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Tag Archives: racism

Did Health Facility User Fees Cut HIV Transmission in 1980-90s Kenya?

Rick Rowden argues that the World Bank was negligent in imposing structural adjustment loans on very poor countries in Africa from the 1980s onwards. He notes that there was little or no evidence at the time that privatizing healthcare would be in any way beneficial in developing countries; on the contrary, the World Bank itself had warned against the introduction of user fees for healthcare in 1980.

After putting tens of millions of people through the disastrous consequences of these untried policies, there is now so much evidence of how damaging they are that even the World Bank agrees user fees are not a good thing. But they have not yet been held accountable, as Rowden argues they should be. Countless numbers of people have suffered and died, health services remain decimated in the worst affected countries to this day; is the World Bank going to try and put right the little that may still be salvaged from the wreckage?

Maybe those in the UK arguing for the imposition of user fees in the National Health Service (NHS) could peruse some of the copious amounts of evidence available showing that such a move will put the health and lives of the poorest and neediest people at risk, while making a handful of wealthy people even wealthier. They can’t use the excuse some would make for the ‘free’ market lunacy of the 1980s, that it was not known what the consequences would be.

But Rowden raises another tantalizing point. He cites one ‘H Stein’ as arguing that the exemption of some preventive services such as vaccinations from user fees, but not curative services, such as STI treatment, “led to the imposition of user fees in STD clinics in places like Kenya in the early 1990s. These fees lowered attendance rates at the worst possible time: the early stages of the HIV/AIDS epidemic in Africa.”

This argument is tantalizing because in the early 1990s HIV transmission among a large cohort of sex workers observed for 20 years had started to decline, and declined fourfold from the 1980s onwards. It is still not clear why HIV transmission declined in this group as members were selected precisely because they were engaging in ‘unsafe’ sex throughout the 20 year period.

Indeed, the national rate of transmission of HIV (incidence) peaked and started to decline in the early to mid 1990s in most parts of the country; it peaked and started to decline long before the government accepted there was a HIV epidemic in Kenya, even before any of the multitude of NGOs turned up to do whatever it is HIV prevention NGOs do (finger-wagging and other variations on that theme).

The authors of a paper on this cohort of sex workers started off their article assuming that HIV transmission is entirely down to sexual behavior. When sex workers who said they always used condoms were found to be HIV positive it was assumed they had ‘overestimated’ condom use. It was assumed that HIV prevalence was at a constant level of 30% among their male clients, although this is likely to be a far more telling overestimation. Other groups among whom HIV prevalence was found to be high were also assumed to have been infected solely through ‘unsafe’ sexual behavior.

It is surprising that risks for non-sexual transmission through, for example, unsafe healthcare (also traditional and cosmetic practices) were never considered for HIV positive people. Facilities were badly run, understaffed, undersupplied and, frankly, dangerous. STI clinics would have been more dangerous still. Why is it that only clients’ sexual risks were considered? Why is that still the case, more than 20 years later?

However, the introduction of user fees and the consequent massive drop in access to STI clinics and other health facilities could have given rise to the observed drop in HIV incidence in the 1990s, which continued into the 2000s. Non-sexual risks for HIV transmission, data for which was never collected, include treatment at an STI clinic, multiple injections, visits to an antenatal clinic, hospitalization, etc.

A 1987 paper by Peter Piot and colleagues finds very high HIV prevalence figures among sex workers, also among men attending STI clinics and women attending antenatal care clinics. But these three groups clearly face the abovementioned risks of being infected with various diseases in health facilities, especially those facilities that are on the brink of collapse; HIV is only one possible healthcare associated infection to which people could have been exposed.

Being a beneficiary of the admirable NHS, I would argue that the service should be further developed as a model for other countries to follow. That is especially true for African countries with very poor healthcare currently, but who, according to the economists who have so far failed miserably to get anything else right, are ‘rising’ economically, riding on a wave of buoyant economies and eye-watering potential for this to continue.

But striving towards universal primary health care is not enough. African countries need safe healthcare, not just any old healthcare. If healthcare access suddenly increases without improvements in safety and infection control, some of the currently declining epidemics may start to increase again. Botswana is an example of a country that decentralized its health services and ended up with one of the worst HIV epidemics in the world, one that is showing little sign of declining right now.

Given continuing high HIV prevalence in wealthier African countries with better access to health services and higher prevalence among wealthier people in urban areas, it is difficult to see Botswana’s experience as mere bad luck. If unsafe healthcare has been a factor in Africa’s worst HIV epidemics then this needs to be thoroughly investigated so that such avoidable transmission is addressed as a matter of urgency. Universal healthcare that is not also safe healthcare will only expose more people to more risks.

[For more about HIV transmission through unsafe healthcare and how to avoid it, see the Don’t Get Stuck With HIV website.]

South Africa Continues to Fail to Reduce HIV Transmission

UNAIDS is strange, perhaps stranger than their numerous UN siblings. They have a single disease as their brief and they have spent 20 years learning next to nothing about it. They keep collecting data about sex, because they insist that HIV is almost always transmitted through unsafe sexual behavior in high prevalence African countries, but nowhere else. They have to shore up their arguments by appealing to prejudices, such as popular beliefs about ‘African’ sexuality, the brutish mentality of African men (yes, all of them) and the pathetic victim status of African women.

So it comes as a bit of a shock to them when they accidentally carry out research that casts doubt on their fondly held prejudices. A paper entitled ‘Sexual relationship power is unexpectedly not associated with unprotected sex in tavern populations in South Africa‘ is a case in point. Of course, alcohol abuse is a terrible social problem in South Africa (and many other countries), and needs to be addressed urgently. So is violence against women, gender based crime and a whole host of other social problems that are endemic in countries with a large proportion of very poor people who live in virtually uninhabitable environments.

UNAIDS is almost as old as South Africa’s epidemic, where prevalence stood at less than 1% in 1990 but rose rapidly to more than 25% over a decade ago and has not dropped below that figure since [I should clarify, these figures are for antenatal clinic attendees, not for the male and female 15-49 year old population, among whom prevalence is 18.8%]. The yearly HIV reports that South Africa shoves out are almost entirely about sexual behavior, with next to nothing about non-sexual transmission of HIV, via unsafe healthcare, cosmetic and traditional practices. I wonder how long it will take before anyone notices that they clearly haven’t even started to understand the worst HIV epidemic in the world.

[For more about sexual transmission risks and HIV prevention, have a look at some estimated risks from various sexual practices.]

Mass Male Circumcision: Western Sponsored Institutionalized Racism

Malawi News Agency has put out a fatuous ‘article’ about a journalist who has been duped into being circumcised in an effort to persuade others to follow his ‘example’. This reminds me that about 6 months ago I blogged about a misinformation service called Internews, connected with the rather smug Gates Foundation and the BBC. Internews boasts about being able to ensure that only ‘positive’ coverage of the US Government’s mass male circumcision program in African countries with medium to high HIV prevalence appears on African news sources.

This Malawian journalist was, apparently, persuaded also by the fact that circumcision is said to protect against human papilloma virus (HPV), although the evidence for this is even slimmer than that relating to HIV. More importantly, many African countries are already receiving assistance to vaccinate millions of Africans against HPV (currently being piloted), so why promote mass male circumcision as well? Are they afraid the HPV vaccination will not give as much protection as their promotional literature claims?

However this journalist was either too innocent, or too well paid off, to check available figures for HIV prevalence among circumcised and uncircumcised men in Malawi. In 2010 HIV prevalence was 14% among circumcised men and only 10% among uncircumcised men. This makes it look as if not being circumcised is protective. But things get a lot worse if you look at the three regions of Malawi, where HIV prevalence and circumcision are very clearly correlated:

Malawi (2)

How much clearer could this be? It is even possible to view these figures for Malawi another way. A 2013 article entitled ‘Mapping HIV clustering: a strategy for identifying populations at high risk of HIV infection in sub-Saharan Africa‘, using the same data (from the 2010 Demographic and Health Survey) identified three major HIV ‘clusters’ in Malawi. The cluster in the North and the one in the center of the country were of relatively low HIV prevalence, where circumcision rates are low. The cluster in the South of the country was of high HIV prevalence, where circumcision rates are high.

Internews and their collaborators would not wish anyone to mention this in a national newspaper, as their express aim is to ensure that only positive coverage about mass male circumcision and HIV transmission sees the light of day; or at least that those who are being told these lies and deceptions don’t know that there are things about circumcision they would be well advised to research. Reading a newspaper that has been bought off by some misinformation service is not research.

The article is full of the usual anecdotal rubbish about mass male circumcision, including some deluded victim of Internews and Co. (also a journalist) who had a problem with penetrative intercourse before being circumcised, the old chestnut about circumcision making people “clean and free of bad odours” (despite making it clear that some of these people suffering from bad odors ‘wear the same underwear for several days), sex being better, etc.

Several times the official claim about mass male circumcision is repeated, that it only ‘gives 60% protection, that people still need to use condoms’ and the usual claptrap. The article even points out that circumcision rates are high in the South and low in the other two regions. But, and this is the clever Internews bit, they don’t bother mentioning that HIV prevalence in the country is highest where circumcision is more widely practiced and lowest where circumcision is less widely practiced.

One of the biggest worries about mass male circumcision is that being circumcised only sometimes appears to be correlated with lower HIV prevalence; just as frequently it appears to be correlated with higher HIV prevalence. Given that there is no known mechanism by which circumcision could protect against HIV infection (only a handful of vague protohypotheses), these differences make it clear that there is a lot more to HIV transmission than circumcision status.

The clear message about mass male circumcision and HIV being payrolled by Internews, Gates Foundation, UNAIDS, PEPFAR and the likes is that Africans are promiscuous, reckless, ignorant and unhygienic; this kind of neo-imperialist institutionalized racism is par for the course in the HIV industry (yes, it is an industry, just like development) and would be condemned as such in most western countries (aside from the US, and perhaps the UK, apparently). So why do we find it acceptable to allow people in high HIV prevalence countries to be systematically deceived?