Sunday, December 9, 2007

The Lord's Gift and Flying Toilets

Living With Corruption
It is 9th December 2007 and I have just watched, for the third time in two days, a CNN special program entitiled, ‘Living With Corruption’, yet another first rate documentary on Africa by the incomparable Sorious Samora. Maybe it is just because I live in Africa and have great interest in the subjects he covers of maybe it his totally unpretentious manner, but I find him one of the best documentary producers around today.

As the title suggests, ‘Living With Corruption’ takes a hard look at corruption in Africa. Some might ask, so what’s new, it’s a subject well chewed over by the media on an almost daily basis. This film gives a new slant, it looks at how corruption rules the lives of the ordinary man and woman in the street. It demonstrates all too horribly and clearly how corruption pervades every level of society, and Samora suggests the entire Continent.
This at times infuriating film depressed and angered me on a number of levels; first because it reminds me of what I have witnessed almost every day of my past six years in east Africa and second because in many ways, Samora is ‘preaching to the choir’, the people most likely to see this film will be people who already know and have an interest in the subject. These are the same people who have witnessed the issue for years and have failed singularly to do anything to change it, I count myself amongst this group.

I doubt that the USA’s domestic CNN channel will make room in its twittering vacuous 24 hour ‘news cycle’ for a program as sober as this. Not least because CNN’s Directors have long since assumed [ or indeed created] an American audience with the attention span of a humming bird, that simply could not concentrate for almost an hour.

Of the many scenes that angered me, the shots of Samora walking at night down narrow alleys of Kibera slum in Nairobi ranked pretty high. His camera pans to the streams of raw sewage and describes the plastic bags under foot as being filled with human waste. There is such a dearth of pit latrines in Kibera, (as in most urban African slums) that the people have solved the problem by shitting in plastic bags and then hurling them as far away from their own dwellings as they can. The practice is called “The Flying Toilet”.

When I lived in Nairobi some years ago, I wrote a piece in early 2003, about HIV/AIDS and public health, essentially criticising the then ‘new’ PEPFAR initiative as being too narrow in its focus. My argument then and now is that attempting to stem the tide of AIDS by offering medicines to those in need is in many ways a pointless task. Giving medicines to people whose living conditions are so appalling they cannot find clean water with which to swallow their medications and cannot find food enough to re-generate their lost body weight, seems an exercise in futility that does no more than make the donor community feel good in the short term.

I entitled that piece The Lord’s Gift and Flying Toilets. Watching Samora’s film prompte me to revisit the piece, it is depressing to see that almost five years on so little has changed for the better and most for the worst.
I have reprised the article below…………..

Medicines for the Hungry
Even if it all comes together and “the Feds” get the money and resources to do what the President has directed, I have serious doubts about the [plan’s] overall impact on the disease, at least in East Africa, because it takes too narrow an approach to the issue and offers a single templated solution. The Harvard economist Jeffrey Sachs recently commented: “…the US administration has latched on to a simplistic vision of what to do, based on a single example, Uganda. It knows little of measures in place in other parts of the world, and that each country needs to shape the best local response”.

I think he’s right. My brief sojourn into HIV/AIDS in this part of the world has taught me that there is no template: even communities abutting each other need different plans of attack. But above all else it has taught me that it is a disease of poverty and that no plan will work unless it deals directly with the underlying social causes of poverty as key objective. A Kenyan friend puts it more bluntly. “Giving medicines to the hungry that live in shacks with no heating, lighting or toilets, consume dirty water and are illiterate will not reverse the scourge.” Another commented: “No community or government can tackle disease when its people are barely surviving on $1 a day.”

This Hecate’s brew of hunger and AIDS is impacting upon Kenya in a multitude of ways. The Country has a population of about 30 million, around 80% live in rural areas and could be broadly considered as farmers. But the demographics are changing rapidly. Farmers who once grew cash crops such as cotton and peanuts cannot find enough healthy members of their family to harvest so they have turned to subsistence crops like maize. But when disease stalks the land on a biblical scale even subsistence farming fails. So the people, particularly the young move to the cities to find security and work. HIV/AIDS is accelerating the pace of urbanization in Kenya and in doing so it is creating another dimension of social problems, which in turn must shape the way HIV/AIDS is managed in those communities.

Living in a Ditch
Kenya’s capital, Nairobi, is a city of approximately 2.2 million and growing daily. Over 60% of the population lives in slums euphemistically called temporary settlements and the numbers are growing at an unstoppable rate. The most infamous is slum is called Kibera. It has the dubious distinction of being the biggest in Africa, with about three quarters of a million people occupying 226 hectares – three-square meters per person. It was most trenchantly described by the BBC’s East Africa correspondent, Andrew Harding as, “Wood fires, fried fish, excrement, and rubbish – the rich stench of 800,000 people living in a ditch…six hundred acres of mud and filth with a brown stream dribbling in the middle…and at least one third of Nairobi lives there.”

The majority of Kibera’s residents work in and around the city, in light industry and the service sector. Most live in tin-roofed shacks connected by mud tracks, which usually double as open sewers. There is an erratic electricity supply for those who can afford it. It is a dangerous place to live. Robbery and violence is commonplace. Drugs, prostitution and heavy drinking of an illegal and potent homebrew called Chang’aa are common recreational activities. The police rarely patrol; vigilantes provide security for a price and sometimes exact terrible punishments: ‘necklacing’ is not uncommon for theft

Lord’s Gift
TB and dysentery are endemic and there are frequent outbreaks of virulent infectious diseases such as meningitis and hepatitis. Rats and other vermin are constant health risk. The HIV prevalence is estimated to be 20% (5% above the national level) but I have failed to find out how this figure was determined). Public health standards would shame a refugee camp. There is little or no running water; contractors bring in most in aging water trucks with logos such as “the Lords Gift” painted down the side. It is sold at exorbitant prices and carried home every day by women and children. Only a hardened Kibera dweller would drink it without boiling. The sewage system is a combination of open sewer and pit latrine. But as numbers multiply there are not enough latrines and in desperation, people resort to the “the Flying Toilet”. In simple terms those with no access to a latrine evacuate into plastic supermarket shopping bags and hurl them as far away from their own shack as they can. The result needs no description.

Reality Check
Now: against this medieval background lets remember our clear and simple mission is to reduce the number of new HIV infections, treat a number infected with Anti Retroviral Therapy (ART) and a considerable number more for the opportunistic diseases of AIDS. In this scenario prevention through education and behavioral change is an uphill struggle. Clinical diagnosis and medication are overshadowed by the need for clean water an adequate diet. How effective will ART be when the patient drinks water laden with cryptosporidia and eats one meal of porridge a day? For those who will never receive ART and who will spend their last days in their shacks in what is euphemistically called Home Based Care, the greatest need is a clean place to lie, a caring nurse, relief from pain and a death with dignity.

This is the reality that our “Emergency Plan for Aids Relief” must deal with. It can only succeed by a broad approach, socio-economic, educational and health. Each country stricken by this plague has unique problems and each must deal with them in an individual fashion. It requires the complete involvement of the people, communities and government. Solutions cannot be designed and imposed by even the most clever, generous and wealthy outsiders. America cannot solve this problem alone and in a way of its own choosing. To have any hope of success, we must act now, the numbers are growing inexorably. It needs huge sums of money, focused, trained human resources and a ‘coalition of the willing’.

This last cliché raises another spectre. If by the time this reaches print we are at war in Iraq, then war will eclipse every other international human priority, HIV/AIDS included. Wars divert attention; wars consume resources. Will America still be able to meet its promises?

Saturday, December 1, 2007

George and the Dragon

Today is World AIDS Day 2007
I decided my contribution would be to dig up all the old pieces i have written on the subject and dump them on this 'Blogsite', if for no other reason than to enable me to track my life against the progress of the disease. I am not happy about where we are but have not yet lost hope.
Here is a piece written back in July 2003. Plus ca change.

George and the Dragon
“But overall the passage of HIV around the world has continued roughly as if we had done nothing” – Richard Feachem, Executive Director of the Global Fund. January 2003

George is a good doctor. He has been practicing internal medicine for almost 5 years, works about 60 hours a week and gets paid about $1,000 a month (his government salary doubled this year). In his free time he is studying for a Masters in Public Health. He is a man with a mission, to save his country from HIV/AIDS. It is an uphill struggle; most of his patients present with the range of opportunistic infections that signal full blown AIDS. He counsels them, tests those who consent to testing, treats what he can, keeps them in hospital until they are fit to walk (60% of the beds in the hospital are taken up by HIV/AIDS patients) counsels them again about diet, clean water and avoiding infection and sends them home. Every day a half dozen join the 700 or so who die from AIDS-related diseases in Kenya.

Today George is very angry. He has just been asked to speak to a man who attended the Voluntary Counseling and Testing (VCT) centre adjacent to the hospital. The man has received his HIV test result. After an hour of patient explanation and guidance he is intransigent, adamantly refusing to inform his sexual partners of his HIV status. In pre-test counseling he disclosed that he was married and that his wife and year-old daughter were living with her parents in Busia, Western Province. He admitted to having a “regular girlfriend” who is pregnant. Smoldering with anger, George heads back to the wards. He tells me. “Even if I could find his wife or girlfriend and get them to counseling and testing, without his consent I am breaking legal and ethical guidelines and could be out of a job. How did we get to the point whereby some foolish law prevents me from telling a household that help is needed and death is on the way?”

HIV Exceptionalism
How indeed? The answer lies in part in the genesis of HIV/AIDS as an epidemic in the USA and its perception as a “homosexual” problem. Randy Shilts in his definitive social history of the disease, ‘And the Band Played On’, exquisitely catalogues the epidemic and its management in the early years. Fear of an unknown, incurable and deadly disease combined with a set of social and moral values loosely known as “homophobia” to create a level of discrimination and stigmatization so powerful that the needs of disease management and public health were overwhelmed by social imperatives. HIV/AIDS was no longer a disease it was a political movement. Out of the turmoil rose the phenomenon of ‘gay rights’, which were designed to protect, at first those suffering from HIV/AIDS and eventually all homosexual men and women from the worst excesses of stigmatization.

A unique coalition formed between the gay community, public health practitioners and civil liberty proponents to avoid prevention measures that might “drive the epidemic underground”. The traditional tried and tested public health measures of disease notification and contact tracing used for diseases such as typhoid, TB and syphilis were abandoned, and medical confidentiality was replaced by anonymity. The new strategy, based upon voluntarism, stressed mass education, counseling and the respect for privacy. This special approach to HIV/AIDS, as opposed to other infectious diseases, dubbed “HIV Exceptionalism” became the norm in the USA. The focus on voluntarism and what had transmogrified from ‘gay rights’ to ‘human rights’, shaped the policies of the Global Program on AIDS at the World Health Organization, which in turn informed the policies of nations around the world, in particular, Sub-Saharan Africa. George’s ability to use the standard tools of disease management to deal with a pandemic which threatens to overwhelm Kenya today is constrained by the peculiar political imperatives of a nation thousands of miles away and two decades ago.

“The public policy challenge is to fight the discrimination at the same time that we fight the virus, not to assume the permanence of the discrimination, exalt it, and argue backwards from there against effective disease control” – Chandler Burr, The Atlantic Monthly June 1997
While no cure exists for HIV/AIDS, we do know enough about the virus to prevent its spread. But after almost 20 years of effort and countless millions of dollars we have signally failed to do so. Why? The more I stare at the problem the more convinced I become that the single biggest hurdle to overcome is stigmatization. It is all-pervasive. The developed world stigmatizes the developing world; Africa in particular it seems has only itself to blame for HIV/AIDS, the issue cursorily dismissed by one commentator as “over-population and over-copulation”.

Within Africa the perception of HIV/AIDS is still shaped by ignorance, misinformation, myth and superstition. Fears of becoming a social outcast deter many from seeking advice and help. Those living with the disease, though often showing little signs of illness, are shunned by their communities and discriminated in every aspect of their lives, even healthcare. Those who seek medical help frequently receive scant care because of discrimination by healthcare workers. The terminally ill, are left to the care of friends and family who rarely have the medical skills to cope and whose own fears result in stigmatization and even neglect. Above all, women are the most stigmatized, often forced into sex to survive and abandoned or brutalized when they become ill from the results.

Although human rights laws can and do protect against discrimination in employment, education and healthcare they can do little to protect against stigmatization which is far more pernicious but less easily defined and identified. In their ground-breaking article in the Lancet in 2002, De Cock et al argue that the real irony is treating HIV/AIDS differently from other infectious diseases almost certainly enhances the stigma surrounding it. Replacing the well-tested precepts of confidentiality with anonymity has created a cult of secrecy, which as the disease progresses, is impossible to maintain. Nevertheless, secrecy remains the orthodoxy despite the fact that promotes rather than breaks the destructive silence surrounding the disease and divides the known infected from the undiagnosed and uninfected. We will never beat the disease unless we get it out in the open

“People will not agree to be tested until the results provide them with more than just a death sentence’ – William J Clinton. February 2003

There is a growing body of opinion within the healthcare professions that HIV exceptionalism, whether for principal or pragmatism, has broken nearly every tenet of infectious disease control and public health management and has failed to prevent the spread of the disease and to protect society at large. Richard Feachem’s comment chillingly echoes the result. In Africa the most obvious result is a complete lack of accurate data on the disease. Most prevalence rates are obtained by complex extrapolation of data obtained anonymously from antenatal clinics designated sentinel sites. HIV/AIDS is rarely entered in death certificates and yet treatment decisions are based upon the assumption that a patient is infected. Truth to tell, we simply don’t know the size of the problem. We can only judge it by the numbers who get sick and die on a daily basis. But why should we be surprised? In the USA and Europe today it’s estimated only half of those infected by HIV are aware of it.

So what is to be done? It is hardly likely that we could return to the authoritarian practices of yesteryear (although Canada’s experience with SARS shows that even “liberal” countries set limits on human rights). Five years ago De Cock and Johnson lead the debate to re-examine current practices; they termed it “normalization.” The concept is further enlarged in the 2002 Lancet article. De Cock describes a new model expanding considerably the practice of HIV testing backed up by enhanced access to care. As Anti-Retroviral (ARV) drugs become more widely available there will be an increased need for testing and more to offer than “just a death sentence”. He discusses four contexts for HIV testing: mandatory testing, VCT for prevention; routine testing for delivery of specific healthcare interventions and diagnostic testing in individual medical care.

Mandatory testing has little utility outside specific situations such as military service. VCT is to be developed as a means of prevention by testing people who are well rather than sick; in universal know-your-status campaigns. The idea being to use VCT as a tool to reduce secrecy and stigmatization. Each test site would be linked to institutions offering care for the infected. Routine HIV testing, which differs from mandatory testing in that it implies a default policy of testing unless an individual specifically elects not to, would be become standard practice in antenatal obstetrics and the management of all sexually transmitted diseases. Finally, diagnostic testing would become routine management for those diseases currently recognized as opportunistic infections such as tuberculosis. Although this does not sound too radical it is a major departure from current practice

I would add to this concept social marketing campaigns of a scale never before attempted. Analogies between the war on disease and terrorism are hackneyed but just as terrorism can only be tackled by addressing the social issues in which breed it, the same is true of HIV/AIDS. It is much more than a simple “bug kills host” argument. Social change on the scale necessary to combat HIV is critically dependent upon an informed public with rising expectations, eventually creating demand. Most of the social marketing campaigns I have seen to date have been to say the least, amateur. I want to see the guys who sell Budweiser at the Superbowl sell HIV prevention to the world.

The Dragon
Whilst researching this article I came across a book in the AMREF library, by an old friend, the former New York City Health Commissioner and Assistant Secretary of Defense (Health Affairs) Doctor Steve Joseph. I confess that I had never read the book “Dragon Within The Gates” until now. It is a fascinating read and eerily prescient. His description of attempting to use the standard tools of public health in particular contact tracing and being thwarted by vested interest echoes down the years. But the greatest resonance came from his accounts of conservative opposition to condom distribution and the fury resulting from his halving the original estimates of HIV infections in the city, which he argued were based on shaky extrapolation of shaky data; thereby threatening research funding. Plus ca change! I have loaned the book to George.

Monday, October 8, 2007

XTB and Mandatory Volunteering

Her name is Maria. Her eyes staring at me over the blue paper face-mask are clouded with fatigue. She sits in silent surrender as the conversation, in English and Spanish, ricochets past. Her entire being concentrates upon lifting rail thin shoulders and pulling in tiny gasps of air into a concave chest. Maria is a beautiful 17 year- old girl and she has Pulmonary Tuberculosis (PTB). The clinical notes tell us it is of a type, resistant to almost every medication available to treat the disease. Maria has what the denizens of international health call Extensively Resistant Tuberculosis. Shortened to the acronym, XTB, it sounds like the name of a new sportscar. Without a miracle, Maria will not live to see her eighteenth birthday, she has what in the old days, before the advent of antibiotics, they called Consumption, virulent TB that is consuming her lungs and there are no longer drugs to cure her, she weighs 70lbs.

Maria is one of a dozen patients lined up quietly, trying to find shade from the stunning heat, outside the back door of the Coliseum Sports Stadium in Buena Ventura, a port city on the northwest coast of Columbia. They are at the back door to avoid the mass of people queueing at the front entrance. Those people are here to see the primary health care teams deployed from the USNHS COMFORT on this its eighth stop in its four month odyssey around the littoral of South America and the Carribean. Our small group of patients all has TB and each has a form of the disease resistant to many or all the medications known as first and second line TB drugs. At best they have Multi-Drug Resistant TB (MDR) at worst, XTB.

They have come to see us because…well because we are here and they have exhausted every other option. To be precise, a microbiologist from the local office of the Ministry of Health (MOH) responsible for the scientific work to determine the level of resistance amongst TB patients in the city, has identified and gathered together over two dozen patients in dire straits. Stricken by MRD TB they are unable to find or afford the expensive options. She has brought them along to get whatever help we can offer. In terms of immediate relief, it is not a great deal.

I am an observer, assistant to a quietly professional Infectious Disease physician, Lieutenant Commander Todd Gleeson, as expertly conducts a detailed examination of each patient and confers through his interpreter with the microbiologist, patient and relatives. Masked up, we escort each in turn to the portable xray machine where a masked technician quickly takes a chest xray and we confirm the extent of the damage through and instant image on a laptop screen. Only a couple of those we assess show any sign of improvement since their last examination. What more is to be done? We are somber when we consider the options. The dozen we have assessed are, we are told, only a few of many more.

When we consult with our collegues, including local medical practitioners, conducting the general primary care clinics, it is apparent that TB is a common disease in the City and in the Region. Equally worrying, conversations with the local practitioners and the symptomatic evidence of our patients suggest that HIV is very present in the community and increasing in frequency. What we are witnessing is a public health crisis in the making and there is little we can do other than sound the alarm.

Finally it is agreed that the COMFORT can provide some limited medication for the most needy and less resistant. A meeting is held with the local MOH authorities exhorting them to sound an urgent warning to the Columbian Government and to seek help from the NGO ‘Partners in Health’ – an organization with great experience and expertise in TB in Latin America. The MOH is also urged to ask for help from the CDC and the Pan-American Health Organization, an agency of the World Health Organization that deals with health issues in Latin America. Gleeson and I muse about the future and the very obvious re-emergence of TB as a global health threat. I offer that we might yet see the return of the Sanitorium as a key means of controlling the disease. We are both silent.

Challenging Travel
Columbia has been the most challenging and in many ways the most rewarding of COMFORT’s ports of call to date and not just because of the burden of disease. The Ship has not been able to reach its intended rendezvous, alongside at Buena Ventura and has anchored off the coast, some miles from the secondry destination Bahia Malaga. Though the latter provides demanding and rewarding medical work, the population is small. The weather has been awful, with heavy rain showers and low cloud.

Getting to and from Buena Ventura has been an adventure for most and a serious challenge for some. It has required us to leave the ship early in the morning, around 6am, travel by small boat to the Columbian naval base of Bahia Mallaga and there transfer to a US Army Blackhawk for a twentyfive minute flight into the City. At the end of a long, hot and damp day, the journey has been most times repeated in reverse, though by late in the afternoon the seas are often much much more lively and the return boat journey long, wet, stomach-churning and exhausting.

Occasionally the lucky few have been picked up from Bahia Malaga or even Buena Ventura, by the tireless and intrepid ship’s helicopters. On a couple of occasions the weather has been bad enough to strand medical staff in Buena Ventura. Thanks to the outstanding work of the US Embassy’s military contingent, known as the MILGP, being stranded has been a far from uncomfortable experience, which I for one, have very much enjoyed. It might have been better from the outset to plan for at least a cadre of medical and administrative staff to stay ashore throughout. Much valuable time, which could have been spent with patients, was consumed travelling.

Rewarding Moments
There have been many rewarding moments during the mission so far. Sometimes I have been lucky to observe the COMFORT’s crew when they happen. Often they have been found in the camaraderie generated by overcoming the challenges of difficult journeys, long demanding days, seemingly endless flows of patients and cooperation to determine a particular diagnosis and a plan of care. Other times they have been found in an individual heart-felt offer of thanks for a kindly ear, expert advice and medications where needed. Sometimes too, through the pride of a successful intervention that alters a life and the uninhibited gratitude of a patient.

One of my favorite moments occurred in Buena Ventura. It concerned a man who was brought to see us in a wheelchair, having been shot in the back some six months previously. He was a fit-looking fifty-year old with a young wife and son. His clinical notes indicated he had a ‘paralyzed left leg’ with a lower leg brace to prevent foot drop. He had been unable to move his leg and confined to the wheelchair since the attack. He has come to the COMFORT convinced we could remove a bullet purportedly lodged in his back and with that enable him to walk again. When he was told that was not possible (an old x-ray showed a small-calibre bullet resting against a lumbar vertebra but not near the spinal column) his face crumpled and the whole family began to cry.

Nonplussed by this sad display we began a detailed physical examination. This showed, other than his wasting left leg, a very fit man with a ‘fully functional physiology’. Yet he had been in the wheelchair from the moment he had left his hospital bed, almost immediately after surgery. Asked if he had ever been encouraged to stand on his ‘good leg’ he shook his head. As luck would have it, the COMFORT’s Physical Therapy Department had deployed a comprensive capability in the Coliseum. Expert advice was sought, from the USAF and Candanian Medical Services PTs.

In short shrift our patient was gently but firmlycajoled and assisted to stand up from his chair and offered a pair of crutches. After some basic instruction he took a faltering step. The first in six months. To his obvious delight and with the encouragement of all around him he soon was able not only to bear weight on and move his ‘good leg’ but also to push his ‘paralyzed leg’ past the good one. In the expert opinion of the physical therapists, our patient would walk, probably unaided within weeks, given intensive therapy. A physician from the local hospital promised the therapy. The family cried again, this time because they were happy.

Volunteering Not Compulsory
No better story exemplifies the challenges of the Columbia Mission and the character of the ship’s crew, military and civilian, than the saga of our last day ashore. It began in the usual way, staggering out of our ‘racks’ (bunk beds) at 4:30am. Shower, shave, coffee, breakfast for those with cast-iron constitutions and muster in the CASREC (Casualty Receiving Department and the launching point for every move ashore) by 5:30am.
It did not take long to determine today was going to be a dificult day. The seas were choppy, the mist was dense and there was a continous drizzling rain. We adopted the usual posture, known to paratroopers as “hurry-up and wait”.

After an hour, the weather was little changed and it was pretty certain the ship’s helicopters would not fly, but at least one of the ship’s small utlity boats, known as hospitality boats, was prepared to make a run for Bahia Malaga where the weather was better and the Army Blackhawks would ferry us to Buena Ventura. Twentyfive volunteers were asked for. It was important we go because we had made commitments to patients from the day before and we had a great deal of medical equipment still in the Coliseum. Of the twentyfive who stood up to go, most were what I called ‘the usual suspects’ the same group of doctors, nurses and medics who seemed to be in every difficult mission, four were Project HOPE Volunteers, two doctors, two nurses, all younger than me - just. I had no choice but be the fifth.

Almost the moment we crossed from the lowered lifeboat to the hospitality boat, the rain began in ernest. As soon as we rounded the Ship from the sheltered leeward side, the boat began to rock and roll. Trying hard to avoid the rain and the sea spray we eyed the waves and held on to the boat, some including me, chattering away to settle the nerves. It wasn’t the choppy seas that bothered us, we trusted the Mariners piloting the boat; it was being seasick.

Half an hour into the journey the boat really began to bounce about, caught by increasing cross-winds and a rip-tide running up the river, a river we had to enter. Our craft began to buck so alarmingly, I would not have been surprised to see Captain Ahab on the prow with a harpoon and a big whale to port. Finally, after many more exciting and drenching moments, the boat made the relatively calm waters of the estuary and from there chugged quietly up to the pier in Bahia Malaga.

There we found to our dismay that the weather had beaten us ashore and the helicopters would not be flying until the rain and very dense low cloud cleared. Not to be defeated, we regrouped, cared for those who were seasick, found shelter and food and hunkered down to to wait out the weather. I wandered to the water’s edge with a couple of the boat crew, seasoned sailors; they were in no hurry to fight the tides and the seas back to the ship. Their advice was we all get some rest. I took it, determined I would not rush to take the boat back, I advised the four Volunteers to do the same. I was sure the weather would clear and the ship’s helicopters would pick us up, eventually. I was going to wait for them; they agreed to do the same.

I scrounged some old mats and a piece of plastic and was soon snoring; only to be woken by the boat’s coxwain who quietly informed me he was, “about to make a run back for the Ship and that much to his dismay, the four, the ‘HOPIES’ were volunteering to accompany him.” More than a little grouchy I found my intrepid comrades and crossly demanded to know what on earth they were thinking, the journey back would be as miserable as the one in and it was poor judgment to make the boat crew responsible for them. My final admonishment was, “Just because you are HOPE Volunteers, it doesn’t mean that *@##* Volunteering is Mandatory!” Chastened, the four settled down to wait. Two hours later the weather began to clear and the air was soon filled with the welcome thump of helicopter blades. We were on our way ‘home’.

As a young army officer, I once had a Commanding Officer who told me, “Your job is to give your soldiers tales to tell without getting them killed”. I think its fair comment that COMFORT’s time in Columbia gave many of its crew, civilian and military, tales to tell. Tales they will enjoy for years to come and which set them apart from the people who were not here with us.

Sunday, September 9, 2007

Health Diplomacy - Tales from the USNHS COMFORT

The MH60 Knighthawk describes a graceful anti-clockwise arc, suddenly to our left a huge red cross looms out of the grey sea. The aircraft turns its nose to the cross, levels up, utters a long shudder as it bleeds away airspeed and lowers itself to the ships deck. The moment the wheels are firm, a host of ground crew in colored jackets descend on the helicopter, in seconds it is secured to the deck, doors opened and we are ushered through the roaring wind of the blades, to the sanctuary of ‘Flight Ops’. As I remove my life-vest and helmet the Knighthawk’s engine tone becomes more urgent and it slowly lifts away, headed back to the shore to collect patients. I am home from teaching at the local medical school.

Home is a white-painted leviathan known as the USNHS T-AH 20 COMFORT; its official title is a hospital ship but its actual presence beggars description. It is almost one thousand feet long, eight floors high and weighs 69,000tons. It has a complement of over 800 souls and carries enough food and water to feed them for a month. It has twelve operating rooms, an enormous ER known as CASREC, cutting edge ICU and post-op capability, state-of-the-art laboratories and a radiology department that would be the envy of any mid-sized American hospital. It has the capacity to manage up to one thousand patients and bring them on and off by air or sea. It is a fully capable trauma hospital at sea, and it is huge!

The COMFORT has been my home for over two months. We have sailed together from Norfolk Virginia to Belize, Guatemala, and Panama, through the Canal, Nicaragua, El Salvador and most recently Peru. As I write, we are heading north again towards the coast of Ecuador, the seventh country in a planned twelve nation tour that began in early June and will finish in October in Suriname.

Health Diplomacy
I am part of an experiment. The brain-child of the Under Secretary of State for Public Diplomacy and Public Affairs, Karen Hughes, it’s called ‘health diplomacy’, the use of national healthcare assets, military and civilian volunteers, to ‘win the hearts and minds’ in strategically important parts of the world, in our case, Central and Latin America. The US Navy has long held it has a vital global role in providing humanitarian relief in natural and man-made disasters and has used assets, including the COMFORT’s west-coast sister-ship the MERCY, in previous operations. The MERCY responded to the Asian Tsunami and the COMFORT to Hurricane Katrina. Recently the US Navy has sought to expand this role to more deliberate, planned humanitarian operations, specifically the provision of healthcare support in under-served areas of the world. In 2007, there are two such missions underway, the COMFORT is operating in Latin America and the USS Peleliu, a helicopter carrier, is working in Southeast Asia. This congruency of international policy and US Navy doctrine has produced a new and fascinating turn of events.

The experiment is novel not only because it is a new role for the Navy and particularly Navy medicine, but also because it deliberately includes contingents from the US Public Health Service and, more contentiously, civilian Non Government Organizations (NGOs) two in particular. Operation Smile, an NGO specializing in reconstructive surgery for cleft lips and pallets, and Project HOPE, a Virginia-based NGO with a long history of working aboard ships to deliver healthcare to under-served areas of the world. Both NGOs feature volunteers, individual doctors, nurses and other healthcare specialists who give their time and expertise for weeks at a time to serve on the ship and ashore in various countries.

Some will raise their eyebrows at the concept of NGOs working so closely with the military. I reserve my judgment; it is too early in the experiment to draw definitive conclusions. I view the Mission as a form of ‘armed reconnaissance’, the Navy is using its reach and power to identify needs in various countries, addressing the immediate needs where it can. The NGOs in turn use their expertise to determine the numbers and types of long-term capacity building projects that are feasible and begin work with the host countries to establish them. One thing is for certain; at the end of this Mission I will have a more informed position than most of my NGO friends. I will most definitely let them know.

Project HOPE

As a HOPE volunteer, I am the COMFORT mission medical director and will serve on the ship for four months. I manage the Volunteers during their stay on the ship. They come aboard in four waves, each of about 20 Volunteers and stay three missions each time. The twelve missions will see almost 100 Volunteers serve on the ship. They provide general surgery, primary healthcare and education, with a heavy emphasis on the latter. HOPE seeks volunteers with specific expertise, experience working in austere environments, good education skills and a strong streak of independence. The independence is an essential attribute for balanced living in a powerful Navy culture but it can cause the odd headache. I describe my job as ‘Manager of the La Scala Opera House’ I have more than one Diva to deal with daily. I nevertheless am in awe of the experience and sheer dedication of the average HOPE Volunteer.

In addition to the Volunteers, HOPE provides what it calls ‘Gifts in Kind’. The HOPE Regional Director for Latin America gathers from the country MOHs, ‘shopping lists’ of medical equipment and medications which individual countries need and find difficult to acquire. HOPE HQ approaches the US manufacturers and businesses in general to donate or buy these resources. They are delivered to their final destinations aboard the COMFORT and presented to the MOH for distribution. This huge generosity of US businesses amounts to millions of dollars annually and is another example of the private face of American altruism.

Tales to Tell
Each country we have visited has presented a uniquely different environment, cultural and working. Advanced teams visited each country months ago and plans were instituted by the US Embassies and the Governments, particularly the MOHs. On arrival the COMFORT either anchors off the coast or [preferably] comes alongside in a port. Up to three teams deploy to undertake primary healthcare missions in separate locations, a fourth to teach. In addition the surgeons deploy in the first few days to triage patients for surgery on board the ship. There is a substantial complement of SEABEES aboard; these redoubtable engineers turn their hand to any construction and repairs that they can accomplish within the ships stay in the country.

There are sufficient tales to tell from the journey so far, to fill this magazine and I will save them for a future date. They range from bouncing down the Guatemalan coast in a storm, the ship is a converted oil tanker and too light for its size so rolls around in a disconcerting [and sickly] fashion, to passing through the Panama Canal (a modern Wonder of the World), through ending up in Nicaragua at the same time as President Hugo Chavez and on Sandinista Day, to the trials of the Crossing the Equator Ceremony. We have seen all manner of people and all manner of illness, fixed some and not others but made many friends.

Emerging Themes
We are now in the second half of our Odyssey and though it is too early to draw absolute conclusions I have some pretty firm ideas about both the good and the not-so-good of the Mission to date. The first point I think it vital to make is that this is a training mission. We set off on the 15th of June over 800 souls from the US Navy, Army, Air Force, US Public Health Service, Canadian Defense Forces and NGO volunteers. Few if any had ever seen each other before let alone worked together. Most, including the majority of the Navy medical staffs had never been to sea before. It was only to be expected that the learning curve for all would be vertical and life would be difficult. It was, and at times painfully so. It is hard to reconcile learning a task and practicing for real at the same time. But this is the reality of the modern Navy, constant turbulence.

We learned quickly and by Panama had grasped the main lessons and were beginning to work together. Peru has witnessed that truly military phenomenon, ‘the Team’, forming in almost every department of the ship. These tight little groups have cultures developed around shared experience and a vernacular that is impenetrable to the outsider. Though we may not appreciate it now, the often painful learning process we went through in each hot and dusty medical site, every frustrating encounter with a creaky communications system, was necessary to produce this very essence of the military culture, the ‘Band of Brothers’.

Competing Imperatives
We have learned too that it is difficult to reconcile two competing imperatives, to visit our ‘medical diplomacy’ on a large number of countries in a relatively short period, and provide substantive medical care in each target country. The latter takes time and the former does not allow it. The result at times has been the disappointment of unmet expectations, frustration amongst clinicians who felt their medical abilities constrained by time and resentment from indigenous medical staffs who felt excluded from events. It could be argued that no matter how long we stayed we would only be ‘scratching the surface’ and that is true, but longer would have been better. We are learning to compensate by making our procedures slicker, using our advance teams to set tighter, more achievable schedules and focusing in on what we do best. Still, the lines at the main primary care site in Trujillo Peru would have put a football match to shame. I contend that future missions would benefit from a more targeted approach, less countries and longer stays.

Trojan Horses
At the tactical level we have learned valuable lessons which we will continue to expand and exploit. The first and by far and away my favorite is what I have nicknamed ‘the Trojan Horse’ approach. The countries we have visited and will visit are overwhelmingly agricultural; animals are an essential element of Everyman’s wealth. It therefore follows that healthy animals mean wealthy owners and wealthy people are healthy people. Yet we did not grasp the full import of this until Nicaragua. Given the current political environment of the Country, we not surprisingly met resentment and disinterest in our offers of primary healthcare. A decision was made at one site, to lead with the USPHS Veterinary Medicine team offering healthcare to animals, principally horses, Nicaragua abounds in horses and they are an essential part of society. The effect was a sudden huge interest in all we were doing including human health. The ‘Vets’ had provided the catalyst to our primary care program. I believe this approach, combining animal and human healthcare in coordinated teams at the community level is a vital lesson learned and key model for future humanitarian operations.

Cabbage Patch Dolls
The second lesson concerns training and education, which should underpin our capacity building in every target country. We must expand our education initiatives and include them in every aspect of our healthcare delivery, from surgery to health promotion, dental care to veterinary care. The first tenet is that all training and education should be through the MOH and the medical teaching institutions and should include host nation teachers and interpreters. This takes a great deal of preparation and planning.

Training and education should be both culturally relevant and shaped to suit the needs and technology of the recipients. To this end we have instituted what I have called ‘come-as-you-are’ first aid at the community level. Rather than teach using the sophisticated technology of the US military, we have shown the Navy Corpsmen how use materials commonly found around households and workplaces as first aid appliances. Even more innovatively, the HOPE midwives teach the management of obstetric emergencies using a cardboard MRE box, Cabbage-Patch doll and a length of parachute cord. With these simple tools they can teach an array of techniques to manage deliveries. The local health workers are enthralled, both with its simplicity and the fact that ‘if it’s good enough for Americans, it’s good enough for us’.

The COMFORT of Home
The COMFORT is the center of our World and though we often complain about the food, the smells, the noise and lack of privacy (I like most ‘officers’ share a small cabin with seven other men) we know it is our safe haven, cool in the tropical heat, with familiar routines and friendly faces and the best hot showers I have experienced in my life. It also houses some wonderful technology and great people. I am fascinated by the Radiology Department which houses a CAT-Scan and is so sophisticated I view it as the modern Anatomists Laboratory. We no longer cut up bodies to see how they work, we map them from top to bottom, inside and out and travel their three dimensional digital images like modern explorers.

I am in awe too of our helicopters and their crew, who never seem to stop working. They fly tirelessly from dawn to dusk and whilst the rest of us are snoring they lovingly take their machines apart and reassemble them under the night sky. Without them and the redoubtable ‘pirates’ of the Military Sealift Command who ferry us faithfully to and from the ship like modern Charons, in almost all weather, we would most times be able to do little more than stare at distant shores.

So here I am for another two months. Some days I feel a little like the character that shot the albatross in the Rime of the Ancient Mariner. Others I am as excited as a latter-day Walter Raleigh. I have already learned much, seen a great deal and met some wonderful people, on both ship and ashore. I look forward to writing more tales and thoughts from our medical Odyssey.

Monday, May 28, 2007

Trout Fishing in Africa

Friendly Fire
Some time ago, I wrote an article for a US magazine, the basic premise of which was that technology has the potential to bring about a revolution in post-conflict southern Sudanese society, particularly in healthcare. I thought that my arguments, though a little thin, were basically well founded and would meet with a sympathetic audience. Not so, I received a deluge of criticsm. What stung me a little was the amount of ‘friendly fire’ I attracted from my colleagues who described my line of reasoning as little more than a hackneyed and naïve view of the power of Western technology that failed to recognize the realities of health and development in southern Sudan and in Africa generally. Chastened but recognizing my discussion was a bit superficial, I pondered the question more seriously, expanded my research and offered a ‘new improved version’ for scrutiny. I have reitereated the argument in this piece.

Bridging the Digital Divide
My contention was that building a new healthcare system for southern Sudan lends itself perfectly to the technologies and techniques of telemedicine. The distance, terrain and climate (8 million people living almost entirely in rural areas of a region one and half times the size of Iraq, where for six months of the year the rains make travel nearly impossible) dictate that resources be concentrated at the primary healthcare level, the point where most patients might reach, despite the constraints of austere terrain and climate. Given the immense logistical challenges of getting patients from primary care to secondary care or even specialists out to primary care the most viable option is to connect the system electronically and in turn connect the regional ‘health intranet’ to the world, enabling economies of scale and access to bodies of medical knowledge hitherto inaccessible. It would bring healthcare to the patient rather than the other way round. The critics argue that the idea of ‘technology jumping’ whilst fine as a ‘vision thing’ ignores the realities of life ‘at the sharp end’. They further contend that the fundamentals need to be in place first: regular electrical power sources, communications, potable water, trained healthcare staff and properly equipped health facilities within reach of communities. They say, in a world of limited resources, the priority should go to immediate needs and not dissipated on ’bridging the digital divide’, an idea whose time has yet to come

Teach a Man to Fish
During my musings I came across a paper in the Canadian Medical Association Journal of September 2001 on the issue of telemedicine in Africa, written by a Dr Ellen Einterz who at the time of writing was working in a rural hospital in Cameroon. The redoubtable Dr Einterz argues powerfully from a position of practical knowledge, she has worked at the sharp end healthcare in Africa for over 27 years. I have critiqued her paper as it crystallizes the doubts and reservations I have heard these past weeks. I hope she will forgive my criticism but she is the only person I have found brave enough to publish her opinions.

She begins delightfully by revising the much-overused aphorism…’teach a man to fish and he eats for a lifetime’, to ‘teach a man to fish and he’ll need to buy a fishing rod, reel, selection of hooks, lines, lures, tackle box and boat’, as a metaphor for the demands and limitations of telemedicine. She acknowledges that [telemedicine] has great potential for continuing medical education, specialist consultation over distance and the exchange of knowledge and ideas but counsels that the ‘seduction of satellites’ should not divert resources from the earthbound problems of healthcare in the continent.

Limitations of Technology
Her catalogue of social and healthcare ‘realities’ in her community is an echo of Sudan and for that matter most countries in Africa. The list includes lack of potable water, unreliable electrical and power sources, no paved roads or telephone system, inadequate healthcare and education, high levels of illiteracy and customs and practices steeped in superstition and myth. I have no quarrel with her argument regarding the challenges faced by her and most healthcare providers in rural Africa. I even agree with her description, borrowed from a Sunday Times of London article, that “the instruments of our computer age are stupid, unreliable pieces of plastic that can, when the wind is in the right direction be so incredibly useful that you can forgive them almost all their faults on the spot”. We diverge in our thinking when she describes the demands and limitations of telemedicine.

She argues, “for telemedicine to work not only must the wind be in the right direction but the rain must not be falling too hard and the electricity must be on; people who until now have never see a computer or used a telephone must be capable of operating, maintaining and repairing equipment; spare parts, updates and upgrades must be budgeted for and available. The increased need for thousands of miles of high-speed telephone lines and large bandwidth must be addressed… Massive droves of teachers, nurses, physicians and surgeons should be trained and induced to serve where they are needed…Telemedicine will not be able to save the millions who die every year of preventable, treatable acute respiratory tract infections or diarrheal diseases… …It will do nothing to halt the spread of TB or HIV/AIDS. Not one millimeter of fibreoptic cable is needed to improve basic obstetric care…”

Western Model
My counter to her indictment of technology is that her model for telemedicine seems to be that developed for medicine in the Western world and it fails to take into account man’s ability to adapt technology, particularly in Africa. Why must there be an archetypal electricity supply? Almost every electrical gizmo on sale in Africa for use in austere environments is designed to use minimum power and has a solar power source developed for it, from mobile telephones, to lighting systems, radio transmitters, computers and satellite dishes. When the sun doesn’t shine industrial strength batteries or lightweight cheap generators take over. Copper wire telephones are history; more mobile telephones are sold every day in Africa than in Europe. As computer manufacturers realize the developed world has reached near saturation point in hardware, they have turned to the developing world for markets; computers are quickly becoming more robust, user friendly, reliable, cheaper and easier to maintain. Satellite communication too is rapidly becoming easier and cheaper. Lightweight, robust and inexpensive hardware such as Vsat™, Rbegan™ and the Thuraya™ satellite phone are driving demand and decreasing costs of both equipment and transmission. Digital cameras are dropping in price and increasing in capability at almost the same speed. Digital microscopes, portable ultrasound machines and a host of telemedicine tools for consultations over distance, are becoming commonly available as manufacturers recognize a potentially huge market for rural healthcare the developing world. Above all, the mobile telephone is shaping and driving the communications revolution and economic future of Africa.

Technology and Health Education
The concept of training and deploying large numbers of nurses, doctors and surgeons to rural areas [where the majority population of Africa still lives] is commendable but history has shown, very hard to achieve. A significant reason for the reluctance of healthcare workers to serve in remote areas is the loss of contact with their mentors, peers and the infrastructure in which they trained. Telemedicine is an ideal means of maintaining that contact and a first-rate tool for continuing medical education.

Finally, the contention that telemedicine will not be able to save the millions who die every year from preventable disease, may be true but I contend that neither will the ‘masses of nurses, physicians and surgeons’ she advocates. History shows that the most vital tool in public health is an educated and active public. The same communications technology that provides for medical diagnostics and specialist opinions can also serve to educate the people; we might call it ehealth. Satellite TV is rapidly becoming one of the most powerful and ubiquitous means of mass communication in Africa; the government of South Africa, which has a national health education program using TV, has long recognized its potential as a health education tool. There is currently a plan in train to trial the program in Kenya, using funds from NEPADS

Communications Revolution in Kenya
A glance at the telephone and Internet systems of Kenya shows how quickly technological change is sweeping Africa. Five years ago there were 300,000 copper wire telephone links in a country of 32 million souls. Today there are only a few more but 1.5 million cell phones. They are simple cheap and use ‘scratch cards’ to pay for airtime. Text messaging is cheaper and more popular than voice. People can talk to each other across three countries of East Africa, Kenya, Uganda and Tanzania, and ‘text’ Africa and Europe for a few cents. Already some ‘wealthy’ young city dwellers are using camera phones. Two years ago Internet access from here was expensive, erratic, confined to big cities and slow as a glacier. Thanks to ICT revolutions such as GSM and GPRS, I can now access and send email in the remotest areas, simply by using my mobile phone. I am convinced that within a year, GPRS and 3G phones will be commonplace in Kenya and across east Africa. The Internet has come to Africa, through the mobile phone rather than the PC. Two years ago a friend who is now the Foreign Minister, told me he had a vision that one day every Kenyan would have a personal address [currently there are only Post Office Box numbers for those who can afford them]. When I expressed my doubts he told me it wouldn’t be a physical address [home or office] but an Internet address unique to every Kenyan. I have little doubt that it will happen. Such is the potential for technological innovation here.

Taking Healthcare to the People
Healthcare and technology are converging fast in this part of the world. There is every incentive for it to happen. The people remain overwhelmingly rural and their healthcare is sparse. Like most countries in the world the epicenter of healthcare expertise and resources in Africa remains in the cities. Given the huge logistic costs and social changes needed to physically expand healthcare out to the people it has failed to happen, despite the efforts of governments and international organizations. The result is the people come to healthcare in huge numbers and enormous cost. By innovative and appropriate use of technology it is possible to take healthcare to the people and significantly improve the current quality and access to care. I don’t know what the technological infrastructure that will shape future healthcare in Kenya or Sudan will look like, only that the systems and technology must be simple, reliable, robust and affordable. I am pretty much sure therefore, that it will be based upon mobile phones rather than PCs. I also am convinced that investing in telemedicine and enhancing healthcare resources in the Horn of Africa need be neither a linear progression nor mutually exclusive.

Returning to the metaphor of ‘teaching a man to fish, in the occupation of fishing Dr Einterz compares telemedicine to teaching a man to fish for trout on a river filled with carp. As a veteran fly fisher who has hunted trout in Africa I can assure her the tools and techniques are equally effective on carp. The technology is not important it’s how you use it that matters.

Tuesday, May 1, 2007

Frightened for Fifteen Minutes

My counselor’s name is Mercy. She is in her early twenties and pretty with intensely sad brown eyes. She speaks so quietly I have to lean forward to hear her. I have the strangest flashback, I am eleven years old again and about to be examined for nits by the school nurse. I am suddenly and irrationally anxious. The morning sun is beating on the tin roof; I can feel the radiated heat and begin to sweat. She is cool and dignified in her clinical coat. In matter-of fact tones she explains the intimate biology of HIV/AIDS pausing now and then to ask me, “Do you have a question?” Each time I answer, a little too firmly, “No.”

We are sitting facing each other; she looks into my face and tells me this is a voluntary test and asks me if I wish to carry on. She follows this by asking me if I am prepared for the result to be positive and what I intend to do. I reply with an overly firm “Yes” and “ I will tell my sexual partner(s). ” She has one more question. Do I understand there is a “window period” between infection and antibodies being produced and if I have had “risky sex” within the last six weeks or so I could test negative but still be at risk? I assure her I am not at risk but have another bout of white-coat hypertension.

Mercy explains the procedure we are about to embark upon. She unwraps the RapidTest. It is a small flat white plastic strip with a long “V” running its length. The test takes ten minutes. She will place one drop of my blood at the cleft. It will disperse and move down the “V”. After about two minutes it will leave a fine red line about three quarters up. This is the control line. If within the next eight to nine minutes a second line appears between the cleft and the control line it will indicate that I am almost certainly HIV Positive (but another test will be made to be certain) if no line appears I am negative.

She produces one of those awful little stabbing instruments; I suppress a shiver and offer the middle finger of my right hand. She cleans it with a soapy disinfectant and squeezes the last knuckle until the pulp is dark red. She picks up the “stabber”…my cell phone rings! I frantically search for the phone to switch it off but she insists I answer it. It’s the garage, my car is finished its service. Sotto voce I answer, “Can I call you back, I am in the middle of…something.” I wonder what his reaction would be if I had said “ an HIV test.”

I apologize. She stabs; I wince and watch the drop of blood ooze to the surface, she deftly places it the cleft of the “V”. We both stare at the plastic strip in silence. I search for something to say. I ask how long she has worked as a counselor, she tells me three years. She is a volunteer counselor, which means she gets paid a stipend whilst she trains and looks for paid work. All the time, I have one eye on the test strip. A line appears three quarters along! Mercy whispers it’s the control line. Inanely I answer “Oh good!” We carry on with the small talk. I ask her if later I can interview her and the other staff for an article I want to write on VCT. I don’t hear the answer; my eyes are glued on the strip. I was last tested in 1997 and although a lot of water has gone under my personal bridge since then I am neither promiscuous nor stupid. But I live in East Africa where hundreds of people die of HIV/AIDS every day; it’s easy to be irrational even if you are sure you are not at risk.

Mercy looks at her watch. Ten minutes are up, no second line. I am negative. I cannot suppress a grin of relief. I thank her (a little too profusely?) and tell her I will be back in a short while to do the interview. Outside, the day looks even more beautiful as I join the throng from our office We have come for a group VCT, an idea dreamed up to promote a national VCT and “know-your-status” campaign. The argument being we cannot exhort people to do it unless we do it too. We all admit to being anxious waiting for the second line. They clamber into vehicles chattering happily and roar off in a cloud of dust. I cannot help thinking how lucky we are; relatively well off, educated and having the support of our friends. What must it be like to come to this place poor, alone and worried?

I return to the small, neat blue-painted building. It is one of a number dotted around the periphery of a huge slum at the edge of the city. The staff is made up of one paid and three volunteer counsellors.
Between them they counsel about 15 clients a day. Few are local, they prefer not to be recognized going into the centre. The majority too (about two-thirds) are women. Most seek help because they are worried or unwell or both. Mainly they come alone but married Muslims almost always together. The test costs the equivalent of $0.50. The key is continuity of caring. Whether the result is positive or negative, clients are encouraged to join the “Post Test Club” which meets frequently in the largest of the center’s rooms. The aim is promote self-help and for the negative to mix with and care for the positive. They also take part in ‘Income Generating Activities’. The NGO that runs the VCT will bank whatever money they can muster until they reach the equivalent of $8.00 which qualifies for a loan to begin a small business such as selling charcoal, or cooked maize snacks. In the face of abject poverty and huge levels of disease in the slum, it may all seem too little too late. But my time in Africa has taught me that only community solutions work and that small is best.

I am buoyed by the moment and the sheer dedication of the staff. Then I witness the classic VCT client case; a metaphor for HIV/AIDS in SSA. She is 32 years of age, a single mother of one small daughter. Her only living relative is a brother who does not want to know her. She is a ‘commercial sex worker’. She uses Depo-Provera as contraception and tries to insist that her clients use condoms but they most times simply refuse and find another sex worker. She needs the money so she takes the risk. She has come to us because she is worried. Her test is negative. She is more determined than ever to give up sex work but desperately needs money to feed herself and her child. She agrees to join the ‘Post Test Club’ and to start saving what little she can of her earnings, to make the key $8.00, so she can get a loan; she thinks she can make a living selling children’s clothes. I look at her face, full of desperate hope, know that the only way she will save that money is from continuing to sell her body, and pray she stays negative for another three months.

My interview finished I head for a cold beer. I think about Mercy taking a two-hour ride to her brothers and sisters totally dependent on her and the mother whose only hope is to get out of commercial sex work. I think back to this morning and my own experience with VCT. I remember the feeling of being ‘frightened for fifteen minutes’. And I feel a fraud.

Wednesday, April 25, 2007

Of Hamlet and Per Diem

‘Something is rotten in the State of Denmark’ – Shakespeare’s Hamlet

Anyone who has even a superficial knowledge of HIV/AIDS in Africa will know that Uganda has an almost mythic reputation as a success story in the long war against AIDS. Long before HIV/AIDS became a global issue, years before the international community began trucking in Wells Fargo-loads of cash, encyclopedias of advice and armies of technical advisors, Uganda had embarked upon its own unique national plan.

In 1986 the new Ugandan president, Yoweri Museveni responded to the emerging HIV crisis with the speed and determination that characterized his rise to power and early years as a national ruler. He embarked on a nationwide tour to tell people that avoiding AIDS was a patriotic duty, they should abstain from sex before marriage and then go on to remain faithful to their partners and to use condoms. This message became the underpinning national strategy, known as ABC, Abstinence, Be faithful and use a Condom. The same year, Uganda's Health Minister announced to the World Health Assembly that there was HIV in Uganda, and the first AIDS control program in Uganda was established. It focused on providing safe blood products, and educating people about HIV/AIDS.

Over the next five years the national programme fought an uphill battle against the disease, which had already reached catastrophic levels. Best estimates show that by the early 1990s the national adult prevalence rate peaked at around 15% and exceeded a staggering 30% among pregnant women in the cities. There is no accurate data on mortality rates during this period but they are believed to have been very high. In 1992 the government ramped up its efforts, adopting a multi-sector approach and coordinating the response to it. The strategy appeared to pay off with surprising speed. HIV prevalence in young pregnant women in Uganda began rapidly to decrease. In 1995 Uganda announced what appeared to be declining national trends in HIV prevalence. Over the next five years, the prevalence rates continued to drop. A national program to prevent mother to child transmission, using ARVs was introduced. By 2001 UNAIDS estimated the national prevalence rate to be around 5%.

The government and international agencies attributed this remarkable success to a combination of strong leadership, open national debate and information programs, community-level prevention and treatment programs and a national strategy based on a simple message, ABC. The model and the message has now become the basis of national strategies across sub-Saharan Africa and world-wide.

AB Small c
So where are we today? Put bluntly, the national strategy is in disarray, victim of politics, religious dogma, corruption and public apathy. The crisis began some years ago with a subtle shift in government policy away from ABC towards greater emphasis on ‘A’ – abstinence. Led by President Museveni and his First Lady, government policy and social marketing strategies now stress abstinence as the cornerstone of current HIV/AIDS prevention strategy.

The result is uproar amongst the national and international AIDS activist communities. The rhetoric and action have been neither balanced nor objective. Museveni caused international consternation at the 2004 International AIDS Conference in Bangkok when he argued, policies that promote abstinence and sex within marriage are more effective in preventing AIDS than those which stress condom use. In April 2006 the Ministry of Education issued a directive banning the promotion and distribution of condoms in public schools. Also in 2006 a Human Rights Watch report claimed that information about HIV transmission, safe sex and condom use had been removed from the school curriculum in Uganda and replaced by information emphasizing abstinence.

The USA is smack in the eye of ‘Hurricane Condom’, specifically the Administration’s pet project the President’s Emergency Plan for Aids Relief (PEPFAR) which aims to provide life-saving drugs to at least two million people with HIV, prevent seven million new infections, and care for the sick and orphaned in 15 countries world-wide. Critics have, from its inception, argued that the initiative is fatally flawed in that it has overtly moral strings attached and is heavily influenced by the views and mores of America’s Christian conservatives. Beneficiaries must emphasize abstinence over condoms and in some cases, condemn prostitution. As one of the first beneficiaries of PEPFAR, Uganda was given $137m for HIV prevention and treatment programmes for 2005 and an additional $170m in 2006. Critics of PEPFAR, both national and international have spent a great deal of energy and resources ensuring the Ugandan media inform the people of this moral agenda.

Matters came to a head in the Fall of 2006 when the Ugandan media launched a string of reports detailing a national shortage of condoms, which they argued had been deliberately precipitated by the government’s nationwide recall of condoms - distributed free in health clinics- on the spurious grounds that they were defective. The debate was further enflamed when the UN Secretary General’s Special Envoy for HIV/AIDS in Africa, Stephen Lewis, told a world-wide teleconference on AIDS, that Uganda’s policy shift has been influenced by the US government “which is now mainly promoting pro-abstinence programmes and less of condom use”.

The truth is far more complex. The US global AIDS coordinator, Dr. Mark Dybul, has repeatedly stated there is no change in US policy and the current emphasis on abstinence is only to ensure a more balanced ABC strategy, which in the past has mostly focused on condom use. I have no reason to doubt his veracity, but it does not really matter. Perception is reality and there is now widespread belief, in Uganda and elsewhere that the USA is attempting to inject its own moral agenda into the global HIV/AIDS debate. It is using the power of money to do so and its actions threaten to undermine what little progress has been made so far, in mitigating the impact of AIDS in Africa.

Scamming the Global Fund
In October 2006 a team from the Geneva-based Global Fund to Fight Aids, Malaria and Tuberculosis arrived to announce the immediate suspension of all grants to Uganda, after a probe revealed “gross mismanagement of its funds”. A subsequent inquiry, led by a respected Judge, revealed mismanagement and fraud on an epic scale.

The total sum granted by the Fund was $201m over two years. The initial report stated that ‘to date only (my emphasis) $45m had been disbursed’. An initial investigation by outside auditors revealed “financial, procurement, governance and management structure irregularities,” a euphemism for fraud and theft. A few examples illustrate the extent of the mess: about $300,000 was lost by poor management of exchange rates between the dollar and Ugandan shilling and $1m was misdirected from monies meant for the private sector into government departments. “Monies amounting to millions of dollars” were paid to national NGOs and private businesses with little or no record of where the money went or how spent.

Government staff were paid hugely inflated allowances for tasks ranging from out-of-hours photocopying to attending workshops and what are known in local vernacular as ‘trainings’. (I am constantly surprised at how much employees of even small local CBOs know about allowances, the term Per Diem is an essential phrase of Ugandan bureaucratic language.)
My two favorite stories from the inquiry were: One official sent his daughter off to an international program for health education using GF monies. Another official presented a series of suspect receipts for fuel spent on official travel. Such was the level of his incompetence, once receipt was made out to a vehicle whose number plate belonged to a caterpillar tractor.

Whilst I was stunned by the blatant nature of the scamming, I was not surprised by the event. The first time I visited the Ministry of Health Kampala I re-named it the Ministry of Land Cruisers – I counted 56 in the parking lot. At the end of 2006 the MOH failed to organize the purchase of 15m doses of Co-Artem – the new WHO-approved malaria treatment – for which the Global Fund had provided $28m. One national newspaper suggested it was because there was little opportunity for fraud. The Minister of Health and his two deputies were forced to resign but despite public indignation and international irritation, none of the culprits have been brought to book. I have no idea how much if any of the money was ever recovered

Root of All Evil
If there is a moral to these two stories it is the corrosive and corrupting effect of money on people and governments, particularly when it is accompanied by explicit donor agendas and is poured into countries, institutions and communities on a scale which overwhelms existing systems for accounting and distribution. I have heard senior government officials publicly state they believed Uganda would be better off without PEPFAR and Global Fund money, that they did fine before it arrived; they invented ABC without outside help and were controlling the epidemic without huge donor funding. The advent of these two funds alone as spawned over 2,500 local NGOs and CBOs, a new national industry, almost impossible to regulate, which serves more to line the pockets of 'snake- oil' salesmen than tend to the sick and needy.

Shocked, Truly Shocked
Although Ugandans are dismayed at the corruption and mismanagement of HIV/AIDS funds they are equally angry at the donor community. They feel they should be given the money, without strings attached; where there is fraud and waste, they should deal with it. They see more than a little hypocrisy in the international community’s reaction and cite international NGOs dissembling over how they spend donor monies. They have a valid point. I am no expert, but I would guess that if you 'followed the money' from K Street to a Ugandan village, of every dollar that begins its journey, only a few cents arrives. It may not be fraud or waste but it certainly smacks of dysfunctional systems.

But Ugandans reserve their greatest disdain for those ‘aid industry’ experts who express their shock and outrage at local mismanagement and corruption, from the comfort of their luxury offices in Geneva or Washington. On command, they descend in hordes by first class flight to Entebbe, issue injured-sounding rebuttals or scathing criticism from the Sheraton Kampala and jet back to their comfortable homes. Rarely is there an admission that they might be part of the problem. Surely someone in PEPFAR could have predicted the birth of a conspiracy theory over the condom shortage and taken early action? Surely someone in the Global Fund knew at least the rumors surrounding the some of the Ministry of Health staff, particularly the Minister? If not, they only had to read the local newspapers (available online) to get the picture.

Now For Something Completely Different
If, as I have argued, things are so SNAFUd, what is to be done? We cannot keep doing what we have always done and when it shows not to be working simply try harder and throw more money at it. The time has come for original thinking and novel approaches. The key is to reduce the opportunities for misappropriation, get more, of every dollar donated, onto the final target and develop long-term independence by making individual Ugandans responsible for their own health and future.

There are many original thinkers in this part of the world. My favourite is a member of the Ugandan Parliament, the Honourable Mr Madada. He launched a project which offered free university education for virgins. In short, any young women can apply for college education providing she is from Kayunaga District and a virgin, she must prove this by subjecting to a virginity test, the details of which were never made clear. Needless to say the concept failed but at least it was original thinking!

Health Savings Accounts
I offer another ‘out of the box’ idea. Somebody out there give me $1m, no strings attached. I will put it in a Ugandan bank (best exchange rates I can get). I will then advertise for 1,000 volunteers from the class of 2010 at Makrere University. All will be required to undergo an HIV test. The first 1,000 that show negative will have a bank account opened in their name, for the sake of propriety we will call it a ‘health savings account’, containing $900 in Ugandan shillings. The contract will be they remain negative until they graduate. At that time they will be tested again and those still negative will have unrestricted access to their savings account and do whatever they please with both the original sum and the interest accrued. How individuals stay healthy - ABC or any variation thereof - is a personal and private concern. If the project is a success, it will be repeated and widened, dependent on donor interest and funding ( if I had access to the $200m given to Uganda by the Global Fund I could impact on 200,000 people).

I can almost hear the howls of indignation from the politically correct. ‘This concept smacks of bribery, it has no place in respectable social science’. I offer the following for consideration:
Almost certainly more than 1,000 will volunteer; those who are positive will be able to seek treatment and long-term care, the negatives will know their status and adjust their lives accordingly
1,000 ‘at risk’ individuals will be trying to stay out of the ‘risk pool’ for three years (over time, this must have some, albeit mathematically small, impact on infection and prevalence rates)
Money spent on administration will be minimal (much less than the majority of current prevention programs).
Opportunities for mismanagement and misappropriation of funds will be very limited
The capital sum will be available for national investment in the intervening years
On successful completion of the three year term, all monies, the capital sum plus interest accrued, will go directly to the individual, without caveat.
The money saved will most probably be spent or re-invested in-country on an individual basis.
Each individual will be incentivized to make personal decisions regarding their current and future health status. Successful completion of the first period may convince them to maintain healthy behaviour.
Individuals will recognize that they are capable of determining their own future.

I doubt that, at first blush, I have convinced many that this idea is anything more than the crude use of financial reward to manipulate social behaviour. Well, that might be true, but is it any more odious than many current schemes? At least it has no moral strings attached, requires minimum administration and does not lend itself easily to misappropriation. Has anyone out there got a better idea?

Monday, April 9, 2007

The Elephant in the Sitting Room

Dark Clouds
My search for clues as to how the 20-year conflict in northern Uganda will end, has drawn me back again and again to the IDP camps and the countless children they contain. I have no doubt there will be an end to the LRA and it will be soon. I also think there will be a second and even more chaotic and probably bloody phase as people return to their lands and disputes over ownership lead to community conflict. But that too will eventually be resolved. A far darker and impenetrable cloud looms, not just over the north but the whole of Uganda; one that threatens Uganda’s stated goal, to emerge as a middle-income economy by 2025 and perhaps the very future of the nation: a population growing at a speed that almost beggars the imagination.

It seems counter-intuitive that a country ravaged by war and disease, particularly HIV/AIDS, on the scale that Uganda has suffered for 25 years, would be undergoing a population explosion. It is even less conceivable when viewed against a background of an infant mortality rate of over 70 per 1,000, a maternal mortality rate of almost 500 per 100,000 live births and a life expectancy at birth of around 50 years. But the population is increasing at a rate that should set alarm bells ringing in Kampala - it has doubled in the past 20 years - yet the subject doesn’t figure on the political agenda, academic debate or social discussion. It is the Elephant in the Sitting Room everyone is trying to ignore.

The facts are carefully and unemotionally laid out in a document, Uganda: Population, Reproductive Health and Development: 2005, by the Ugandan Ministry of Finance, Planning and Economic Development. It is a little-known publication, which Google failed to identify in the welter of online articles on youth, gender, HIV and other socio/economic subjects concerning Uganda. I am well aware of the saw, “Statistics is like a lamppost to a drunk. It's there more for support than illumination” but I offer some numbers from the book to underpin my argument.

The Fertility Rate in Uganda (numbers of babies each woman produces in her lifetime) is currently somewhere between 7 and 8, little changed over 30 years. The Replacement Rate (numbers of babies required to sustain a stable population) used in demographic science, is 2.1. All countries in the developed and many in the developing world are close to or below that rate. Neighboring Kenya is about 4 and falling. Nigeria, often cited as a country with a looming population problem is 5.5. The Ugandan population is currently estimated at 29m, if the Fertility Rate continues unchecked the population will double to 60m by 2025. If it halves to 3, the figure will still be a huge 45m by this date. I have found no evidence of a drop in the rate.

Young in a Slum
There is a school of thought that argues population growth on this scale is not all bad and that Africa has traditionally suffered from too small a population to grow a strong internal market. This may be so, but a combination of high birth rates and the ravages of HIV have skewed Uganda’s population. Over 55% of the population is under 16 years, the average age of Uganda is 14 years and a few months. This has short and long-term implications: the child dependency ratio (numbers of child dependents to adults) is 100:100 placing huge strain on working adults and social services, particularly schools and health services. In the long term these children will enter the workplace which currently cannot provide modern-economy jobs for even a fraction of its workforce, estimated as an annual need of 200k. At current predictions there will be a requirement for between 0.5m and 0.75m new jobs a year by 2025, an impossible goal to achieve.

As if this isn’t daunting enough, there is another distortion to the equation, urbanization. The population of the capital, Kampala was 450k in 1980, today its about 1.5m, small by African city standards, but it’s an overcrowded city with over 50% of the population in temporary housing (euphemism for slums). If the present rate of urbanization of 7% continues unchanged (the trend throughout Africa is upwards) at the current rate of population growth, Kampala will be a huge 3.5m by 2025 (and double its current size to 2.8m if this rate halves). Nationwide, the estimated increase in urbanization - to 18.5m by 2025 - will require another 12 “new Kampalas” to be built in less than two decades. Population growth halved will still need 9 “new Kampalas”. It is hard to imagine how the country could develop housing, infrastructure and power for 9 or more new cities in less than 20 years

Contraception and Culture
During my investigations, I discovered amongst all the troubling predictions, a startling fact: in Uganda, research shows 35% of married women currently want to space or limit their births but are not using contraceptives. There is no data on unmarried women who do not want to get pregnant but don’t use contraception but it would be a fair guess that the figure is even higher. The UNFPA estimates the overall ‘contraceptive prevalence’ as less than 20%. Why this unmet need exists is difficult to discern but appears to be a mixture of government complacency - it has not identified high population growth as a critical threat to development, traditional culture – family planning has never been a cultural practice, and the attitudes and moral teaching of religious organizations and faith-based groups, which fundamentally disapprove of contraception or believe that freely available contraceptives - particularly condoms for the unmarried - promotes promiscuity, with increased risk of unwanted pregnancies and HIV.

More recently the Government, led by the President and First Lady, have been overtly manipulating the long-standing A(bstinence) B(e faithful) C(ondoms) approach to HIV prevention by placing greater influence on AB and less on condom use. The result has included a nation-wide shortage of condoms, which must have impacted upon their availability for contraceptive use.

Marketplace Morality
There has been much talk about the undue influence of the US in this domestic turmoil, particularly condom availability. Matters came to a head when the UN Secretary General’s Special Envoy for HIV/AIDS in Africa, Stephen Lewis, told a world-wide teleconference on AIDS, Uganda’s policy shift has been influenced by the US government “which is now mainly promoting pro-abstinence programmes and less of condom use”. Dr. Mark Dybul, the US global AIDS co-coordinator, rebutted the charge, stating there was no change in US policy, current emphasis on abstinence is only to ensure a more balanced ABC strategy.

Research suggests Dr Dybul is being economical with the truth. USAID policy and procurement regulations for contraceptives, including condoms for HIV prevention, for foreign aid projects can be found at ADS 312.5.3d of the organization’s procurement manual. The key words amongst all the jargon are: “Source/Origin and Nationality - Contraceptive products shall meet the requirements for U.S. source, origin and nationality”. In other words recipients of US funding for both reproductive health and HIV prevention programs must buy American. Maybe the US government indeed has no hidden moral agenda for shaping Ugandan reproductive health policy, unless you count the morality of the marketplace. But the effect of such blatant trade protectionism can only be to limit availability of reproductive health resources to Uganda and elsewhere, by denying access to cheaper, equally high-standard generic contraceptives on the global market.

Rearranging the Deckchairs
Whereas Uganda, as a sovereign state, does not welcome overt outside interference in domestic policies, the very disturbing scenario I have described for Uganda’s population and development must surely impact upon national and, in turn, regional security. Given that the USA, as one of Uganda’s largest aid donors, has much influence on national issues, it seems sensible foreign policy for the US government to offer guidance and resources to help Uganda limit the worst effects of its rapid population growth. To do otherwise is to do no more than help the Ugandans rearrange the deckchairs on their personal Titanic.

Thursday, March 29, 2007

The Road to Hell

The Road to Hell

The road to hell is paved with good intentions – Samuel Johnson.

Poisonous Aid
In early 2006, when President Museveni of Uganda, was threatened by donor countries who did not like his ‘undemocratic methods’, essentially ‘fixing’ his re-election, he announced that Uganda did not need any foreign aid, particularly aid which came with conditions often harmful to his country. It was a storm in a teacup. Within a few months Museveni was forgiven and most of the bilateral aid was switched on again.

I think he is, for the most part, right. Aid, particularly so-called development aid, is poisoning Uganda, creating a culture of dependence and resentful beggary, undermining rather than aiding economic growth. Today, of every dollar spent by the Ugandan government, 40cents is aid money. Such levels of economic dependence, totally distorts every aspect of the nation’s economy. It is the manure, which enables a corrupt government to thrive. Nor is Uganda unique in this respect. There is a growing and uneasy realization that the huge amounts of aid money poured into Africa has had little effect on the average poor African. I am convinced there is an urgent need, not to increase aid to Africa but to fundamentally overhaul the existing system, even to cut it radically in certain areas.

When war and natural disasters strike immediate humanitarian relief aid is often needed and can have a good effect, it can save lives. But if aid could make Africa prosperous it would have done so by now. Despite nearly a trillion dollars of aid since independence in the 1960s, much of Africa is worse off now than it was then. We like to think that the reasons lie in flawed strategy, much was spent by outsiders with little knowledge of Africa’s needs or consultation with Africans, the continent is littered with abandoned projects roads leading nowhere and factories without fuel or raw materials. We also are told, by luminaries such as Bono and Geldorf, we simply haven’t given enough. To ‘make poverty history’ we must do things better and double our spending. Digging deep in our wallets we don’t stop to ponder the unintended consequences of our overwhelming helpfulness on fragile African societies and economies.

Dependent and Resentful
Aid makes up half the domestic budgets of half of Africa’s countries. Making some as dependent as when they were colonies. In many, aid serves to undermine the economy, stifles entrepreneurship and enables poor governments to abdicate responsibility for providing services to its citizens. Uganda for example, is currently struggling to manage the sheer volume of foreign money coming into the country to fund aid programs, which it estimates as about $1bn this year. One effect is to push up the value of the Ugandan currency, which in turn makes the country’s fragile export market (coffee, tea and flowers) less competitive, threatening jobs and economic growth and increasing dependence on aid.

Aid creates and sustains unequal relationships, talk of partnerships between donors and governments are a distortion, Richard Dowden of the Royal African Society writes “We like it when they take ownership of the program but we mean our program. We don’t like it if they start having their own ideas”. This high-handed attitude creates resentment at every level of government. It is exacerbated when the people exerting control have little cultural understanding, are paid salaries many times greater than local staff and drive around in huge gas-guzzling SUVs. When programs are ineffective or fail even the poor African who rarely feels the direct impact of aid, notices and resents the ‘dude in the Land Cruiser’

Aiding and Abetting
Aid sometimes enable governments to pursue and sustain policies, which harm its citizens. The Ugandan Government’s terribly defective strategy to defeat the LRA in Northern Uganda by corralling the people into IDP camps is aided and abetted by the World Food Program . Without this food the government would be forced to find an alternative solution to the conflict. Ethiopia’s seemingly endless and biblical famines are not just the result of drought and over-population, but of a fatally flawed Marxist government policy, which denies land ownership to individual peasant farmers. Tenant farmers have no incentive to care for the land. Every famine, the government cries out for and receives international food aid and avoids dealing with the deeper political issues.

Quality of Mercy
My greatest criticism of contemporary development aid is its quality. It seems to me that the basic ethos of aid remains a voluntary transfer of charity from rich countries to poor. We give money, tell them how to use it, minutely scrutinize their activities and hold them accountable for failure. There is little or no donor accountability, particularly downwards to the people meant to benefit from the aid. The result is that aid is hugely distorted and badly managed by donors.

Real Aid
Last year, the NGO Action Aid produced a very revealing study of modern development aid, entitled Real Aid. It shows that every donor country exaggerates the true quantity and quality of its aid, though some are more self-interested and economical with the truth than others. The first revelation is that globally only 40% of development aid goes to low income countries and only 30% to countries in Sub-Saharan Africa. The majority of aid goes to middle income countries, which strikes me as an odd strategy for poverty reduction. Second, debt-relief is counted as Official Development Assistance, jargon for aid. This despite the fact that most debt relief is no more than a paper transaction to narrow the gap between what a country is due to pay and what it is able to pay. Third, services for immigrants/refugees are also counted as ODA. Both seem to be double accounting and there is no doubting its distortion. France spends $0.5bn a year on its national refugee issues and over 40% of its ODA is debt relief.

Experts and Exports
When it gets into the details of how the actual money is spent the revelations are eye-popping. A quarter of all aid is spent on Technical Assistance (TA) a catch-all phrase encompassing companies and consultants from donor countries to provide the recipient with expert advice and assistance often at huge cost. In Africa alone, donors employ an estimated 100,000 technical experts. Some donors are very exclusive in their choice of expertise, for example, 25 of the 34 largest recipients of the UK technical assistance contracts listed on the Department For International Development (DFID) website are British. None of the remaining nine is from a developing country. Lest Americans feel self-righteous, the UK spends 16% of aid on TA, the US is top of the class, spending 47%.

Transactional and administrative costs gobble up another 14% of the money. Not to mention time and effort, the average African country is estimated to produce 10,000 quarterly reports to donors a year and to host 1,000 donor visits. But the prize for pork goes to something called ‘tied’ aid. A whopping 40% of all aid outside of TA and food aid is tied to the purchase of goods and services from the donor country. As an example, the President’s Emergency Plan for AIDS Relief (PEPFAR) which has committed $15billion over 5 years, requires funding is only provided for branded drugs. US pharmaceutical companies get lucrative contracts but less people will get life-saving treatment than if cheaper generic drugs were used. The US is not alone in tying aid in this fashion but it certainly heads the pack at 70% of its aid, with only Italy beating it at 92%. Some countries, including Britain, have recently untied their aid but there is a long way to go to end this form of ‘aid as trade’.

Moral Guidance
Faced with these facts, it is small wonder that African governments appear less grateful and enthusiastic about aid than many donors believe they should. It is also easier to understand why funds get misappropriated with impunity within recipient countries and corruption is endemic to aid programs. Quite frankly, the examples set by most donor countries - exaggerating amounts, round-tripping monies through TA , tying aid to donor commercial interests and the profligate waste of funds through poor management – provide very poor moral guidance.

Aid and Dignity
In questioning whether Africa needs aid in order to develop, whether aid should be increased, even doubled according to findings of last year’s G8 Summit on Africa, I realize I run contrary to such great ‘social scientists’ as Bono and Geldorf (but I still like the former’s music and could never stand the talent-less Boom Town Rats). I have though, no qualms in criticizing the current quality of development aid, the dissembling, waste and distortion, clear for all to see. There is an urgent need to clean it up before increasing it.

I also believe that giving aid feels good and indeed our intentions are mainly good (though they may pave the way to hell). But there must be better ways to help Africa. We must pursue policies that enable Africa to develop its own way under its own steam, with dignity, able to compete and earn its living in the world.