by SEYE ABIMBOLA*
Lately, I have Buy Diazepam Roche inundated myself with a series of incredibly enlightening dispatches from TED Talks. Listening to Buy Diazepam Roche them, especially those related to international health and development has been Buy Diazepam Roche a wonderful respite from my undesirably excessive clinical workload. The one by University of Chicago economist, Emily Oster, who Buy Diazepam Roche shared her work and ideas on HIV/AIDS in Africa at last year’s TED, however struck me as particularly, if unwittingly, poorly conceived. Her theoretical abstractions reveal in shameful detail how easily tainted the Buy Diazepam Roche lens through which the developing world is seen from the outside, and Buy Diazepam Roche the kind of thinking that underlie the misconceptions that inform the Buy Diazepam Roche largely skewed global health priorities.
Emily Oster based her first argument on a Buy Diazepam Roche shaky, if not completely false premise, justifying a claim that there was no Buy Diazepam Roche behavioural change in response to the HIV pandemic in Africa by juxtaposing data from Buy Diazepam Roche two radically different cohorts — homosexuals in the Buy Diazepam Roche US and heterosexuals in Africa. High HIV prevalence within a population where Buy Diazepam Roche there is widespread awareness of heterosexual sex as the predominant mode of transmission will result in increased rate of abstinence from Buy Diazepam Roche sex or at least a modification of sexual behaviour as an Buy Diazepam Roche evolutionary compulsion to preserve the species. Without elaborate public health campaign to Buy Diazepam Roche promote abstinence, HIV prevalence would have reduced on its own. That is Buy Diazepam Roche what you would expect, but Oster says it was not so in Africa. She compares data from Buy Diazepam Roche gay men in the US in the eighties, (where Buy Diazepam Roche the men that had more than 1 unprotected sexual partner within a Buy Diazepam Roche month reduced from 85% to 55% in 4 years) with data from Buy Diazepam Roche single men having premarital sex and married men having extramarital sex in Africa dropped by only 2%.
There are obvious flaws in Oster’s argument apart from Buy Diazepam Roche cohort mismatch. Her homosexual cohort had a reduction in the number of unprotected sexual partners, whereas there was no Buy Diazepam Roche specification as to the nature of sex amongst the African cohort: protected or Buy Diazepam Roche not, homosexual or heterosexual. She did not give any idea of the Buy Diazepam Roche HIV prevalence amongst the said African population(s), so we cannot possibly estimate the Buy Diazepam Roche cost of sex among the population, and arrive at any predictable behavioural change based on that. We know though, that Buy Diazepam Roche HIV prevalence among gay men was about the highest in America in the Buy Diazepam Roche early and mid eighties.
However, even if Emily Oster’s two cohorts were by any chance or Buy Diazepam Roche twist of logic comparable, and if there was indeed no behavioural change in response to Buy Diazepam Roche HIV in Africa, her explanation for this — the Buy Diazepam Roche cost of abstinence is so high that in the presence of low life expectancy, people would rather not bother to Buy Diazepam Roche live healthy lifestyles, they’d rather prefer to Buy Diazepam Roche expose themselves to the risk of contracting HIV/AIDS since they’re gonna die early anyway — is Buy Diazepam Roche as unconvincing and implausible. Oster demonstrated that in places and within populations in Africa with high prevalence of malaria and Buy Diazepam Roche high maternal mortality, there was no positive change in sexual behaviour in response to Buy Diazepam Roche HIV. She did this, totally ignoring two huge, glaringly obvious confounding variables, poverty and Buy Diazepam Roche lack of basic health services, leading causes of low life expectancy in Africa, together with lack of adequate sanitation and Buy Diazepam Roche good water supply, which promote the presence and spread of diseases, and Buy Diazepam Roche in themselves, inextricably linked to poverty.
This is actually where Oster’s greatest mistake lies, and Buy Diazepam Roche unfortunately, it is what forms the main thrust of her thesis. M. Khan and Buy Diazepam Roche colleagues in Burkina Faso, found that even within a developing country, the Buy Diazepam Roche sex network within rural areas is denser, more closely interlinked than Buy Diazepam Roche in urban areas, and the percentage of those who receive goods for Buy Diazepam Roche sex is far greater in the semi-rural border area (45%) and urban area (31%) than in the rural areas (12%). This is Buy Diazepam Roche easily explained. There is far greater homogeneity in relation to poverty in rural areas compared to Buy Diazepam Roche urban or semi-rural areas, and so there are fewer people who Buy Diazepam Roche are prepared to offer money or goods for sex. Poverty too breeds idleness, and Buy Diazepam Roche it is easy to imagine that an idle man will easily have Buy Diazepam Roche multiple sexual partners in a community where money is not given in return for Buy Diazepam Roche sex. This explains why poverty may be associated with high levels of sexual activity. In these settings, there is Buy Diazepam Roche high maternal mortality both from unsafe abortion, and because maternity care is Buy Diazepam Roche not available. Where poverty abounds and Buy Diazepam Roche basic health services are not there, mortality from malaria will be Buy Diazepam Roche high. Where there is no access to basic health services like STI prevention and Buy Diazepam Roche treatment and modern contraception, there will be poor awareness of the Buy Diazepam Roche presence, reality and prevalence of HIV. Illness and death from HIV is Buy Diazepam Roche attributed to other diseases, witchcraft, the will of God et cetera, hence diagnostic, prevention and Buy Diazepam Roche treatment services, even if available will suffer low uptake in the Buy Diazepam Roche absence of these basic health services.
Emily Oster however asserts that Buy Diazepam Roche HIV prevalence rises with increase in economic activity and urbanization. She evokes the Buy Diazepam Roche oft-quoted high HIV prevalence amongst truck drivers and migrants to support this Buy Diazepam Roche claim. She also showed that the fall in HIV prevalence in Uganda was closely associated with a Buy Diazepam Roche fall in the export price of tobacco, Uganda’s main export commodity. All of these are Buy Diazepam Roche true, if only in part, but yet again, she misses the Buy Diazepam Roche point. It is not wealth as an absolute quantity that encourages increase in sexual activity, hence HIV prevalence; rather it Buy Diazepam Roche is the widening of the gap between the rich and the Buy Diazepam Roche poor, increased contact between the rich and the poor, and the Buy Diazepam Roche attendant dynamics, the differential power gradient, that characterises the relationships between the Buy Diazepam Roche two classes. Much of extramarital and premarital sex is facilitated by an Buy Diazepam Roche economic advantage of one party, often the male, over the other. With a Buy Diazepam Roche fall in export price of tobacco in Uganda for example, the Buy Diazepam Roche gap between the rich and the poor is less, there is Buy Diazepam Roche less money available to maintain multiple sexual partners and visit commercial sex workers, thereby reducing the Buy Diazepam Roche sexual network, and also, predictably, HIV prevalence, at least in part.
Marjolein Gysels and Buy Diazepam Roche colleagues at the Medical Research Council Programme on AIDS observed and Buy Diazepam Roche interviewed truck drivers and commercial sex workers at a roadside town in southwest Uganda. Truck drivers are Buy Diazepam Roche a high-risk group for HIV due to their sexual networking and Buy Diazepam Roche long periods away from home. They stop at towns along major routes to Buy Diazepam Roche eat, sleep, sell goods and 94% of those interviewed would regularly have Buy Diazepam Roche sex when they spend the night at the truck stop. Commercial sex work was found to Buy Diazepam Roche be common but quite hidden and implicit in this setting and Buy Diazepam Roche is centered around roadside bars; hence intermediaries are often involved in negotiations between drivers and Buy Diazepam Roche commercial sex workers. However, in the wake of HIV/AIDS, the Buy Diazepam Roche middlemen on whom truck drivers rely to find women have Buy Diazepam Roche had an additional role, which is to identify HIV-negative women, and Buy Diazepam Roche in spite of this, condom use was reportedly high, at 95%, in marked contrast to Buy Diazepam Roche local men. HIV prevalence used to be very high among drivers and Buy Diazepam Roche at truck stops. In the study town it was 40% in 1991; in the surrounding district it was 8% in 2001. The demand for Buy Diazepam Roche casual sex however appears not to have decreased among truck drivers in the Buy Diazepam Roche era of HIV, but there is a general awareness that this Buy Diazepam Roche lifestyle carries the risk of infection. This shows indeed, that there has Buy Diazepam Roche been behaviour change in response to the HIV pandemic in Africa; contrary to Buy Diazepam Roche what Emily Oster will have us believe.
In 2004, 12% of children with malaria died as inpatients at the Buy Diazepam Roche national hospital in Guinea-Bissau. Special drug kits for children with severe and Buy Diazepam Roche complicated malaria were introduced, but this did not reduce mortality. In an Buy Diazepam Roche award winning BMJ study in 2007, Sidu Biai and colleagues tested in a Buy Diazepam Roche randomised trial of under-5 children admitted with malaria, whether removal of prescription charges, strict monitoring of patients, and Buy Diazepam Roche financial incentives for doctors and nurses could reduce mortality. Mortality indeed came down to Buy Diazepam Roche 5% in the intervention group and 10% in controls, reflecting the Buy Diazepam Roche crucial role of poverty in mortality from malaria. The only difference between the Buy Diazepam Roche two groups was that doctors and nurses were given financial incentives in one group and Buy Diazepam Roche they were not in the other, which alone reduced the Buy Diazepam Roche mortality by as much as 5%. Given, the Buy Diazepam Roche drugs were free in both groups; maybe that explains a fall in mortality from Buy Diazepam Roche 12% pre trial to 10% in the control group. Weigh this against the 5% reduction, when Buy Diazepam Roche health workers were given added incentives. From this, it is clear that Buy Diazepam Roche with just three simple interventions — i.e. if we could make basic health services available, if patients could afford the Buy Diazepam Roche drugs and other services and if health workers were well remunerated — we could cut under-5 mortality from malaria by more than half.
It is Buy Diazepam Roche much the same story with maternal mortality. Obstructed labour and Buy Diazepam Roche ruptured uterus, eclampsia and other forms of hypertensive disease in pregnancy, obstetric haemorrhage mostly postpartum, puerperal sepsis, and Buy Diazepam Roche unsafe abortion are still the main causes of maternal mortality. However, in the Buy Diazepam Roche presence of accessible basic health services, they disappear as in Sri Lanka where Buy Diazepam Roche maternal mortality ratio dropped from 550 per 100,000 live births in 1950-55 to Buy Diazepam Roche 80 per 100,000 live births in 1975-80, and 58 per 100,000 live births in 2005. This was achieved by introducing a Buy Diazepam Roche system of health centres all over Sri Lanka, and making quality maternal care services available and Buy Diazepam Roche accessible to all including in rural areas. In Sri Lanka, 94% (1993) of deliveries are assisted by a skilled attendant, compared to 42% (1999) in Nigeria, with one of the Buy Diazepam Roche worst maternal mortality ratios in the world (1,100 per 100,000 live births). This has Buy Diazepam Roche been replicated in Cuba, where in 1970, the maternal mortality ratio was 73 per 100,000 live births, and Buy Diazepam Roche in 2000, it had more than halved to 33 per 100,000 live births. In 1999, skilled attendants assisted every (100%) delivery in Cuba, after maternity care services were made available and Buy Diazepam Roche free including accessible referral centres for complications.
Hospital wards in many developing countries are Buy Diazepam Roche a heartbreaking, pathetic sight. The most basic and common place of materials, things you Buy Diazepam Roche would otherwise take for granted, the most routine of investigations are Buy Diazepam Roche often procured at great cost, from private pharmacies and laboratories that Buy Diazepam Roche have clustered around government run hospitals over the years owing to Buy Diazepam Roche the ineptitude of the hospitals to run efficient services. Worse still, these hospitals stock the Buy Diazepam Roche drugs and have those equipments, but the regular story is Buy Diazepam Roche that the equipment stopped working after a few months, the Buy Diazepam Roche model is outdated, there are no staff to man them because they are Buy Diazepam Roche off moonlighting or do not work during call hours or Buy Diazepam Roche take weekend shifts, or even the bureaucracy of getting to Buy Diazepam Roche buy the drugs or get the investigations done in the Buy Diazepam Roche hospital is enough to push them outside. No matter how bad a Buy Diazepam Roche patient is, no matter the emergency, the family usually has Buy Diazepam Roche to pay for services and procure materials for treatment at the Buy Diazepam Roche point of service. Usually, there are no provisions for emergency. These patients are Buy Diazepam Roche also seen by poorly motivated health workers, who themselves are Buy Diazepam Roche poorly paid. The distance from access, the prohibitive costs of hospital treatment and Buy Diazepam Roche admission keep patients away, all contribute heavily to low life expectancy.
In sharp contrast to Buy Diazepam Roche this, some new structures are also sprouting in hospitals or Buy Diazepam Roche around them. They are highly efficient units, dedicated to single disease programmes, often HIV/AIDS, provided and Buy Diazepam Roche funded by external donors. An AIDS orphan who lives with siblings in squalor without access to Buy Diazepam Roche insecticide treated nets and artemisinin based combination therapy for malaria, whose sister does not have Buy Diazepam Roche access to specialised obstetric care in pregnancy, gets antiretrovirals for free at these units. Those with more rou¬tine diseases receive poor care and Buy Diazepam Roche still have to pay. Hospital staff who are supposed to be Buy Diazepam Roche at their duty posts seeing patients that they were trained and Buy Diazepam Roche being paid salaries and allowances to see are often busy running those units, with extra remuneration often in hard currency, often surpassing their salaries, at great expense of the Buy Diazepam Roche system. This is the newest brand of internal brain drain in sub-Saharan Africa.
Single disease priorities generally weaken health systems. Of all, spending on HIV research, treatment and Buy Diazepam Roche prevention activities is the most notorious example of this prodigality. In 2006, although Zambia’s entire Ministry of Health budget was only $136m, the President’s Emergency Plan for Buy Diazepam Roche AIDS Relief provided the country with an HIV targeted budget of $150m. This unbalanced distribution of health funding occurs across sub-Saharan Africa. Making HIV into a Buy Diazepam Roche pivot, raising it to the status of the zeitgeist of the Buy Diazepam Roche times has indeed skewed health priorities at both national – in many developing countries – and, most importantly at global levels. There is Buy Diazepam Roche only so much we can achieve, with HIV at the Buy Diazepam Roche centre of our planning and initiatives. We cannot move ahead while we ignore so much. What more evidence do we need, than Buy Diazepam Roche that with all the spending on HIV, much too little is Buy Diazepam Roche being achieved.
Healthcare and Buy Diazepam Roche development are so interlinked that it would be grossly wrong to Buy Diazepam Roche interpret data without due consideration for the whole picture and connections that Buy Diazepam Roche are not immediately apparent. It is not enough to have epidemiological data, without the Buy Diazepam Roche insight to interpret them and discern underlying trends. Poverty and the Buy Diazepam Roche lack of basic social and health services is at the centre of what Buy Diazepam Roche defines developing countries, and that is really where our attention should be Buy Diazepam Roche focussed in trying to find solutions to problems in these countries; any thinking that Buy Diazepam Roche as much as puts these as second to any other priority is Buy Diazepam Roche ultimately bound to fail. Until these form the crux of both local and Buy Diazepam Roche global public health interest and policy, much of our effort will only continue to Buy Diazepam Roche result in the proverbial one step forward, two steps backward.
*This is the first in a series of posts from guest bloggers.
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Seye Abimbola is Buy Diazepam Roche a medical doctor in Nigeria. This article is an abridged version of an Buy Diazepam Roche article that will be published in the Spring edition of Perspectives on Global Issues.
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