibility of higher complication rates should be mentioned. Finally, Complications, which can be severe, include poor cosmetic outcome… is clearly designed to play down severity.

But more importantly, catastrophic complications are omitted altogether. Fully informed consent means telling people everything, however rare, which might alter the decision of a reasonable patient/parent. In gynaecology we mention the 1 in 10,000 risk of temporary colostomy after laparoscopic surgery for example. Unless we have a double standard for Africa, the complications below, which all appear elsewhere in the guide, should be mentioned. Italic text and pictures are all taken from the guide.

HIV, and other blood borne infections.

In male circumcision programmes a major concern is the potential transmission of bloodborne […] HIV and hepatitis B virus, to […] patients. The risk of acquiring HIV from an HIV-infected person through a needle-stick injury is estimated at 0.3% […] . The risk of acquiring hepatitis B virus infection, after being stuck with a needle that has been used on a person with hepatitis B infection, ranges from 6% to 37%, […] Most instances of transmission of infection in health-care facilities can be prevented through the application of standard precautions. If “it is a major concern” and only “most […] can be prevented”, it should be mentioned.

Amputation of the penis [picture available at ripe-tomato.org]

This extremely rare complication can be minimized by using good surgical technique but is unlikely to be eliminated. Unfortunately, even under ideal circumstances and with experienced surgeons [it] continues to occur.

Destruction of the penis by electro cautery.

One should NEVER use an electric current [..] with a metal Gomco clamp. […] The use of electrocautery […] has resulted in total ablation of the penis during male circumcision. To avoid this devastating complication, surgeons must be educated that electrocautery has to be strictly avoided when using a Gomco clamp.

Urinary retention from retained Plastibell rings.

Some of the most serious complications ever seen [retention and bladder rupture] […] have resulted from retained Plastibells. Educating the family to closely monitor the wound and the infant’s urine output is paramount with the use of this device.

Penile necrosis following the Plastibell technique [pictures available at ripe-tomato.org]

These two poor fellows aren’t going to be great in the sack.

Degloving – removal of the skin of the shaft [picture available at ripe-tomato.org]

None of these complications are common, but they all occur. If infant circumcision programmes get rolled out widely in developing countries, it is inconceivable that everyone will read all 140 pages of the WHO manual In the real world sterilisation goes wrong, mismatched Yellen clamps get packed together, and diathermy and wrong sized Plastibells get used. Even if they don’t, infants wriggle. Parents should be told.

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

93% of South African Maternity Wards Unsafe for Mothers and Babies

2 Comments Posted by on March 30, 2013

Despite the constant claim from UNAIDS and the HIV industry that HIV is almost always transmitted through unsafe heterosexual sex in African countries, though nowhere else in the world, it has yet to be demonstrated how appalling conditions in hospitals in high HIV prevalence countries hardly ever result in HIV and other serious diseases being transmitted. After all, relatively unsafe conditions in Western countries have resulted in incidents of healthcare transmitted HIV on numerous occasions. TB has been transmitted in hospitals in South Africa. So why not HIV and other bloodborne diseases?

A recent audit carried out in South African hospitals found that 93% of maternity wards are not safe for mothers or babies. This is no surprise to people who have frequently commented on the fact that HIV prevalence is often higher among women who give birth in health facilities than it is among women who give birth at home. But South Africa has the highest HIV positive population in the world. Do UNAIDS and the HIV industry really want to stick to their contention that these conditions hardly ever result in HIV transmission?

In the past, UNAIDS’ response has been that they would prefer to see people attending health facilities, as it is better for their health. But there is a lot of evidence that health facilities are not safe places. Even the UN itself has issued guidance to their own employees to carry their own medical equipment when working in high HIV prevalence countries, as safety in health facilities can not be guaranteed unless they are ‘UN approved‘. So they can’t have it both ways: if health facilities are unsafe for UN employees, they are unsafe for South Africans.

In the absence of any other explanation, I would suggest that UNAIDS and the HIV industry exhibit a profound form of institutional racism and sexism (because far more women are infected with HIV than men). I could be wrong and the industry may have the best interests of South Africans at heart. But if that’s the case, why is almost all the industry’s literature about sexual behavior and a few other things considered to be illicit or even illegal, such as intravenous drug use, male to male sex and commercial sex work?

HIV transmission through contaminated blood is extremely efficient, which is why intravenous drug use is so dangerous. But the highest use of syringes and other skin piercing instruments is found in health facilities (and also in traditional medicine practices, pharmacies, hairdressers, tattoo parlors and various other contexts to which UNAIDS and the industry appears to be completely blind). Hundreds of millions of injections are given every year; the majority are either unnecessary or the treatment could be administered non-invasively.

Apparently the maternal mortality rate is a massive 310 deaths per 100,000 live births in South Africa. In addition to threatening the lives and health of mothers, these conditions threaten the lives and health of babies and young children too. People are not made aware of the dangers of hospital transmitted infections. And what hospital transmitted infection could be more of a risk in extremely high prevalence areas than HIV? The virus tends to be far more common in built up areas, close to main roads and hospitals. In contrast, it tends to be a lot less common in more rural and isolated areas.

Yes, people need accessible healthcare, but no, not at all costs. If healthcare is unsafe, as it clearly is in South Africa and many other African countries (where conditions can be so bad that most people don’t use health facilities, and HIV prevalence is a lot lower), this will not reduce the transmission of HIV or other diseases. The worst place to go if you want to avoid a transmissible disease is a hospital if conditions there are as bad as they are in most African countries. Indeed, some epidemics, such as ebola, have hospitals as their epicenter, and the epidemic is only stopped when the hospital is closed.

This is not to say that all health facilities are dangerous, though the majority of them seem to be in South Africa. Nor is it to say that all healthcare workers could be doing more harm than good, though a lot seem to be doing harm in South Africa. Congratulations to the country on publishing the report, but it won’t do anyone any good until people are aware of the risks they face, and especially of the fact that HIV is not always transmitted sexually. Some of the worst HIV epidemics were almost definitely started by unsafe healthcare practices. How do we know that these same practices are not still contributing to some of the worst epidemics?

Out of 3,880 hospitals audited, some other findings include:

  • Only 32 of the facilities audited complied with infection prevention and control;
  • Only two facilities could guarantee patients’ safety;
  • Just 161 facilities were clean enough to meet the audit’s tough standards; and
  • Staff attitudes towards patients were awful – just 25% of staff in clinics were found to embody positive and caring attitudes

It’s time to stop treating South Africans and other Africans as if they are somehow different from non-Africans, as if their sexual behavior is almost uniquely dangerous, as if everyone who is HIV positive must have engaged in some kind of illicit behavior. People need to know that hospitals are dangerous places so they can take steps to avoid being infected with HIV, TB, hepatitis or any other disease while in hospital. That means UNAIDS and the HIV industry need to give up their obsession with ‘African’ sexuality, sexual behavior and sexual mores. It’s not all about sex, so let’s act accordingly.

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

10 years later: Continuing unethical and incompetent behavior by medical professionals coincides with conflict of interest, leading to millions of unexplained HIV infections

Comments Off on 10 years later: Continuing unethical and incompetent behavior by medical professionals coincides with conflict of interest, leading to millions of unexplained HIV infections Posted by on March 15, 2013

Health care professionals in African ministries of health, the World Health Organization (WHO), donor organizations, and foreign universities participating in HIV-related research in Africa know the proper response to unexpected HIV infections (eg, in children with HIV-negative mothers, in spouses with one lifetime HIV-negative sex partner). That response is to find the source of the infection by tracing and testing others who attended suspected hospitals and clinics, and thereby to identify and correct unsafe practices to protect other patients. There have been no such investigations of unexpected HIV infections in any country in sub-Saharan Africa.

Health care professionals are ethically obligated to give patients accurate information about risks. The World Medical Association’s Declaration of Lisbon on the Rights of the Patient[1] states: “A mentally competent adult patient has the right to give or withhold consent to any diagnostic procedure or therapy. The patient has the right to the information necessary to make his/her decisions…” and “Every person has the right to health education that will assist him/her in making informed choices about personal health and about the available health services.”

Medical researchers trying to find what is different about HIV transmission in Africa that could explain the world’s worst HIV epidemics know that the best way to do so is to trace and test sex and blood contacts when someone shows up with a new or unexplained infection. Unfortunately, medical researchers (who are also health care professionals) have been reticent to find their colleagues’ contribution to Africa’s HIV epidemics. For example, 44 studies[2] that followed more than 120,000 adults in Africa and observed more than 4,000 new HIV infections linked only 186 (4.6%) of those infections to HIV-positive sex partners, all of which were spouses the study had been following all along. No study traced and tested any sex partner (spouse or other) not already included and followed in the study. No study traced blood contacts, and few studies reported any information about blood risks. Despite lack of evidence (avoided and ignored evidence) all studies assumed infections came from sex. (These 44 studies were randomized controlled trials of interventions to prevent HIV in African adults.)

For 30 years, medical professionals have accused HIV-positive Africans of careless or immoral sexual behavior. But if one looks for what is different in Africa vs. the US and Europe, what jumps out is not sexual misbehavior but rather unethical, immoral, and incompetent behavior by health care professionals: not investigating unexpected HIV infections; not warning the public about unsafe health care; and mismanaging research so as not to find risks for HIV.

Ten years ago, on 14 March 2003, WHO held a one-day meeting to discuss the role of unsafe medical injections in Africa’s HIV/AIDS epidemics. WHO staff arranged the meeting after a series of articles[3][4][5] in the International Journal of STD & AIDS during 2002-03 called attention to decades of overlooked evidence that unsafe health care infected Africans with HIV. The 20 invited attendees[6] included three co-authors of these articles (Brody, Gisselquist, and Potterat).

WHO staff managed the meeting as part of a continuing cover-up of hospitals’ and clinics’ contribution to Africa’s HIV epidemics. The meeting was closed to the public. A first press release, prepared by WHO staff in the days before the meeting and released before it ended, misleadingly claimed:[7] “An expert group has reaffirmed that unsafe sexual practices are responsible for the vast majority of HIV infections in sub-Saharan Africa…”

Later that year, WHO’s meeting summary[8] acknowledged that “No consensus emerged from the conference” on whether “sexual transmission was responsible for the large majority of HIV infections.” The summary also noted “universal agreement…that better data on the possible role of unsafe injections, and other health care practices, in HIV transmission are needed to more definitively determine their role in HIV transmission in sub-Saharan Africa.”

Unfortunately, the events of the last 10 years show a continuing unwillingness on the part of too many health care professionals to do what is needed to find and stop HIV transmission through unsafe health care in Africa.

[1] World Medical Association. 2005. Declaration of Lisbon on the Rights of the Patient. Ferney-Voltaire, France: WMA. Available at: http://www.wma.net/en/30publications/10policies/l4/ (accessed 18 August 2012).

[3] Gisselquist D, Rothenberg R, Potterat JJ, Drucker E. HIV infections in sub-Saharan Africa not explained by sexual or vertical transmission. By: Int J STD AIDS 2002; 13: 657-666. Available at: http://www.robertogiraldo.com/reference/Gisselquist_TransmissionIsNotSexual.pdf

[5] Gisselquist D, Potterat JJ, Brody S, Vachon F, Let it be sexual: how health care transmission of AIDS in Africa was ignored. Int J STD AIDS 2003; 14: 148-161. Available at: http://www.cirp.org/library/disease/HIV/gisselquist1/gisselquist1.pdf

[6] WHO. Unsafe injection practices and HIV Infection. Meeting summary (14 March 2003 meeting, undated summary posted by WHO later in 2003). Available at: http://www.who.int/hiv/strategic/mt14303/en/index.html (accessed 6 January 2013).

[7] WHO. Expert group stresses that unsafe sex is primary mode of transmission of HIV in Africa. Media Center statement 14 March 2003. Available at: http://www.who.int/mediacentre/news/statements/2003/statement5/en/index.html (accessed 6 January 2013).

[8] WHO. Unsafe injection practices and HIV Infection. Meeting summary (14 March 2003 meeting, undated summary posted by WHO later in 2003). Available at: http://www.who.int/hiv/strategic/mt14303/en/index.html (accessed 6 January 2013).

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

UNAIDS Getting to Zero: Zero Lies, Zero Double Standards and Zero Institutional Racism

Comments Off on UNAIDS Getting to Zero: Zero Lies, Zero Double Standards and Zero Institutional Racism Posted by on March 2, 2013

According to George Ochoa “An infection spread by unsafe injection practices can happen anywhere” and finds that “Since 2001…at least 48 outbreaks caused by unsafe injection practices have occurred in the United States, with the majority (90%) in outpatient settings (10 in pain clinics and nine in oncology clinics). Twenty-one of the outbreaks involved hepatitis B or hepatitis C; 27 were bacterial. More than 150,000 patients required notification to recommend bloodborne pathogen testing following exposure to unsafe injections.”

But if UNAIDS is right, George Ochoa is wrong; HIV infections through unsafe injection hardly ever occur in high HIV prevalence countries, which are mostly in sub-Saharan Africa. That must explain why, since the HIV epidemic began 30 years ago, no outbreak investigations have been carried out in sub-Saharan Africa.

UNAIDS’ ‘Kenya Aids Epidemic Update 2011’ briefly mentions re-use of injecting equipment during immunization programs (which account for a small percentage of all injections administered). They say “In a study of young men (ages 18–24) in Kisumu, men who received a medical injection in the last six months were nearly three times more likely to be HIV-positive”.

However, the report also claims that a minuscule percentage of HIV infections were a result of any kind of unsafe healthcare and that “Sexual transmission accounts for an estimated 93% of new HIV infections in Kenya, with heterosexual intercourse representing 77% of incident infections. Adults in stable, seemingly low-risk heterosexual relationships make up the largest share of new HIV infections.”

Did they assess the non-sexual risks faced by those people in ‘seemingly low-risk’ relationships? The report says “Among adult participants in the 2003 Kenya Demographic and Health Survey who said they had “no risk” for HIV, nearly 1 in 20 (4.6%) were in reality HIV infected”. The implication is that all those people were infected sexually, but they just didn’t realize they were at risk. For the authors of the UNAIDS report, the people in question were either stupid, liars or stupid liars.

The report recognizes that if there is a large number of HIV positive people in the population, the risk for each sex act is higher. But they don’t acknowledge that the same circumstances also make the risk of infection from an unsafe injection or other skin piercing procedure far higher. HIV prevalence is about 10 times higher in Kenya than it is in the US. But there have been no reported outbreaks of HIV or any other disease as a result of unsafe healthcare in Kenya or any other sub-Saharan African country.

Another study, by WHO, says that “around half the injections used across the world are unsafe for administration, with a worse ratio in developing countries”. So is it possible that George Ochoa is right in stating that “An infection spread by unsafe injection practices can happen anywhere”, and UNAIDS wrong? Well, shocking as it may seem to those who look to UNAIDS as an institution that specializes in HIV, what they say to Africans is different from what they say to UN employees.

Here’s what they have to say to UN employees: “Use of improperly sterilized syringes and other medical equipment in health-care settings can also result in HIV transmission. We in the UN system are unlikely to become infected this way since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment. Extra precautions should be taken, however, when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere. It is always a good idea to avoid direct exposure to another person’s blood — to avoid not only HIV but also hepatitis and other bloodborne infections.”

They also say: “In several regions, unsafe blood collection and transfusion practices and the use of contaminated syringes account for a notable share of new infections. Because we are UN employees, we and our families are able to receive medical services in safe healthcare settings, where only sterile syringes and medical equipment are used, eliminating any risk to you of HIV transmission as a result of health care.”

I don’t know about anyone else, but I tend to believe the warning they give to UN employees, but that suggests they are lying about the risk that Africans face from unsafe healthcare. Why would this august institution lie about a very serious risk of HIV infection in the highest HIV prevalence countries in the world? Well, I can’t answer that question. If it’s vital to warn UN employees, it should be vital to warn those who don’t actually have much choice about which health facilities to use, UN approved or otherwise.

UNAIDS’ current touchy-feely campaign is called ‘Getting to Zero: zero new infections, zero discrimination, zero Aids related deaths’. How about ‘zero lies, zero double standards and zero institutional racism’ as an alternative set of objectives?

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

WHO Acknowledges HIV Risk in Ugandan Hospitals?

Comments Off on WHO Acknowledges HIV Risk in Ugandan Hospitals? Posted by on February 10, 2013

I know infection control professionals are not common in African countries but I hadn’t realized that up till recently there were none at all in Uganda. I wonder how many there are in countries that have received only a fraction of the funding Uganda has received, especially HIV funding. A WHO article about their ‘African Partnerships for Patient Safety’ initiative announces that one hospital, seven hours drive from the capital city, now “has its own infection control professional, the first in the country”. The article proudly states that “just two years ago, patient safety was an obscure concept that was almost impossible for hospital staff to apply when faced with practical realities”.

Could this be the same WHO that tells us that the vast majority of HIV infections in Uganda are a result of unsafe sex? True, the fact that patient safety was an ‘obscure concept’ does not mean that HIV transmission through unsafe healthcare is common. Rather, it means that we, WHO included, have no idea whether such transmission is common or not. We don’t know what proportion of HIV transmission is a result of unsafe healthcare and, therefore, what proportion is a result of the WHO’s beloved sexual transmission. Not that this stops WHO, UNAIDS and others from droning on about African sexual practices, ‘dry sex’, concurrency, circumcision, widow inheritance, long distance truckers, commercial sex workers and the rest, as if that’s all there is to HIV epidemics where many of the people infected face little or no obvious sexual risk.

The most striking thing about the official Modes of Transmission Survey for Uganda is that the largest group contributing to new infections consists of people in stable heterosexual couples. In many of those couples the index partner, the one infected first, is female (fewer males are infected but there is equally little evidence that they were all infected through unsafe sex). As the first to be infected, these women could not have been infected by their partners. So how were they infected? According to UNAIDS and WHO thinking, they must have had sex with someone other than their partner. The UN’s IRIN news service refers to them as ‘cheaters’, which is a reflection of IRIN’s typical style and level of sensitivity. But can the Modes of Transmission Survey rule out non-sexual transmission of HIV through unsafe healthcare, traditional and cosmetic practices in this group of people who face such low sexual risk? The simple answer is ‘no’. For UNAIDS, WHO and other institutions, it is simply taken for granted that the bulk of transmission is through unsafe sex. Questions about non-sexual risks are rarely raised and peremptorily dismissed if mentioned.

Survey after survey shows that those who engage in unsafe sex are no more likely to be infected that those who don’t; often, those who don’t engage in unsafe sex are more likely to be infected. High HIV prevalence does not tend to cluster in isolated areas, except where there have been major health programs. It does tend to cluster among wealthier, better educated, more mobile, employed people who are close to major transport routes and close to or in major cities; coincidentally, they also tend to be much closer to health facilities. Is one infection control expert in an isolated hospital in Uganda going to make much difference to transmission rates? Possibly in that hospital. But it is the initial assumption made by WHO, UNAIDS, etc, that needs to change: knowing someone’s HIV status tells you nothing about their sexual behavior and knowing about their sexual behavior is not a good predictor of their HIV status.

That may sound counter-intuitive if your ‘intuition’ is based on reading mainstream press, and even much of the more specialized scientific literature. HIV in African countries is almost invariably associated with sexual behavior. In Western countries this is not the case. HIV in wealthier countries tends to be attributed to intravenous drug use and male to male sex. Even in Asian countries, people are sometimes given a little benefit of doubt; they may have been infected through unsafe healthcare. But in African countries with the worst epidemics, there has never been an investigation into healthcare practices; there has never been an investigation into why so many women in Uganda (for example) are infected when their husbands are not, and where these women did not face any other obvious risks; there has never been an investigation into why so many babies are infected when their mothers are not; in fact, what proportion of babies are infected whose mothers are not? We don’t know the answer to these questions we appear not to even want to ask.

Does the ‘African Partnerships for Patient Safety‘ indicate an admission that patient safety could be a factor in some of the world’s worst HIV epidemics, after thirty years of insisting that HIV is all about sex and wasting billions of dollars accordingly, or is it mere lip service? I won’t be holding my breath.

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

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