Monday, January 21, 2008

Reservoir Dogs

One morning, just before Christmas, I was startled by the banner headlines of my local newspaper, which read, ‘Uganda Hit By Epidemics!’ Closer inspection revealed that apart from the ‘usual suspects’, cholera and meningococcal meningitis which have plagued the parts of country recently, two new pestilences are stalking the land, Bubonic Plague in Nebbi, West Nile and Ebola in Bundibugyo, western Uganda.

The outbreak of Bubonic Plague is the latest in a series of epidemics of yersinia pestis that periodically afflicts the border between northwestern Uganda and eastern Democratic Republic of Congo (DRC). The catalyst is exceptionally heavy rains; this past year has seen widespread flooding of the region. The rats, the primary reservoir, meal-ticket and main means of transport for the fleas, the key vector, move into human habitation to avoid drowning. The disease kills the rats, the fleas jump hosts and off we go; ‘The Black Death’ on a miniature scale. As usual, the local health service’s reactions were slow, medicines in short supply and a few hundred caught the disease; about 20, mainly women, have died to date.

The outbreak has been contained in the major towns along the Border but has certainly not been extinguished. It is hardly surprising; the populations are huge, over-crowded and grindingly poor. Healthcare resources are minimal and it’s a long way from Kampala. Central government’s attitude to the epidemic is exemplified by the statements made to the press by the Minister of State for Primary Healthcare, Dr Otaala and the Director General of Health Services, Dr Zaramba. At the press conference Dr Otaala attributed, “the recurrence of [P]lague in Nebbi…….is due to the primitive culture of indigenous people, where men sleep in beds and women on the floor. The people mainly affected are women because in Nebbi women only come up on the bed for sex.” Dr Zaramba, obviously seeking to clarify his Boss’s offensively patronizing statement elaborated, “The flea that causes the Plague can only jump six inches high, if everybody was sleeping on a bed, there would be no Plague in the country.” Now why didn’t someone in CDC think of that!

‘The Plague’ has deep historical connotations for many but it no longer frightens the way it did our forefathers. Not so Ebola Hemorrhagic Fever (EHF). Thanks to Richard Preston’s not-bad account of Ebola-Reston in a government laboratory and the hysterical film ‘Outbreak’ in 1995, Ebola has a truly frightening global reputation; to be fair, not without cause. It has an impressive mortality rate of between 50% and 80%. The last time it visited Uganda was 2000/1; it sickened about 450 people in three towns, spread across the north and west, and killed 250. This time it seems to be contained in western Uganda, in a region surrounded by national parks. To date over one hundred people have been diagnosed with EHF and about 40 have died.

What makes this outbreak as interesting as it is scary, is its relatively slow progression. The estimate is it began in September 2007 and was not officially recognized until December. This may in part be to the paucity of healthcare resources in the region but skeptics also suggest that the Government kept it quiet because they did not want to frighten away the Commonwealth Heads of Government Meeting, a huge international junket held in Kampala in late November. The disease became international news in early December.

The second issue is the relatively low mortality of this outbreak compared to others. It seems that the pathogen is a new subtype (the three known to date are Ebola Sudan, Ebola Zaire and Ebola Reston). Paradoxically, the slow progression and low mortality could be very bad for us humans. Scientific opinion holds that humans are ‘dead-end hosts’ for EHF and the speed at which the virus kills us limits its ability to propagate; slowing down the process may enable it to spread more efficiently.

Finally, the so-called index case, the first known casualty, seems to have been a hunter who killed and ate a monkey (primates of all types are common food source in the region). The Government and wildlife organizations are warning locals not to eat monkeys (or chimpanzees or gorillas) which is good for the primate population but primates are just as susceptible to the disease as humans, an outbreak in 2000 in DRC is estimated to have killed 5,000 lowland gorillas. They [primates] are not the reservoir host, which normally carries the disease asymptomatically. The monkey that was killed was probably sick, this week a number of dead monkeys were found in the nearby national park.

“At this point you are entitled to ask: Damn, what is it about bats?’ David Quammen .
This outbreak comes at a key moment in the study of Ebola and growing array of viruses such as Marburg, Hendra, Nipah and the corona-viruses of SARS, which are producing new and frighteningly lethal human diseases. Virologists collaborating on international research have strong scientific evidence the reservoirs for these and other pathogens, are bats. This should come as no surprise. They have been around a long time, are hugely adaptable and can be found almost everywhere on the planet. It seems the reservoir for Ebola might be a fruit bat. There are lots of them in the forests of western Uganda and the DRC. Moreover, as human population pressure mounts, people increasingly encroach on the natural habitat of the bat and every other wild animal.

This brings me to the point of my argument. Both of ‘Uganda’s Epidemics’ are zoonotic diseases: Infectious diseases that can be transmitted from animals, wild and domestic, to humans. The really surprising issue (for me at least) is how many zoonotic diseases there are and the burden of disease for which they are responsible. A recent study by the University of Edinburgh calculates that of the 1,710 pathogens afflicting humans, 832 are zoonotic (49%). Among the so-called new and emerging diseases 75% occurred first in animals.

A cursory ‘Google’ produces a veritable avalanche of information on Zoonoses. To study zoonotic disease is to study the path of human history. A couple of examples might serve to illustrate. Yellow Fever, the scourge of the New World for much of the 18th, 19th and early 20th Centuries, that almost stopped the building of the Panama Canal, probably originated in west Africa and traveled to the Americas in the mosquito larvae living in the water barrels of slave ships.

West Nile Virus, a mosquito-borne virus, appeared in the USA in 1999 attacking and killing birds, horses and humans and is now considered enzootic/endemic to the USA. It was first identified in West Nile District Uganda, the setting of my Bubonic Plague story, in 1937. How it got from Nebbi to Nebraska in 70 years is a mystery almost certainly as related to human movement as the migration of Yellow Fever.

Sleeping Sickness or Trypanosomiasis is another disease with an odious reputation. There are two types. African Trypanosomiasis is transmitted by the tse-tse fly from wild animals to domestic cattle and dogs and humans. Data on the disease is sparse; it affects mainly the rural poor who are ill-served by modern healthcare and is an appalling way to die. New World Trypanosomiasis or Chagas Disease is transmitted the Reduviid or “kissing bug”. Chagas Disease infects about 18m people every year in Central and South America, about 50,000 die. Charles Darwin is believed to have succumbed to the disease. The principal reservoir for Chagas is the domestic dog. A recent study found that people could significantly reduce the risk of infection by excluding dogs from bedrooms.

Reservoir Dogs
It seems that ‘man’s best friend’ is a reservoir for a significant number of zoonotic diseases. ‘Fido’ is host to an array of worms, which regularly infest our children, sometimes with awful results like Ocular Larva Migrans, where worms migrate to the child’s eye, and to adults, particularly a tapeworm, which migrates to the liver and causes chronic inflammation known as Hydatid Disease. In Sudan, the domestic dog is the principal reservoir for a terrible disease known as Kala Azar or Visceral Leishmaniasis. Domestic dogs are also the principal reservoir for rabies, in Africa. About 55,000 people, mainly children, die of Rabies every year.

Adapted to Travel
Despite Ebola’s fearsome reputation, it and other exotically-named viruses are seen as diseases of primitive far away places, unlikely to be encountered in the average American ER. That may be true today, Ebola has not yet adapted to distant travel, but if history is any judge, it will soon, and the results could be ghastly. Consider the evolution of the perfectly adapted virus, HIV. It almost certainly jumped to humans from primates in the same way as Ebola and probably the same part of the world. But it kills so slowly it has managed to become a global pandemic, killing millions within 50 years. Even more worrying SARS, a corona-virus which probably spilled over from horseshoe bats and which infected many thousands and killed over 700 people on its first world tour, has disappeared from our radar but will probably return with a vengeance soon, its vector, the international traveler. Finally, there is Avian Influenza, the boogey man of the infectious diseases. One of its ancestors scythed the human race less than one hundred years ago, when the world’s population was much smaller and travel slower. I shudder to think what havoc it would reap in over-crowded poverty stricken Africa or Latin America.

One Medicine
When I began examining the issue of zoonotic disease what puzzled me the most was why, given that zoonoses contribute hugely to the burden of disease and the very clear and intimate relationship between human health, animal health and the ecosystem in which both exist; their respective sciences are so stove-piped. I am not sure they always were. Where we are now seems to be the result of the narrowing of our scientific viewpoints and the specialization of our professions, driven partly by the sheer volume of what we have to know. The history of human health is replete with accounts of men and women who took a broader view of human health than simply the absence of disease; individuals who described, promoted and practiced what has been called ‘One Medicine’ or latterly ‘One Health’.

Amongst the most famous proponents of ‘One Health’, three deserve special mention. Rudolph Virchow, a 19th Century German physician and statesman, often cited as the Founder of Modern Medicine, wrote extensively about the link between human and animal diseases and coined the term zoonosis. William Osler, a Canadian physician and former pupil of Virchow who became one of the four ‘Founding Fathers’ of Johns Hopkins School of Medicine, began his scientific life as a veterinarian and is credited with creating the term ‘One Medicine’. Ironically, whilst at Oxford in 1919, Osler fell victim to the great zoonotic disease of the era, the Influenza Pandemic. Finally, no account of the One Medicine movement would be complete without mention of Calvin Schwabe, the legendry epidemiologist from UC Davis School of Veterinary Medicine, who until his death in 2006, was the leading proponent of a unified approach to human and animal health. His monograph, ‘Veterinary Medicine and Human Health’ remains a classic.

One Health Now and the Future
So where are we now? ‘One Medicine’ is unquestionably a resurgent concept, growing in strength as the public and the scientific communities become increasingly aware of global ecological disturbance directly attributable to human population pressure. The growth of One Medicine ( I prefer One Health) is evinced by the creation of organizations like the Consortium of Conservation Medicine (see and One World, One Health (see The most recent conference, the Fifth Annual ‘One Medicine’ Symposium, held at the University of North Carolina In December 2007, provided clear directions for future collaboration between scientists involved in the entire spectrum of human, animal and ecological health. I also strongly recommend the excellent article I quoted by David Quammen in National Geographic October 2007.

One Health and the Community
I confess to some reservations regarding how ‘One Health’ is developing, essentially as the academic pursuit of elite scientists. I believe there is an urgent need to include the ‘foot soldiers’ of human and animal healthcare in the debate and in the action, particularly in the developing world where most of the action and interaction is taking place. My experience in Africa and Latin America leads me to believe that the community healthcare workers, who form the backbone of healthcare in most developing countries, know little about zoonotic disease, the inter-relationship between human and animal health, (their domestic animals or wildlife) and even less about their environment and ecology. Yet, as the Ebola story indicates, it is the community healthcare worker who comes first in contact with infectious disease outbreaks, ancient or emerging. Invariably community healthcare providers are so ill-prepared they are amongst the first victims.

I am advocating a fundamental review of what is taught and practiced as community health and healthcare in the developing world. I believe I have illustrated the vital importance of zoonotic disease in the health of people, particularly the rural poor. Most rural peoples are agriculturalists and own domestic animals; healthy animals add to the wealth of their owners, sick animals increase their poverty. The more rural people encroach upon wildlife habitats, the greater the risk that diseases which live relatively innocuously in the wild, will spill over into domestic animals and humans, Uganda’s Ebola outbreak is a good example. I offer an idea. Train two types of community healthcare worker under the same roof; one in human health and one in veterinary health and deploy them to work in teams together in the community. Maybe that’s a concept worthy of a trial project somewhere in Latin America, soon.

Monday, January 14, 2008

Dude Where's My Landcruiser?

I wrote this back in late October 2006 and have no idea why I did not post it at the time. Still, as a synopsis of events in Uganda at that time, it covers most issues and, perhaps tragically, events are little changed today. We still have no peace accord with the LRA, we still struggle with malaria, electricity remains rationed and erratic and there is an acute fuel shortage. This time because of civil unrest in Kenya but also because the government gave away its strategic fuel reserve to its friends and forgot to ask for it back. But, thanks to a bulk buy of top-of-the-range SUVs for the Commonwealth Heads of Government Meeting last November [07] we have many more Landcruisers, Hummers, BMWs etc. The roads remain awful. The population continues to increase at an exponential rate, urged on by a Government which believes that Uganda's future development hinges upon 'growing a population large enough to create its own internal market'. As far as we are aware, we have not yet been stricken by Bird Flu, but who cares. We have Ebola Fever again.

Interesting Times
"May you live in interesting times" is popularly believed to be a Chinese curse but more likely owes its origins to a speech by Robert F. Kennedy in Cape Town, South Africa, on June 7, 1966. Nevertheless, it resonates with life in Uganda today.

The 20-year conflict in the north of the country is slowly but surely drawing to a close. An agreement called a Cessation of Hostilities has been in place for a month and the Lord's Resistance Army (LRA) has moved the bulk of its 'fighters' into agreed safe areas in southern Sudan under the aegis of the army of south Sudan, the Sudanese People's Liberation Army (SPLA). The next step will be for the LRA to agree to the release of 'non-combatants'-women and children. This will probably happen within a few days.

The political center of gravity of the final stages of the conflict has now shifted to the Hague in the Netherlands and has become far more complex. At issue are matters of international law and the outcome of the debate will have global ramifications. A synopsis of events is essential to understanding the current crisis. In 1999, in order to inject fresh political initiative into ending the war in the north, the government passed into Ugandan law, an Amnesty Act, in effect offering amnesty to all LRA insurgents who surrendered. From 2000 to early 2004 many LRA members sought and received amnesty. The senior leadership did not. In 2004 the newly formed International Criminal Court (ICC) in the Hague intervened publicly in the conflict, announcing that the Ugandan government intended to amend the national Amnesty law to exclude the senior leadership of the LRA and had [also] asked the Chief Prosecutor [of] ICC to investigate charges of 'crimes against humanity.' The amnesty law was amended and in late 2005 the ICC issued arrest warrants for Joseph Kony and the top leadership of the LRA on charges of war crimes.

From the outset, there was heated debate over the perceived 'outside interference' of the ICC (even though their involvement was at the request of the Ugandan government). Many northern Ugandans believed it threatened the short-term quest for an end to the war and prospects for long-term peace, which would have to be based upon reconciliation rather than retributive justice. Many, too, saw the ICC as the 'international community' meddling in sovereign issues.

Now matters have come to a head. When peace talks began, the Ugandan government stated publicly their wish for greater flexibility over the ICC arrest warrants, even suggesting they be dropped if there was a conclusive peace deal. The LRA have repeatedly stated they will not accept any deal that includes arrest and trial by the ICC. The ICC remains implacable, insisting that the warrants be enforced and those indicted brought to trial. The result is a complicated impasse with serious implications for the future of international law. In my opinion, fault lies with the ICC, which failed to appreciate the complexities of the Uganda conflict and acted precipitously. It will be fascinating to see who backs down and how.

The Pale Horseman
Even as the peace talks in Juba began to show promising results, a scary shadow was cast over them. Pestilence appeared in the town, in the form of confirmed H5N1 'Bird Flu.' An unknown number of local domestic poultry were found dead and dying of the disease and an unknown number have since been slaughtered. There have been no confirmed cases of the disease in humans. Given my last missive to this magazine, which dealt with H5N1 in northern Uganda, I feel like Jeremiah.

Juba, the capital-city-in-the-making of south Sudan, is about 200 miles from Gulu. The road between the two towns is a constant stream of vehicles carrying every animal, vegetable and mineral that can be bought in Uganda and sold to satisfy Juba's rapidly growing appetite. The outbreak was first reported there on Sept. 6. Since that date, information has been scarce and direction from Uganda's Avian Influenza Task Force has been of the 'don't panic' variety. No attempt has been made to stop the flow of domestic poultry in and out of the towns or to map the 'backyard chicken projects' spread across the north, so that when the disease arrives, swift intervention will be possible. There are so few resources available and so little planning and preparation has been undertaken, I suspect that when the disease breaks out in the IDP [internationally displaced person] camps, the government will have little alternative but to send in the Army to supervise the culling of birds. Given that domestic fowl are a vital cash crop in the camps, this move will further alienate the Army from the IDPs. We wait with bated breath and try not to cross the line between alert and alarm.

Re-Thinking Silent Spring
On Sept. 15, the World Health Organization (WHO) made an announcement forcefully endorsing the wider use of the insecticide DDT to combat malaria across Africa. In one sweep, the WHO reversed a 30-year old policy of ambiguity on the issue of DDT and poured gasoline on a fire that has burned in Uganda for years; the argument between health professionals fighting an uphill battle against the disease, agricultural businesses that worry about the threat to their markets, particularly in Europe, and ecological activist groups, mainly international.

The data on malaria in Uganda are mind-numbing. It is the single biggest killer of children under five, accounting for about 100,000 child deaths country-wide annually. The country's maternal mortality rate is about 550 for every 100,000 pregnancies, [and] malaria is a key factor in the majority of these deaths. But the figures mean nothing unless viewed in the context of day-to-day life in the country. Whereas a kid's sick note to school in the U.S. may read, "Johnny has had a cold," in Uganda it will more likely read, "Samuel has had malaria." It is the single biggest cause of [lost work] days; nobody bats an eyelid when Fred comes back to work, looking gray and thin after a week off. They assume malaria. It is quite simply a part of life here and always has been.

In the 1980s, HIV/AIDS hijacked the public health agenda in Uganda. Interest in malaria as a disease threat waned. In the past few years, as HIV/AIDS rates dropped and public fear diminished, malaria came back on the agenda. The problem was how best to tackle disease prevention. The optimum method, proven successful in the [United States] and southern Europe in the 20th century, was by attrition of the vector, the mosquito. There is too much water in Uganda to contemplate 'draining the swamp.' Most insecticides are ineffective or too expensive for large-scale use. The most effective and cheapest, DDT, was essentially banned by international opprobrium. Many donors wouldn't fund malaria programs that contemplated using DDT. Fresh flower and vegetable markets, particularly in Europe, threatened embargoes on products originating from regions using DDT. The only tool left in the box was insecticide-treated nets (ITNs).

They (ITNs) have not proved to be the 'silver bullet.' The science has yet to be done to prove why they have not had a significant impact. I can offer a [firsthand] observation. They work for me at home [in Gulu] because we live in a spacious house with a big, well-ventilated bedroom. It is relatively cool at night, even under a mosquito net. I have spent nights in small dark windowless huts and boiled under my net. I can imagine, but only just, what it would be like to try and keep the average Ugandan family of two adults and seven kids, living in a 12-foot diameter hut, under mosquito nets all night. The number of nets distributed is no indicator of use.

So the debate has turned again to insecticides and to DDT. This is neither the time nor the place to debate the detailed science of DDT but it seems clear that the infamous reputation it gained in the '70s owes much to the amounts and methods of use. The WHO, in reversing its policy, is advocating small concentrations of DDT be sprayed in emulsions onto the walls of huts, houses and other buildings, and only [up] to a few feet above the ground. [DDT is used in a form called 'internal residual spray,' indoors only and low down toward the ground. Mosquitoes usually rest about one to three feet above the ground.]

This form of precision use, in conjunction with ITNs, is another saga in the long war against malaria and seems eminently sensible. It is already used in 10 countries in Africa. But the battle has multiple fronts and the most intractable is the political. I can understand the reticence of the Ugandan Ministers of Agriculture and Export. They worry about the fickle markets of Europe and the potential impact on a shaky economy. The decision should be a national one, made by the government, weighing the economical, health and social risks. What I cannot accept is interference from international activist groups such as Beyond Pesticides, which campaigns against the use of DDT in Africa from the comfort of its mosquito-free moral high ground on E Street in [Washington], D.C. Particularly when they rationalize their position with platitudes of the caliber of, "[W]e should be advocating for a just world where we no longer treat poverty and development with poisonous band-aids, but join together to address the root causes of insect-borne disease..." I have a piece of advice for them. If you want a credible voice in the fray, come and live in Gulu for a year. And leave behind your unaffordable Malarone [an antimalarial drug that costs $33 a week] and designer packs of insect-repellent 'wipes.'

Demography And Destiny
This month has also seen the publication of the government's State of Uganda Population Report (SUPRE). It was a damp squib, meriting only brief mention in the middle pages of the national newspapers and not a whisper of national debate. The report's most hard-hitting line is to warn of the "[m]is-match between a population growth of 3.2 per cent and economic development." Closer examination shows what a 3.2 per cent growth means: the current population of 28 million will double to 56 million in less than 20 years and double again to over 100 million by 2050. The most staggering statistic: there will be 28 million 'job seekers' in 20 years time. This is set against an economy-already struggling to keep up with a rapidly growing population with ever-rising expectations-pole-axed by a catastrophic hydro-electric power-shortage, resulting from the drop in the levels of Lake Victoria. Plans to rebuild the power industry to get back to the levels of two years ago are estimated to mature in five years, [and] to get ahead of the game will take another five years [after that]. The best advice the authors of the report can offer is "[P]lan, plan, plan."

The level of debate in the media has bordered on the fatuous. It has included celebrating 'Uganda's natural fertility as gifted by Nature,' to blaming current economic woes on colonization, [and] to dire examples of economic crises in European countries with low population growth. If 'demography is destiny' was ever true, then it is so in Uganda. And the people are ignoring it.

Dude, Where's My Land Cruiser?
You would imagine with all these momentous events in train or just over the horizon, Uganda's leaders would be consumed with affairs of state, Parliament would be conducting all-night sessions on the future of northern Uganda, bird flu, DDT and plans for economic recovery. Not so. The most contentious current issue among Uganda's lawmakers is official cars for Members of Parliament (MP). This august body of individuals, totaling 300, is debating the necessity of each having an official car to travel to their constituencies. Moreover, given the appalling state of the roads and the huge numbers of road accidents, the MPs believe it vital that their cars be SUVs (Land Cruiser size) to give them better protection in an accident. Never mind the poor constituent who has to travel the same roads crammed on the back of open pick-ups. The cost of this essential 'perk' to the taxpayer? Uganda 20 billion shillings, about $10 million, and that does not take into account fuel and maintenance. [There are about 2 million shillings to $1,000 U.S.]

But this pales into insignificance when compared to the government's spending on official vehicles. A recent government report showed that it maintains a fleet of 11,000 'luxury cars,' mostly SUVs and double-body pick-ups. The total annual cost of fuel and maintenance is 54 billion shillings, about $27 million. There is no mention of capital costs, but at $40,000 per vehicle, I estimate the total at nearly half a billion dollars.

The Ministry of Health has almost 3,000, the Ministries of Education and Agriculture over 1,000 each. The most damning indictment is that few of these vehicles ever leave Kampala or the big towns, [and] most drivers reported they had never used four-wheel drive. They are used to ferry officials from home to office and meetings. The [State of Uganda Population] Report notes that the excessive number of SUVs in the Health and Education ministries was probably the result of the large number of donor projects they are required to run. That statement is worthy of further detailed examination and I intend to do just that. The other question that nags me is how much money comes from the Ugandan taxpayer to fund this obscene display of bureaucratic excess and how much comes from taxpayers in other nations?

The Turbo Effect

Last month, December 07 to be precise, I wrote that in order to mark World Aids Day 2007, I would resurrect a number of articles I had written in the dim and distant past, on the subject of HIV/AIDS and plonk them on this site. It seems to date I have only posted one. Keeping my promise and because i think this piece remains relevant today, I have another offering, The Turbo Effect. Here it is essentially unedited from its original, published in US Medicine in 2002. It may, one day, be of interest to some wandering soul.

Cognitive Dissonance
In 1957 a Stanford University social psychologist Leon Festinger published his theory on behaviour called cognitive dissonance. In simple terms it is the distressing mental state in which [in Festinger’s words] people "find themselves doing things that don’t fit with what they know, or having opinions that do not fit with other opinions they hold”.
Festinger considered the human need to avoid dissonance as basic as the need for safety or to satisfy hunger. It is a drive to be consistent, so strong it can make us change our belief in an effort to avoid a distressing feeling. The more important the issue and the greater the discrepancy between behavior and belief, the higher the magnitude of dissonance that we will feel. In extreme cases cognitive dissonance is like our cringing response to fingernails being scraped on a blackboard—we’ll do anything to get away from the awful sound. After a year of near total immersion in HIV/AIDS in sub-Saharan Africa, I am struggling with an acute bout of “the CDs”.

Hard Talk
The source of my discomfit is a series of review articles in the International Journal of STD and AIDS 2003: 14. The authors are a group of international scientists whose principal author has a rather catchy name, David Gisselquist PhD. The articles address the factors that account for the rapid spread of HIV/AIDS in Africa. I admit that when I first read them, although my interest was piqued I was most influenced by the opinions of ‘my elders and betters’ in the world of HIV/AIDS and public health who abound in Nairobi. They almost unanimously dismissed the articles and the studies that underpin them as “flawed science”. About ten days ago I sat down to watch a current affairs program on BBC World satellite TV called “Hard Talk”, which specializes in the contentious and the topical; grilling those brave enough to subject themselves to inquisition. On this occasion, to my surprise and delight it was the aforementioned Gisselquist and some luminary from the London School of Tropical Medicine and UNAIDS. The ensuing battle was short sharp and painful, for my money Gisselquist came out on top and I once again set about the rather turgid prose and dense tables that epidemiologists deem as the only fitting means to publicize their science. The “CDs” set in after the first iteration.

Sex Central
The authors’ thesis is that almost from the outset of the pandemic, the consensus amongst influential AIDS experts has been that heterosexual transmission accounts for the overwhelming majority of adult HIV infections in Africa, yet the scientific evidence to support such a belief is questionable. They argue that the conventional wisdom regarding adult HIV infections in Africa emerged as a consensus in 1988. In that year,
the World Health Organization’s (WHO) Global Program on AIDS circulated estimates that 80% of HIV infections in Africa was due to heterosexual transmission, 10.8% from mother-to-child transmission, 6% from blood transfusions, 1.6% from contaminated medical injections and other health care procedures, and 1.6% from men who have sex with men (MSM) and injection drug use (IDU). Estimates for heterosexual transmission have inched upwards since. According to the World Health Organization’s 2002 World Health Report, ‘current estimates suggest more than 99% of HIV infections prevalent in Africa in 2001 are attributable to unsafe sex’.

They further argue that if experts had treated the consensus as an hypothesis—which it was and still is—and had used it to guide research to test competing hypotheses, it could have played a constructive role. Unfortunately, many experts have accepted the consensus as fact and not seen the need for further research to test its estimates. The result has been that the consensus has suppressed inquiry and dissent as researchers in Africa—and in Asia and the Caribbean—have often assumed sexual transmission without testing partners, without asking about health care exposures, and when conflicting evidence nevertheless emerges—such as infected adults who deny sexual exposures to HIV—routinely rejecting it.

Turbo Charge
The key to the Gisselquist et al argument is that studies in Africa show that sexual activity levels in the general population are comparable to those reported elsewhere, especially North America and Europe. Moreover, transmission efficiency studies amongst African couples produce estimates remarkably similar to studies of couples in the developed world. So, their argument goes, if African sexual behaviour is comparable to North American and the virus moves between heterosexual couples with the same efficiency north or south of the equator, why has the disease moved so much faster in Africa than in the developed world and why has heterosexual sex been more effective as a means of transmission in Africa than the developed world? What additional factors cause the so-called “turbo effect” that has enabled the disease to spread so rapidly compared with other regions of the world?

Quality of Care
The authors examine the history of AIDS in Africa from 1983 to 1988. Through extensive literature searches and studies they demonstrate that during the period there was considerable debate about the role of healthcare in the spread of the disease. They produce both anecdotal and science-based evidence to demonstrate that during this time, poor healthcare practices had a considerable impact on the spread of HIV/AIDS. Contaminated blood products and the use of unsterile needles for the administration of drugs and vaccines were acknowledged as key factors in the spread of the disease in certain regions of the Continent. This was recognized by experts but considered of secondary import to sexual activity.

They go on to argue there is evidence to show that in those early years of the spread of the disease, health care exposures caused more HIV than sexual transmission in some regions of Africa; suggesting that as much as half of all adult infections during that time were related to healthcare exposures.

Interests, Assumptions and Opportunism
Why was this evidence ignored? The authors argue that papers published around 1988 reveal a number of considerations that might have encouraged a mindset prepared to see heterosexual transmission as the driving force in Africa’s HIV epidemic. First, it was in the interests of AIDS researchers in developed countries—where HIV seemed confined to MSMs, IDUs, and their partners— social groups outside of general society - to present AIDS in Africa as a heterosexual epidemic devastating “ordinary people”. In a prominent 1988 article in Science, Piot and colleagues argued that ‘Studies in Africa have demonstrated that HIV-1 is primarily a heterosexually transmitted disease and that the main risk factor for acquisition is the degree of sexual activity with multiple partners, not sexual orientation’ .
Second, there may have been an inclination to emphasize sexual transmission as an argument for condom promotion, coinciding with pre-existing reproductive health programmes and efforts to curb Africa’s rapid population growth. Third, the role of sexual promiscuity in the spread of AIDS in Africa appears to have evolved in part out of prior assumptions about the sexuality of Africans. Fourth, health professionals in WHO and elsewhere worried that public discussion of HIV risks during health care might lead people to avoid immunizations. A 1990 letter to the Lancet, for example, speculated that ‘a health message—e.g., to avoid contaminated injection materials—will be misunderstood and that immunization programmes will be adversely affected’ .
In summary, peripheral and opportunistic considerations combined with an increasing display of cognitive dissonance amongst the cognoscenti to cause the evidence to be misinterpreted or completely ignored.

Yesterday’s News
Some might argue, “so what?” Even if its all true, these were events of nearly 20 years ago. Even if the quality of healthcare was a significant factor in the spread of HIV/AIDS in the 1980’s it no longer holds true. Across Africa basic healthcare has considerably improved and healthcare providers are well aware of and take precautions against the spread of HIV through faulty practices. Moreover, few would doubt that today heterosexual sex is by far the most likely means of transmission.

Trust Me I’m a Doctor
There are a number of reasons to be concerned about these studies. First, they raise genuine questions about the fidelity of scientific thought 20 years ago and do little to persuade the reader that things have changed for the better. Why should Africans trust those [predominantly from the rich developed world] who promised so much and yet have had little impact on the disease? Second, the image of African sexuality and promiscuity as the almost exclusive cause of the disease and the major focus for intervention tends to a patronizing even racist attitude towards the problem. Third, there is a growing body of opinion that circumstances and vested interest are driving those who manage HIV/AIDS in Africa to deal with it in a vertical or stove-piped manner, independent of other health issues; to view it as one scientist described as “HIV exceptionalism” . If we fail to realize that HIV/AIDS is yet another [albeit terrible] infectious disease to add to the many that plague Africa, there is a danger that we will fail to strengthen our public health and health services. The result will be a resurgence of poor healthcare services and practices as a significant factor in the continuing spread of the disease, a complete loss of trust in healthcare systems and an increase in disease of all kinds in Africa.

The Gisselquist writings bother me. I commend them to anyone interested in HIV/AIDS in the developing world. Flawed science or not, they raise questions about the blind faith we seem to place in science and our ability to accept conventional wisdom without demure. The problem is we have in turn asked millions of helpless people to trust us and if we lose that trust the battle against HIV/AIDS will receive a serious setback. The least we can do is re-examine the evidence and re-open the debate. Africans deserve the truth. As to whether I believe in the “turbo effect”, yes. Though I very much doubt that I will ever be able to identify it. I have one consolation; writing this has eased my cognitive dissonance.

Tuesday, January 8, 2008

Kleptocracy in Crisis

Kleptocracy in Crisis
Three of the happiest years of my life were spent living and working
in Kenya. Today I sit in the relative calm of northern Uganda and
view, with great sadness but no great surprise, the events of recent
weeks. I would have kept my counsel had I not read three articles on
the subject in recent days, one really irritated me and the other two
inspired me to scribble this piece. The first article was in the
Washington Post, by Caroline Elkins, a Harvard professor and author of
a history of the end of colonial rule in Kenya, Britain's Gulag. I
have read the book, along with the much better, Histories of the
Hanged by David Anderson. Sadly her thesis degenerated into an
anti-British tirade within a few chapters and never recovered. As one
critic offered, "I shudder for those of her students who expect
academic rigour: Elkins doesn't let facts stand in the way of a good
rant". Her WP article, followed the same trajectory.

I much preferred the latest two essays by Richard Dowden on the Royal
African Society's website,
But it was the excellent Op-Ed piece in today's [ 08 Jan] Nation, a
Kenyan daily newspaper, that really galvanized me into type. It is at

Like the author of the op-ed piece, Macharia Gaitho, I am not surprised at the crisis in Kenya, its
been a long time coming, but the factors have been in place for many years.
What we are witnessing is a concatenation of events, most beyond the
control of Kibaki, Odinga or any current leader: Here are a few:

Ever-increasing population pressure ( 9m to 30m in 45 years)
Over 80% of the population squeezed onto less than 10% of the land ( 80% of Kenya is arid or semi-arid land)
A very young population (the average age is just 18 years)
An economy that cannot keep pace with population growth
Or the
Rising expectations of the rural and urban young and poor
Ever-increasing Urbanization
A yawning chasm between the rich and the poor
A leadership that shamelessly misappropriates the nation's resources
and exploits the poor, primarily through promoting tribal differences
Endemic corruption at every level of society

The result, a huge population of young people whose relatively simple
expectations, the dignity of a job and some disposable income to buy
the odd Tusker beer, watch the Premier League on TV and maybe one day buy an old
Toyota, appear to be receding with each passing day. Long-term
sustainable improvement in the quality of their lives, is no more than
development jargon

There is an unknown number of young men without jobs in Kenya. Thirty
years of military experience and six years in humanitarian aid work in
Africa has convinced me the most dangerous creature on Earth is a
young man without a job. This is as true of Newcastle, New Orleans and
Najaf as it is Nairobi. It is the dignity and sense of purpose that is
as important as the salary. Men without jobs view themselves as
outside society, disenfranchised and owing nothing to their community
or society in general.

Not only do they not have a job, there is little hope of ever finding
one. They do their best to find some means of 'income generation'
-selling puppies, songbirds, sunglasses and mobile telephone
paraphernalia, filling in potholes [and then digging them out again]
and general panhandling - only to have their noses rubbed in the mud
daily by sneering Wabenzi and patronizing Muzungu in their SUVs.
Moreover, though tourism is a vital part of the economy it also
enables poor Kenyans who come in contact with tourists ( and for that
matter immigrant Europeans and Asians, expats in NGOs, missionaries
and the UN) to see 'how the other half live' and to contrast their own
lives and prospects. These hugely angry young men [and some women] are
fertile ground for the seeds of anarchy and social upheaval. The
portent to this storm has long been obvious in the high levels of
violent crime endemic to the country, not for nothing is Nairobi known
as 'Nairobbery'. The rise of the secret and violent Kikuyu sect,
Mungiki and its mirror organization, the Kalenjin Warriors, was also a
harbinger of terror to come.

Complacent, comfortable institutions like the UN, other International
Organizations and NGOs have ignored the gathering clouds and offered
no more than to help Kenya rearrange the deckchairs on their Titanic.
Who knows how many millions have been spent on sensitization workshops
and 'income generating activities'. Even when disaster happens, the
first into the breach are the UN and NGOs. Where are the government
institutions, where is the Corporate Social Responsibility of Kenya's
big businesses and the donations of Kenya's super-rich?

What we are witnessing is the culture of co-dependency. The Kenyan
government is doing the minimum to help the urban and rural poor, the
victims of current violence. The 'aid industry' critically dependent
upon such disasters to justify their existence, jobs and fundraising,
are again vying for time on CNN. In some respects, the 'aid industry'
is complicit in the disaster, refusing to tell the truth to power, for
fear they be PNGd and jumping into the breach at the first opportunity
and without caveat. In their actions and attitudes I can hear echoes
of 'The Whiteman's Burden' – 'we [Westerners] have to save the poor
Kenyans because their Government and civil society cannot'

Even through the narrow prism of the TV camera, it is clear to see
that the majority of those committing acts of violence in this civil
upheaval, are young men, of every and any tribal and political
affiliation. Their only common denominators are anger, frustration and
poverty. They have nothing so they have nothing to lose and are
focused on destroying all and everything, I suggest this is classic
nihilism. I would make Frantz Fanon's, in The Wretched of the Earth,
mandatory reading for every would-be Kenyan leader. What we are
witnessing in Kibera and Eldoret he describes as 'catharsis through
It is mendacious and misleading for observers to imply that this
social conflict is primarily about Kikuyu- Luo tribal enmity. Though
tribal differences are a strong feature of Kenyan society and a factor
in this crisis, it ignores the fact that Ex-President Moi, one of
Kibaki's closest advisers and both Moi's sons and the long-time
enforcer for the for the Mount Kenya mafia, Simon Biwot, all deposed
from their Parliamentary seats, in this election, are of the Kalenjin
tribe. It is groups of young Kalenjin men, the so-called Kalenjin
Warriors who have been putting the Kikuyu to the sword. If this was
simply tribalism, Kibaki would surely have pressured Moi and the Kalenjin leaders to intervene.

Blaming yesterday's colonialism and today's tribalism is to suggest that Kenyan's, both the leadership and the people, have no responsibility for current events and no control over their futures, that it is their inexorable destiny. No amount of blaming the past can excuse the appalling leadership of today. This is the soft bigotry of low expectations.

In his excellent book on Command in Battle, Rick Atkinson describes
how every night, the then Commander of the 101st Airborne Division in
the Gulf War, General Patraeus, asked the same trenchant question,
"Tell me how this ends". Here are my offerings.

I concur with Macharia Gaitho, the Genie is out of the Bottle. At best
we will have slow return to simmering discontent. A government of
compromise, presided over by an uncomfortable partnership of Odinga
and Kibaki will maintain power, using the crude tools of patronage and
tribalism. Neither man has much to offer that is radically new or
different. Both are aged, as rich as Croesus, hugely self-absorbed and
remote from the people, though Odinga casts himself as a populist.
Either or both will fight for the status quo and will use the tools of
state to crush any resistance.

The young, unemployed and disenfranchised, will return to violent
crime, mostly robbing the poor but occasionally the rich, and the
pressure will slowly build up until it explodes again in the future.
Spinoza offered, "There is no hope without fear and no fear without
hope". Maybe he is right, maybe the fear created by this current bout
of violence will galvanize Kenyans into radical change. It will take
much courage and huge effort. The biggest hurdle will be to break down
the 'culture of the Mzee', a veneration of the elderly, particularly
old men, a deeply entrenched taboo that suffocates, original thought
and innovation, the prerogative of the young.

In practical terms, there must be a more equitable distribution of the
nation's wealth, mainly through the creation of jobs, lots and lots of
them. Building a modern national infrastructure, roads, railways,
electrical grids and water and sewage systems would employ a lot of
people for a very long time. It would also be a far more useful way to
spend foreign aid than 'workshops on sensitization, income generation
activities, IECs' and the usual paraphernalia of the 'aid industry'.

I am making these comments as a Muzungu, living [ relatively]
comfortably in northern Uganda. I am however,
not a fool, I can see the same dark clouds on the horizon as I saw in
Kenya, perhaps bigger and more ominous. The population is growing at a
frightening rate and the nation's leadership is in an advanced state
of cognitive dissonance. Corruption is pandemic and the leadership
presides over another shameless kleptocracy. To watch Ugandan society
up close and personal is to observe Darwinism in action, only the
strong survive.

But the young, and they are huge in number, want more than a life of
subsistence. Urbanization is almost as rapid as population growth. Not
so much because there is no land to work, there is more than in Kenya,
but because the young want more than a life in a hut, with a parafin
lamp and to hoe a row of maize. Among their many aspirations, they too
want at least to be able to watch the Permier League on TV at the
weekends. Those few hours in front of the TV are used for far more than supporting a favorite team (though the support borders on the fanatical) It provides the [predominantly] young men with a meeting place to discuss the issues of the moment, including politics and also gives them a window on a wider world, one with seemingly endless opportunities and wealth. Here's a thought: Is football a revolutionary force which will shape Africa's future?

Predicting the future is no more than entertainment but without the
sort of radical action I have suggested, I am pessimistic for the
future of Kenya, Uganda and indeed much of Africa. I offer only this
quote from a man much cleverer than I.
A world of this magnitude of inequality is inherently unstable. Peace
is in the palm of the devil
- Fouad Ajami