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Keith Hart writes:

The contrast between Zuma and Cheap Valium Suppliers Mbeki could hardly be greater, a tribal chieftain in the Cheap Valium Suppliers mould of Bolingbroke or Henry Tudor against Mbeki’s Othello, a Cheap Valium Suppliers man happy to be photographed dancing in Zulu warrior gear versus the Cheap Valium Suppliers austere western intellectual with his stiff suits and goatee beard. The number of Zuma’s wives, lovers and Cheap Valium Suppliers children is uncountable. He was once tried for raping an HIV-positive woman who Cheap Valium Suppliers was the daughter of a trusted political aide; claimed that it Cheap Valium Suppliers was his duty to satisfy any woman who appeared to want him; and Cheap Valium Suppliers took a shower after the act so as not to catch the Cheap Valium Suppliers disease. Jacob Zuma epitomises the image of African male sexuality that Cheap Valium Suppliers Thabo Mbeki tried so desperately to counter. Yet Zuma appointed a Cheap Valium Suppliers leading progressive medic as Minister of Health; and he has pushed through drastic changes in government AIDS policy, winning singular praise from Cheap Valium Suppliers AIDS social movements for having committed state resources to the fight. Only recently Zuma made public his own HIV status (negative after four tests). Political leaders like this Cheap Valium Suppliers make nonsense of the stereotypes that pass for analysis of South Africa’s trajectory.

Now at last many more South Africans have Cheap Valium Suppliers access to the most effective sources of prevention and treatment known to Cheap Valium Suppliers normal science, although this is still highly unequal and plagued by Christian and Cheap Valium Suppliers traditional beliefs affecting the use of condoms, for example. The whole story is Cheap Valium Suppliers mind-boggling. You couldn’t make it Cheap Valium Suppliers up. Because of or despite all this, South Africa has stimulated a Cheap Valium Suppliers number of compelling book-length studies by leading anthropologists which, taken individually and Cheap Valium Suppliers together, offer a remarkable chance to reflect on how our discipline might illuminate a Cheap Valium Suppliers tragedy that has implications for how we all live in today’s world. Here I will briefly consider three: Didier Fassin’s When Bodies Remember (2007), Robert Thornton’s Unimagined Community (2008) and Ida Susser’s AIDS, Sex, and Culture (2009).

Read the Cheap Valium Suppliers whole article, including his review of the three books, here Order Klonopin Mastercard.

by SEYE ABIMBOLA*

Lately, I have Cheap Valium Suppliers inundated myself with a series of incredibly enlightening dispatches from TED Talks. Listening to Cheap Valium Suppliers them, especially those related to international health and development has been Cheap Valium Suppliers a wonderful respite from my undesirably excessive clinical workload. The one by University of Chicago economist, Emily Oster, who Cheap Valium Suppliers 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 Cheap Valium Suppliers lens through which the developing world is seen from the outside, and Cheap Valium Suppliers the kind of thinking that underlie the misconceptions that inform the Cheap Valium Suppliers largely skewed global health priorities.

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

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

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

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

Marjolein Gysels and Cheap Valium Suppliers colleagues at the Medical Research Council Programme on AIDS observed and Cheap Valium Suppliers interviewed truck drivers and commercial sex workers at a roadside town in southwest Uganda. Truck drivers are Cheap Valium Suppliers a high-risk group for HIV due to their sexual networking and Cheap Valium Suppliers long periods away from home. They stop at towns along major routes to Cheap Valium Suppliers eat, sleep, sell goods and 94% of those interviewed would regularly have Cheap Valium Suppliers sex when they spend the night at the truck stop. Commercial sex work was found to Cheap Valium Suppliers be common but quite hidden and implicit in this setting and Cheap Valium Suppliers is centered around roadside bars; hence intermediaries are often involved in negotiations between drivers and Cheap Valium Suppliers commercial sex workers. However, in the wake of HIV/AIDS, the Cheap Valium Suppliers middlemen on whom truck drivers rely to find women have Cheap Valium Suppliers had an additional role, which is to identify HIV-negative women, and Cheap Valium Suppliers in spite of this, condom use was reportedly high, at 95%, in marked contrast to Cheap Valium Suppliers local men. HIV prevalence used to be very high among drivers and Cheap Valium Suppliers at truck stops. In the study town it was 40% in 1991; in the surrounding district it was 8% in 2001. The demand for Cheap Valium Suppliers casual sex however appears not to have decreased among truck drivers in the Cheap Valium Suppliers era of HIV, but there is a general awareness that this Cheap Valium Suppliers lifestyle carries the risk of infection. This shows indeed, that there has Cheap Valium Suppliers been behaviour change in response to the HIV pandemic in Africa; contrary to Cheap Valium Suppliers what Emily Oster will have us believe.

In 2004, 12% of children with malaria died as inpatients at the Cheap Valium Suppliers national hospital in Guinea-Bissau. Special drug kits for children with severe and Cheap Valium Suppliers complicated malaria were introduced, but this did not reduce mortality. In an Cheap Valium Suppliers award winning BMJ study in 2007, Sidu Biai and colleagues tested in a Cheap Valium Suppliers randomised trial of under-5 children admitted with malaria, whether removal of prescription charges, strict monitoring of patients, and Cheap Valium Suppliers financial incentives for doctors and nurses could reduce mortality. Mortality indeed came down to Cheap Valium Suppliers 5% in the intervention group and 10% in controls, reflecting the Cheap Valium Suppliers crucial role of poverty in mortality from malaria. The only difference between the Cheap Valium Suppliers two groups was that doctors and nurses were given financial incentives in one group and Cheap Valium Suppliers they were not in the other, which alone reduced the Cheap Valium Suppliers mortality by as much as 5%. Given, the Cheap Valium Suppliers drugs were free in both groups; maybe that explains a fall in mortality from Cheap Valium Suppliers 12% pre trial to 10% in the control group. Weigh this against the 5% reduction, when Cheap Valium Suppliers health workers were given added incentives. From this, it is clear that Cheap Valium Suppliers with just three simple interventions — i.e. if we could make basic health services available, if patients could afford the Cheap Valium Suppliers 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 Cheap Valium Suppliers much the same story with maternal mortality. Obstructed labour and Cheap Valium Suppliers ruptured uterus, eclampsia and other forms of hypertensive disease in pregnancy, obstetric haemorrhage mostly postpartum, puerperal sepsis, and Cheap Valium Suppliers unsafe abortion are still the main causes of maternal mortality. However, in the Cheap Valium Suppliers presence of accessible basic health services, they disappear as in Sri Lanka where Cheap Valium Suppliers maternal mortality ratio dropped from 550 per 100,000 live births in 1950-55 to Cheap Valium Suppliers 80 per 100,000 live births in 1975-80, and 58 per 100,000 live births in 2005. This was achieved by introducing a Cheap Valium Suppliers system of health centres all over Sri Lanka, and making quality maternal care services available and Cheap Valium Suppliers 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 Cheap Valium Suppliers worst maternal mortality ratios in the world (1,100 per 100,000 live births). This has Cheap Valium Suppliers been replicated in Cuba, where in 1970, the maternal mortality ratio was 73 per 100,000 live births, and Cheap Valium Suppliers 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 Cheap Valium Suppliers free including accessible referral centres for complications.

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

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

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