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by SEYE ABIMBOLA*

Lately, I have Buy Valium Bluelight inundated myself with a series of incredibly enlightening dispatches from TED Talks. Listening to Buy Valium Bluelight them, especially those related to international health and development has been Buy Valium Bluelight a wonderful respite from my undesirably excessive clinical workload. The one by University of Chicago economist, Emily Oster, who Buy Valium Bluelight shared her work and ideas on HIV/AIDS in Africa at last year’s TED Buy Cheap Ambien, however struck me as particularly, if unwittingly, poorly conceived. Her theoretical abstractions reveal in shameful detail how easily tainted the Buy Valium Bluelight lens through which the developing world is seen from the outside, and Buy Valium Bluelight the kind of thinking that underlie the misconceptions that inform the Buy Valium Bluelight largely skewed global health priorities.

Emily Oster based her first argument on a Buy Valium Bluelight shaky, if not completely false premise, justifying a claim that there was no Buy Valium Bluelight behavioural change in response to the HIV pandemic in Africa by juxtaposing data from Buy Valium Bluelight two radically different cohorts — homosexuals in the Buy Valium Bluelight US and heterosexuals in Africa. High HIV prevalence within a population where Buy Valium Bluelight there is widespread awareness of heterosexual sex as the predominant mode of transmission will result in increased rate of abstinence from Buy Valium Bluelight sex or at least a modification of sexual behaviour as an Buy Valium Bluelight evolutionary compulsion to preserve the species. Without elaborate public health campaign to Buy Valium Bluelight promote abstinence, HIV prevalence would have reduced on its own. That is Buy Valium Bluelight what you would expect, but Oster says it was not so in Africa. She compares data from Buy Valium Bluelight gay men in the US in the eighties, (where Buy Valium Bluelight the men that had more than 1 unprotected sexual partner within a Buy Valium Bluelight month reduced from 85% to 55% in 4 years) with data from Buy Valium Bluelight 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 Valium Bluelight cohort mismatch. Her homosexual cohort had a reduction in the number of unprotected sexual partners, whereas there was no Buy Valium Bluelight specification as to the nature of sex amongst the African cohort: protected or Buy Valium Bluelight not, homosexual or heterosexual. She did not give any idea of the Buy Valium Bluelight HIV prevalence amongst the said African population(s), so we cannot possibly estimate the Buy Valium Bluelight cost of sex among the population, and arrive at any predictable behavioural change based on that. We know though, that Buy Valium Bluelight HIV prevalence among gay men was about the highest in America in the Buy Valium Bluelight early and mid eighties.

However, even if Emily Oster’s two cohorts were by any chance or Buy Valium Bluelight twist of logic comparable, and if there was indeed no behavioural change in response to Buy Valium Bluelight HIV in Africa, her explanation for this — the Buy Valium Bluelight cost of abstinence is so high that in the presence of low life expectancy, people would rather not bother to Buy Valium Bluelight live healthy lifestyles, they’d rather prefer to Buy Valium Bluelight expose themselves to the risk of contracting HIV/AIDS since they’re gonna die early anyway — is Buy Valium Bluelight as unconvincing and implausible. Oster demonstrated that in places and within populations in Africa with high prevalence of malaria and Buy Valium Bluelight high maternal mortality, there was no positive change in sexual behaviour in response to Buy Valium Bluelight HIV. She did this, totally ignoring two huge, glaringly obvious confounding variables, poverty and Buy Valium Bluelight lack of basic health services, leading causes of low life expectancy in Africa, together with lack of adequate sanitation and Buy Valium Bluelight good water supply, which promote the presence and spread of diseases, and Buy Valium Bluelight in themselves, inextricably linked to poverty.

This is actually where Oster’s greatest mistake lies, and Buy Valium Bluelight unfortunately, it is what forms the main thrust of her thesis. M. Khan and Buy Valium Bluelight colleagues in Burkina Faso, found that even within a developing country, the Buy Valium Bluelight sex network within rural areas is denser, more closely interlinked than Buy Valium Bluelight in urban areas, and the percentage of those who receive goods for Buy Valium Bluelight sex is far greater in the semi-rural border area (45%) and urban area (31%) than in the rural areas (12%). This is Buy Valium Bluelight easily explained. There is far greater homogeneity in relation to poverty in rural areas compared to Buy Valium Bluelight urban or semi-rural areas, and so there are fewer people who Buy Valium Bluelight are prepared to offer money or goods for sex. Poverty too breeds idleness, and Buy Valium Bluelight it is easy to imagine that an idle man will easily have Buy Valium Bluelight multiple sexual partners in a community where money is not given in return for Buy Valium Bluelight sex. This explains why poverty may be associated with high levels of sexual activity. In these settings, there is Buy Valium Bluelight high maternal mortality both from unsafe abortion, and because maternity care is Buy Valium Bluelight not available. Where poverty abounds and Buy Valium Bluelight basic health services are not there, mortality from malaria will be Buy Valium Bluelight high. Where there is no access to basic health services like STI prevention and Buy Valium Bluelight treatment and modern contraception, there will be poor awareness of the Buy Valium Bluelight presence, reality and prevalence of HIV. Illness and death from HIV is Buy Valium Bluelight attributed to other diseases, witchcraft, the will of God et cetera, hence diagnostic, prevention and Buy Valium Bluelight treatment services, even if available will suffer low uptake in the Buy Valium Bluelight absence of these basic health services.

Emily Oster however asserts that Buy Valium Bluelight HIV prevalence rises with increase in economic activity and urbanization. She evokes the Buy Valium Bluelight oft-quoted high HIV prevalence amongst truck drivers and migrants to support this Buy Valium Bluelight claim. She also showed that the fall in HIV prevalence in Uganda was closely associated with a Buy Valium Bluelight fall in the export price of tobacco, Uganda’s main export commodity. All of these are Buy Valium Bluelight true, if only in part, but yet again, she misses the Buy Valium Bluelight point. It is not wealth as an absolute quantity that encourages increase in sexual activity, hence HIV prevalence; rather it Buy Valium Bluelight is the widening of the gap between the rich and the Buy Valium Bluelight poor, increased contact between the rich and the poor, and the Buy Valium Bluelight attendant dynamics, the differential power gradient, that characterises the relationships between the Buy Valium Bluelight two classes. Much of extramarital and premarital sex is facilitated by an Buy Valium Bluelight economic advantage of one party, often the male, over the other. With a Buy Valium Bluelight fall in export price of tobacco in Uganda for example, the Buy Valium Bluelight gap between the rich and the poor is less, there is Buy Valium Bluelight less money available to maintain multiple sexual partners and visit commercial sex workers, thereby reducing the Buy Valium Bluelight sexual network, and also, predictably, HIV prevalence, at least in part.

Marjolein Gysels and Buy Valium Bluelight colleagues at the Medical Research Council Programme on AIDS observed and Buy Valium Bluelight interviewed truck drivers and commercial sex workers at a roadside town in southwest Uganda. Truck drivers are Buy Valium Bluelight a high-risk group for HIV due to their sexual networking and Buy Valium Bluelight long periods away from home. They stop at towns along major routes to Buy Valium Bluelight eat, sleep, sell goods and 94% of those interviewed would regularly have Buy Valium Bluelight sex when they spend the night at the truck stop. Commercial sex work was found to Buy Valium Bluelight be common but quite hidden and implicit in this setting and Buy Valium Bluelight is centered around roadside bars; hence intermediaries are often involved in negotiations between drivers and Buy Valium Bluelight commercial sex workers. However, in the wake of HIV/AIDS, the Buy Valium Bluelight middlemen on whom truck drivers rely to find women have Buy Valium Bluelight had an additional role, which is to identify HIV-negative women, and Buy Valium Bluelight in spite of this, condom use was reportedly high, at 95%, in marked contrast to Buy Valium Bluelight local men. HIV prevalence used to be very high among drivers and Buy Valium Bluelight 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 Valium Bluelight casual sex however appears not to have decreased among truck drivers in the Buy Valium Bluelight era of HIV, but there is a general awareness that this Buy Valium Bluelight lifestyle carries the risk of infection. This shows indeed, that there has Buy Valium Bluelight been behaviour change in response to the HIV pandemic in Africa; contrary to Buy Valium Bluelight what Emily Oster will have us believe.

In 2004, 12% of children with malaria died as inpatients at the Buy Valium Bluelight national hospital in Guinea-Bissau. Special drug kits for children with severe and Buy Valium Bluelight complicated malaria were introduced, but this did not reduce mortality. In an Buy Valium Bluelight award winning BMJ study in 2007, Sidu Biai and colleagues tested in a Buy Valium Bluelight randomised trial of under-5 children admitted with malaria, whether removal of prescription charges, strict monitoring of patients, and Buy Valium Bluelight financial incentives for doctors and nurses could reduce mortality. Mortality indeed came down to Buy Valium Bluelight 5% in the intervention group and 10% in controls, reflecting the Buy Valium Bluelight crucial role of poverty in mortality from malaria. The only difference between the Buy Valium Bluelight two groups was that doctors and nurses were given financial incentives in one group and Buy Valium Bluelight they were not in the other, which alone reduced the Buy Valium Bluelight mortality by as much as 5%. Given, the Buy Valium Bluelight drugs were free in both groups; maybe that explains a fall in mortality from Buy Valium Bluelight 12% pre trial to 10% in the control group. Weigh this against the 5% reduction, when Buy Valium Bluelight health workers were given added incentives. From this, it is clear that Buy Valium Bluelight with just three simple interventions — i.e. if we could make basic health services available, if patients could afford the Buy Valium Bluelight 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 Valium Bluelight much the same story with maternal mortality. Obstructed labour and Buy Valium Bluelight ruptured uterus, eclampsia and other forms of hypertensive disease in pregnancy, obstetric haemorrhage mostly postpartum, puerperal sepsis, and Buy Valium Bluelight unsafe abortion are still the main causes of maternal mortality. However, in the Buy Valium Bluelight presence of accessible basic health services, they disappear as in Sri Lanka where Buy Valium Bluelight maternal mortality ratio dropped from 550 per 100,000 live births in 1950-55 to Buy Valium Bluelight 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 Valium Bluelight system of health centres all over Sri Lanka, and making quality maternal care services available and Buy Valium Bluelight 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 Valium Bluelight worst maternal mortality ratios in the world (1,100 per 100,000 live births). This has Buy Valium Bluelight been replicated in Cuba, where in 1970, the maternal mortality ratio was 73 per 100,000 live births, and Buy Valium Bluelight 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 Valium Bluelight free including accessible referral centres for complications.

Hospital wards in many developing countries are Buy Valium Bluelight a heartbreaking, pathetic sight. The most basic and common place of materials, things you Buy Valium Bluelight would otherwise take for granted, the most routine of investigations are Buy Valium Bluelight often procured at great cost, from private pharmacies and laboratories that Buy Valium Bluelight have clustered around government run hospitals over the years owing to Buy Valium Bluelight the ineptitude of the hospitals to run efficient services. Worse still, these hospitals stock the Buy Valium Bluelight drugs and have those equipments, but the regular story is Buy Valium Bluelight that the equipment stopped working after a few months, the Buy Valium Bluelight model is outdated, there are no staff to man them because they are Buy Valium Bluelight off moonlighting or do not work during call hours or Buy Valium Bluelight take weekend shifts, or even the bureaucracy of getting to Buy Valium Bluelight buy the drugs or get the investigations done in the Buy Valium Bluelight hospital is enough to push them outside. No matter how bad a Buy Valium Bluelight patient is, no matter the emergency, the family usually has Buy Valium Bluelight to pay for services and procure materials for treatment at the Buy Valium Bluelight point of service. Usually, there are no provisions for emergency. These patients are Buy Valium Bluelight also seen by poorly motivated health workers, who themselves are Buy Valium Bluelight poorly paid. The distance from access, the prohibitive costs of hospital treatment and Buy Valium Bluelight admission keep patients away, all contribute heavily to low life expectancy.

In sharp contrast to Buy Valium Bluelight this, some new structures are also sprouting in hospitals or Buy Valium Bluelight around them. They are highly efficient units, dedicated to single disease programmes, often HIV/AIDS, provided and Buy Valium Bluelight funded by external donors. An AIDS orphan who lives with siblings in squalor without access to Buy Valium Bluelight insecticide treated nets and artemisinin based combination therapy for malaria, whose sister does not have Buy Valium Bluelight 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 Valium Bluelight still have to pay. Hospital staff who are supposed to be Buy Valium Bluelight at their duty posts seeing patients that they were trained and Buy Valium Bluelight 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 Valium Bluelight 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 Valium Bluelight 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 Valium Bluelight 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 Valium Bluelight pivot, raising it to the status of the zeitgeist of the Buy Valium Bluelight times has indeed skewed health priorities at both national – in many developing countries – and, most importantly at global levels. There is Buy Valium Bluelight only so much we can achieve, with HIV at the Buy Valium Bluelight centre of our planning and initiatives. We cannot move ahead while we ignore so much. What more evidence do we need, than Buy Valium Bluelight that with all the spending on HIV, much too little is Buy Valium Bluelight being achieved.

Healthcare and Buy Valium Bluelight development are so interlinked that it would be grossly wrong to Buy Valium Bluelight interpret data without due consideration for the whole picture and connections that Buy Valium Bluelight are not immediately apparent. It is not enough to have epidemiological data, without the Buy Valium Bluelight insight to interpret them and discern underlying trends. Poverty and the Buy Valium Bluelight lack of basic social and health services is at the centre of what Buy Valium Bluelight defines developing countries, and that is really where our attention should be Buy Valium Bluelight focussed in trying to find solutions to problems in these countries; any thinking that Buy Valium Bluelight as much as puts these as second to any other priority is Buy Valium Bluelight ultimately bound to fail. Until these form the crux of both local and Buy Valium Bluelight global public health interest and policy, much of our effort will only continue to Buy Valium Bluelight 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 Valium Bluelight a medical doctor in Nigeria. This article is an abridged version of an Buy Valium Bluelight article that will be published in the Spring edition of Perspectives on Global Issues Xanax Buying Mexico.