Zambia .... or the crazy world of NGOs

One of the things C & I really wanted to understand once on the ground in Zambia .... was quite how the seemingly simple intervention for PMTCT (at its most basic just one tablet for the mum at delivery .... to the WHO recommended treatment - which is still less mind you than the extended preventative treatment any of us would get in the west - of one or two anti-retroviral drugs from 28 weeks and then syrup to the baby for anything from 1 day to a week after delivery .... and exclusive breast feeding - meaning absolutely NOTHING but breastmilk not even water - for 6 months if you can't guarantee safe water or continuous supply for formula feed ... which is essentially the whole of sub-saharan africa) needed to be integrated into the whole system of ante-natal care as a whole .... especially in more rural areas ....

An African health minister once warned me of NGOs that often enter countries with promises of quick-fix interventions e.g. a programme of vitamin A supplementation which was feted to cure all children of blindness at a cost of just 7 million dollars ... which in order to be implemented actually put on the overstretched national health system a cost of 77 million ... which clearly the NGO didn't consider in its costs .... i think today - we've all learned our lesseons somewhat but trying to triangulate this whole new approach to addressing the health system's needs ... yet avoiding the temptation to try and fix everything .... and still show results in the short term to please your donors .... is a complicated politricky dance ....

We visited urban and rural clinics packed to the rafters with expectant mothers and children pressed against all the sick and the competing for the attention of the heroic clinical staff .... rudimentary government labs and sleek NGO funded training centres ... pharmacies ..... community groups .... government ministries (its amazing that you can just get appointments with health ministers - imagine doing that at home! see - that is the indignity of being poor and having to welcome every idiot with a cheque book) ..... and swish NGO offices (fully complete with fleets of white 4x4s with tall flagpoles that sweep imperiously over rural roads .... C&I had a tiny starlet which showed us up totally as a pimply teenager in this very grown-up world of NGO multinationals)

I developed a huge respect for poor african health ministeries who have to juggle the demands, (well and not so well intentioned) interventions and directives of local organisations, NGOs, donor agencies, private sector etc etc .... one visit to the central medical stores showed boxes piled up from all over the world - condoms from the US, China, Sweden etc etc .... drugs from India ... bicycles from Germany .... bed nets from Britain ... all heaped up .... and they have to make sure that the they all get out to the right clinics spread across the country (often taking upto a week to travel) and coordinate expiry dates plus the politricks of difference agencies only wanting the clinics they support to receive the drugs they donate (yes i'm outing the Japanese)

This NGO driven agenda was most evident when we visited a rural clinic about 2-3 hours outside Lusaka .... where an amazing young clinical officer (sort of more than a nurse but not quite a Dr) ran a clinic with one other nurse for a catchment area of more than 10,000 people .... he provided a full set of services for his patients .... including the dual-therapy PMTCT that we are struggling to implement even in rich South Africa .... he proudly showed us the computer and printer carefully covered in plastic sheeting on his desk donated by an NGO so that he could use a patient 'smart-card' system and electronic medical record system that's being rolled out through an american PEPFAR initiative as a health system improvement .... however he still draws graphs of his quarterly achievements by hand (displayed behind the desk) and the pharmacy stock room was down to its last bottle of AZT and other ARVs (not to mention non-HIV drugs...) .... because no one has ever really taught him how to use the machine except for the smartcard .... and he still relies on copying everything painstakingly by hand ... because electricity tends to only be on for a couple of hours a day ....

When we were about to leave .... he refused at first to shake my hand .... "i won't say goodbye to you my sister until you promise me a borehole for the clinic" .... i was flabbergasted .... a borehole! but he had a computer!! He emotionally admitted that they had no water at the clinic so one of the two of them had to spend two hours a day fetching water to keep on hand for deliveries at the clinic, plus their own needs ..... a borehole would cost 11,000 kwatcha .... probably the half the cost of the unused printer on his desk ..... this is Development gone Mad.

P.M.T.C.T

Perhaps i got a little ahead of myself on the whole Malawi post earlier .... and perhaps should explain how it is i'm here in Africa again and not in London as i'm supposed to be ....

Some of you know that since I really didn't know what I wanted to do when I got back to London after/despite almost 4 years away .... I typically tried to keep all my options open (yes - my legendary commitment phobia still looms large) .... and so rather predictably I seem to now run around like a headless ninja .... gadding between the NHS, the London School of Tropical Medicine and attempting to do some consultancy work for NGOs on the side (the busy-ness of all this means that I can be smug about not having time to narrow my options down and make a decision) ....

Through the consultancy work - a friend/colleague and I were asked to look at the issue of mothers transmitting HIV to their babies (i.e. mother to child transmission - MTCT) which can occur during pregnancy, at birth and through breastfeeding .... and then tasked with developing a strategy for the NGO to scale up services in a yet-to-be-determined African country to prevent it (hence PMTCT).

The background tragedy is that there are now hugely effective ways to do stop this transmission happening ... and frankly we barely see kids born with hiv here in the west anymore .... but despite the science and treatment being known, tried and tested .... less than 15% of women who need it most actually have access to this treatment .... leading to hundreds of thousands of babies born unnecessarily exposed and infected ..... so that today over 90% of all children infected with HIV were infected by their mothers ....

And so C and I have travelled to Zambia and Malawi for a couple of weeks to look at how these two countries are addressing the problem given their high rates of HIV infection and to see why a prevention issue that seems to be such a no-brainer on the face of it (much easier than abstinence or condoms .... plus its all about babies .... great pics for development pornographers .... etc etc) has seemingly been languishing as the cinderella programme of the HIV world ....

African Swansongs ...

What is it with hated global leaders making their final victory laps in Africa?

Tony Blair practically reviled at home and most of the rest of the world by the end of his time in office .... was greeted rapturously in Sierra Leone and ... er... Libya .... in part at least for Britain's part in ending the bloody conflict in West Africa .... and for championing the (largely inconsequential) Commission for Africa ....

And now its the turn of George Bush .... possibly the most disastrous president in recent history ... to many a walking crime against humanity ... whose vast catalogue of terrible programmes and heinous decisions has perhaps just one redeeming highpoint - namely PEPFAR (and to a lesser degree his Malaria initiative) ....

Now I've raged against PEPFAR a few times on this blog ..... and there are many issues on which I vociferously disagree with it and think its been a pernicious influence on the fight against AIDS ... however ... quite aside from the fact that it paid my salary for over 2 years .... there's no denying that (at least the treatment-allocated) money has reached down to the poorest of the poor (very unusual for aid money) .... and amazingly is actually doing what its supposed to be doing - both vertically and horizontally strengthening health systems in the recipient countries ...

A personal hero of mine - South African Dr Francois Venter (head of the HIV Clinicians Society in SA .... and all-round firebrand) sums up what I think most of us feel ......

"I look at all the blood this man has on his hands in Iraq and I can't quite believe myself but I would say it's a bold experiment from the last people in the world I would expect to do it, and it is saving a lot of lives. To intervene on such a scale and make such a difference is huge,"

And it is true that this is a remarkable achievement by a man who inherited the dubious legacy of President Clinton in Africa (the debacle of Somalia, the unforgivable blunders over Rwanda, the embassy bombings in Kenya/Tanzania etc) ... and who was once described by Nelson Mandela as a man "who can't think properly"....

But was it really enough? And was it what Africa needed?

PEPFAR is now widely acknowledged to have stemmed from Colin Powell and arose from a national security fears (also culminating in AfriCOM - the US African Command) ..... and its now its pretty clear that AIDS has not caused widespread political unrest nor failed states nor strengthened terrorism ....

In addition PEPFAR was heavily championed by evangelical movements in the US ... a sort of modern-day missionary-ising of Africa "saving the poor black people from themselves" .... but who are now (thankfully) seeing their leverage slip away and their global purge on sex in tatters ....

PEPFAR hasn't democratised .... it hasn't stabilised .... it was definitely conceived of in US national interests ... but extraordinarily it has genuinely helped some people in need and it has given them a precious few more years of life ... with a hope that more will come ... and it has undeniably set the pitch for the future of HIV treatment having to be made available and rolled out in the developing world as well as the developed ....

So as for what is next on the America-Africa agenda? Well we'll just have to wait for what President Obama thinks ....

Heart of Darkness indeed ....

I hear you groan loudly at the cliche ... i know i know ... pretty much as bad as "out of africa" ..... but truly this piece from the Guardian today makes you realise why things haven't changed that much in Congo since Joseph Conrad ....

The IRC apparently have estimated that an extra 45,000 people are continuing to die each month in the country .... repeat - an extra - so that's over and above whatever horrendous death rate would be expected in a central african country .... and that's despite the civil war having supposedly ended in 2002 .... horrifically pretty much half of those deaths are children .... in a country where one in 5 children doesn't make it to their 5th birthday ....

I was in Goma in June (photos from the trip) ... and it was truly the most scary place i'd ever been .... just minutes across the border from Rwanda - and bang - the danger was palpable .... as though anything and everything nasty could happen and no one would ever know about it or find you afterwards ..... and of course - the poverty was devastating and universal ..... resulting in the most pronounced survival instinct i'd ever seen (by which i mean a general MO to fleece anyone and everyone especially if they look a bleeding heart NGO-type liberal ... which the Congolese seem to be able to sniff out in seconds with expertise ... i clearly stood no chance at all) ....

So it's no surprise that most of these additional deaths are entirely preventable .... needless deaths related to pregnancy or early childhood problems, simple infections and wily old foes such as malaria ..... nothing for which there isn't cure or a remedy .... and which according to development people like Jeff Sachs could be reversed for say the cost of a month's war effort in iraq .... call me a a starry-eyed dreamer ... but just imagine if things like this were raised in some of the democratic debates instead of bill clinton's dancing abilities ..... that would be real change ....

The PEPFAR Conference

Where to start when describing this conference?

Firstly its been a ground breaking meeting since for the very first time the US-funded PEPFAR conference has invited in other agencies such as the WHO, UNAIDS, GFATM etc ....... given USAID's terrible reputation for engaging only in bilateral programmes and never contributing to basket-funded projects - this has represented a huge step forward ... its also meant that we've been graced by experts from all these different groups moving the emphasis away from toeing the PEPFAR line (abstinence good/condoms bad etc) .... and so the conference has been reinvigorated from mere forum where the various PEPFAR organisations show off their results and are suspicious of sharing"secrets of success" .... into a meeting where issues are being properly debated, difficulties and challenges openly aired and strategies that work highlighted ....

Secondly its also been amazing to be at such a diverse gathering - although it is a little ridiculous to be a British Indian representing Africa interacting with a Ugandan representing the US government and a Yank speaking for India .... but its great to see such a mix .... and i have revelled in meeting people from Cote d'Ivoire or Nepal or Djiboutie ..... it does however make me feel a little pity for poor white people with no decent national costume to bring colour to such an event ....

Thirdly its also been a conference where Africans have been given their place and time alongside american or european "experts" to present their experiences .... all too often we hear western academics lecture to us - setting standards and dispensing lofty advice ..... so its seems this forum has finally spawned true "south-south" cooperation as we share thoughts on the problems we face .... and debate how we should implement guidelines as best for own own contexts .... and i have been humbled by the courage, motivation and innovation shown by colleagues battling the epidemic with limited funds in areas bereft of all infrastructure .....


Fourthly - the conference was opened by Paul Kagame, the Rwandan head of state (and ex-RPF leader whose military tactical brilliance is credited with having ended the genocide) and was attended by the whole of the Rwandan parliament emphasising the political will behind efforts to control HIV in country where it was spread primarily as a result of the rape and torture carried our during the genocide. Last summer in Toronto - the Canadian Prime Minister refused to attend the International AIDS Conference (the gays aren't in line with his christian beliefs) ... and in South Africa - not only does our President not believe HIV causes AIDS and our Health Minister the laughing stock of the world but she also snubs all HIV conferences in the country and bans her staff from attending .... So it was really heartening to see that there are leaders on this continent who are prepared to confront this challenge ... the prevalence rate here in Rwanda is around 3% - just imagine if the South African government had shown this leadership when we had such low rates ....

Finally the main issues discussed have also been different to previous conferences i've attended .... the activists shouting for access to treatment and rights for health workers/prostitutes/one-armed lesbians etc are thankfully absent .... western buzzwords such as pre-exposure prophylaxis (essentially the morning-before weekend wonder pill for people that want to go out and have unprotected sex) and hot-of-the-press new drugs have rightly been disregarded as irrelevant to us .... instead the topics have ranged from how to responsibly implement male circumcision across our countries and cultures and how to improve our prevention of mother to child transmission (a real tragedy: a simple method exists yet is somehow shockingly poorly implemented) .... to the value of opt out (ie mandatory) HIV testing and how to integrate malaria and TB into HIV programmes or how to reach orphans and vulnerable children ....

I won't bore you with a litany of facts and figures ...... it suffices to say that we seem to be losing the battle with the current lip service that is being paid to properly funding and supporting the efforts so desperately needed .... over 25 million people have died from HIV since the early 80s and conservatively over 20 million currently live with HIV today .... that means that at present over 45 million people have died or have been condemned to die (and thats not counting the 3 million infected each year) .... 45 million people ...... that's more than 7 times the number of people that died in the Holocaust .... the majority of whom live in Africa ...

And so its appropriate that this conference has taken place in Rwanda - where 13 years ago - whilst it burned like hell on earth - the world turned its back and navel gazed in embarrassment ... after which Bill Clinton and Tony Blair amongst others pledged that we would never let it happen again .... Today however we see the same apathy and disinterest and i'm-sorry-but-what-can-i-do face making - and its not just AIDS .... tragedies have unfolded in Iraq, Afghanistan and Darfur ....

Kevin de Cock from the WHO gave a rousing plenary address yesterday urging western donor nations to honestly commit funds and honour promises made ... but also impressed upon us the importance of all of our roles and contributions to these efforts .... and he floored the whole audience by ending with a quote Martin Luther King:

History will have to record that the greatest tragedy of this period of social transition was not the strident clamor of the bad people, but the appalling silence of the good people .....

'Tis the season of the AIDS conference .... and meeting heroes ....

AIDS conferences are as much theatre as they are anything to do with real science or furthering the cause of people living with HIV .... my first experience was last year at the International AIDS conference in Toronto - a veritable circus for activist organisations, fringe groups and people who frankly just like to protest .... as well as a media love-fest for celebs, politicians and philanthropists. For every serious NGO, pharma company and scientist - there were groups such as grandmothers against AIDS, transvestites, transexuals, multisexuals and a whole bed-zone for sex workers of every shape, hue and flavour ....

The big conference this year is in Sydney in July, but there is also the PEPFAR shebang in Kigali in mid-June (on which more later since I'm actually going to that one) but to kick the season off this week is the South African AIDS conference in Durban - probably the most important national level conference in Africa ....

And with good reason .... South Africa has the largest number of HIV cases in the world .... and has both stories to be proud of as well as to wish swept under the carpet .... we've all heard the tales of Thabo Mbeki refusing to believe in HIV and stating that he doesn't even know anyone with AIDS, as well as our mad-as-a-hatter health minister Mantu Tshabalala Msimang who trashes ARVs and promotes garlic, lemons and the african potato ...

However - SA was also the host country for the 2000 International AIDS Conference (Durban) where for the first time the idea of ARV treatment for all was truly advocated for .... demanding decreases in the cost of treatment ... arguing on the basis of human rights that the developing world could not be ignored or used merely as a lab for drug testing without experiencing the benefits of such advances .....

SA is also the country which hosted the PEPFAR conference last year(Durban again) where the impact of this US funding body was properly debated and where we argued that rather than the US government being able to claim that the American people had out 1 million patients on treatment ... instead such funds should be used to actually strengthen health services and enable countries to put their own people on ARVs in a way that would be sustainable beyond George Bush ....

And its the home country for the TAC (Treatment Action Campaign) arguably the organisation who have done the most globally to spearhead the campaign to bring treatment to the developing world, to bring down the cost of drugs, to advocate for the rights of people living with HIV and to force a blinkered South African government to confront that they were allowing what some compare to a genocide to exist within the country ....

So we are all looking forward to this year's conference knowing that things are slowly beginning to change here (thanks in great part to the TAC amongst others) .... and proud that whatever we debate here will have massive impact on other national conferences in Africa and will form the basis for the big international conferences coming up ...

However when i walked onto my flight to Durban this morning ... i was gobsmacked to see that i was sitting next to THE Zackie Achmat (in economy no less!) - the founder of the TAC, one of Time magazine's Heroes and a Nobel Peace prize nominee .... sadly i was too travel sick to talk lots to him (i know most people grow out of it when they're 12 - but what can i do?!) .... and was frankly too shy to chit-chat with a man who is really one of my living heroes .... all i could do was thank him repeatedly for everything that he's done ... and ask him shamelessly for the cheesy photo below ....

From the American People .....

There's nothing like posing with a little black baby for a bit of goodwill ... and George's PR machine picked a great one yesterday for the big announcement that PEPFAR (President's Emergency Plan for AIDS Relief) would be extended for another 5 years .... and the amount pledged was doubled to 30 billion dollars ....

Wow.

Apparently Laura Bush is coming to Africa next month to promote this extension of the initiative ... her favourite organisation here is the Mothers to Mothers to Be Programme (predictably - no condom education needed in this one or that would complicate matters).

As President Bush said:
“She and I share a passion .... We believe that to whom much is given, much is required.”

The current PEPFAR (2003-2007) pledged 15 billion dollars over 5 years (now closer to 18 billion) .... and aimed to put 2 million people on treatment ... in all honesty today the number of people supported on ARVs through PEPFAR is probably closer to 1 million ... but most controversially the programme has taught 61.5 million people on abstinence ....

Now don't get me wrong - this renewal of PEPFAR is truly a great and wonderful thing ... especially for an administration whose frugality in terms of development aid has contrasted massively with its spending on defence .... and also it doesn't take a cynical mind to see this is a fabulous distraction from a dismal record on climate change, iraq, human rights etc etc .... and that the whole programme has played very nicely to extend the legacy of the Christian Right ....

However there is no doubt that through this extra funding lives will be saved and that new infections averted .... additionally PEPFAR certainly has bipartisan support ... and it is a relief that George has ensured that the funding will be committed well into the next government ......

Even better - this announcement throws down the gauntlet for the next week's G8 summit ... especially to the Germans and Italians who have been less than generous so far and who might be embarrassed into action .... and it might prompt Tony Blair to make some wild promises (even if just to piss off Gordon) as a final hurrah ....

As President Bush said yesterday:
“Once again, the generosity of the American people is one of the great untold stories of our time .... Our citizens are offering comfort to millions who suffer, and restoring hope to those who feel forsaken.”

.... but if George really does want this to change the way that the world views America .... then lets just hope that somehow PEPFAR and the new son-of-PEPFAR will be run on policies based on real evidence and not ideology ...

Sisters are doing it for themselves ....

A few days ago I was visiting some of our sites in rural mountainous Mpumulunga in midst of the Deep Freeze that gripped the whole country ... we ourselves didn't have heating ... the electricity was skittish and the water supply was downright pre-menstrual ... one night Zanele, Bongani and I had to sleep in every item of clothing we had brought along it was so so cold .... so I was a little grumpy when I was asked to drive my colleague to meet with a support group at a nearby squatter camp ... sure to be even more cold, dark and miserable ....

I should explain here that in post-apartheid south africa .... most black people still live in the black townships, most indians live in the indian townships etc and the white people still live in nice houses in the suburbs .... but the older townships are fairly established communities now with cultures and infrastructure of their own .... the really poor people here live in squatter camps or "informal settlements" which are essentially wood and corrugated iron shacks clustered with no water, electricity, roads etc and incredibly high rates of crime ....

Realising that I couldn't get out of it ... i duly left my computer and credit cards in the B&B, took off my earrings, watch and anything else shiny .... keeping only some "mugging cash" on me for emergencies (better to have a few notes to hand over than to deny having anything at all) .... but i was pretty nervous as we navigated the dirt track and stopped at the shack of one of the women who leads an HIV support group that we work with ....

.... and then I heard the sound of music from within .... any of you who have ever lived in SA will know why i mention this ... south africans seem to be born with some natural ability to sing perfect four part harmony at the drop of a hat .... and every meeting or gathering starts and ends with music, singing and dancing ... its the sort of singing that seems to lift your soul with it (think the scene with the opera in the shawshank redemption) .... and makes you feel that somehow life can be beautiful after all ...

These women are poor - i mean properly rags-dirt-shack-beggar poor .... and yet they manage to band together each week and walk to visit all the other people in their community who are also HIV-positive to look after them and check they take their medications properly ... they don't ask for payment or glory ... they just do it out of a hope of something better for the whole community .... and when i walked in they greeted me as if i was one of their own .... and offered me hospitality as though i was the queen of england ....


They then proudly showed me their scheme to raise funds for themselves and ensure that they eat healthily .... a small area of green garden amidst the misery of the shacks .... growing sugar beets and sweet potatoes, spinach and tomatoes, papayas and avocados .... they have to dig with their hands and irrigate using precious water they ferry up in jerry cans ... and they don't let men into the group because they just steal the money and get drunk .... (the chap in the picture is my friend Bongani)

I was overwhelmed by what they have managed to do with no training, education or advice .... I reached into my pocket and found my emergency 500 rand (about $75) - and gave it to them for a wheelbarrow, seeds, a spade and some wire to keep out marauding chickens .... the hijackers and muggers would just have to find someone else to demand cash from today ....

Yet more south africa

The last i promise of "typical" south african stories .... but this one really infuriated me ...

I was at Edendale hospital this week ... yes the one where 80% of the inpatients have HIV .... where TB is second nature .... and where I can't even walk onto the paediatric ward without getting all teary .... and like all hospitals in South Africa - the nurses rule the roost and the doctors wander around looking like shell-shocked bunnies trying to fire-fight emergencies and generally do what the nurses tell them to ...

So despite my trepidation and knowing how it gets to me - I had to see some cases on the kiddies level (natch - i was told to by one of the chief nurses) ... and let me just say here that it is NOTHING like children's wards anywhere that i've ever been used to ... no toy areas or play therapy for these kids ... no bright colours or happy murals .... they just lie three to a bed .... and are so skinny that they actually fit .... and so sick they don't move very much ....

So imagine my outrage when i caught the nurses (all typically "rubenesque" zulu women) on the ward chomping down the hospital meals MEANT FOR THE CHILDREN!! And when i opened my mouth to protest - the ward sister just waggled her finger at me ..... and i meekly knew my place ....

Sometimes africa just bites you in the bum ....

A very south african story ...

Crime, drugs and HIV - any country come to mind?

This story is from an area that I work in - its postcard-picture-perfect with rondavels straight out of a No 1 Ladies Detective agency book and has hills covered in romantic mistiness .... but sadly bugger all else to do but drink and have sex .... which would explain the massive rates of HIV ...

And so the local thieves have caught upon a new way to help while away days in tropical heaven .... you steal the ARV drugs from patients with AIDS (cunningly too weak to fight back) as they leave the ARV clinic .... and you smoke them with weed - which apparently give you a better high than anything else on the local market .... and then hope that it protects you from catching the HIV too .... genius ....

Happy TB Day

Very randomly i recently bumped into a couple of old mates from medical school who are here in SA working at Edendale hospital where by chance i myself work and teach at once a month ... Sanj is there as a paediatrician and Sam as an anaethestist ... obviously as befitted the occasion we shared many memories over many many drinks ... but also - for the first time since arriving in SA - i was able to openly share the experience of whats its actually like being here in the eye of the HIV storm ....

Edendale is a district hospital in Kwa Zulu Natal .... chronically understaffed and under-resourced ... the patients are all poor and black .... and an average medical take brings in over 100 new patients a day ... the casualty department is awash with blood and bullets (sam's first case on her first day here was solo-anaethetising a patient with an axe in his heart) .... and tragically over 80% of the medical in-patients are HIV positive ....

I don't think i can ever really explain the reality of what such figures mean .... percentages just don't convey what you feel when so many people seem to be dying around you .... and you just feel overwhelmed by your inability to do anything at all of any real use .... its as though you are sticking little pink plasters (band-aids in american) of aid, help or arvs on huge stab-wounds on society and watching helplessly as the blood gushes through .... you know that whatever you've done is merely pissing in the wind and you just have to hope that somehow miraculously things are going to get better ... before then having to focus on the next horrific case .... humiliating and utterly apathy-inducing ...

The worst place of all however are the paediatric wards .... i can't even bring myself to go there anymore .... i don't know how the doctors and nurses there face everyday rows of stick thin kids often two to a bed .... most lying listlessly waiting to die (since often they arrive far too late to be able to do anything for them) usually of some complications of their HIV ... its heartbreaking and totally demoralising ....

Edendale truly is at the eye of the HIV storm even in south african terms .... however the tragedy is it is now also at the epicentre of the twin epidemic of TB .... and especially XDR TB ....

Most of you will have seen the articles about XDR TB ... its had lots of very factual media coverage .... but on the coal face - XDR TB means any normal TB drug you have is frankly useless .... and so you put the patient in a side room and usually just watch them die (90% die here) over an agonising few days to weeks .... and then you have the dilemma that you have to isolate them away since so many of the general population are HIV infected that you'd be exposing them to almost-certain death as well ...

And the other kick to our collective balls is that we can't even diagnose XDR TB at the moment essentially until the patient fails treatment for normal TB .... we simply don't have any good testing for it .... so the patient basically has several weeks or months in which to spread the infection around the community before being locked up in the hospital to wait to die ....

Its World TB day today ... and unsuprisingly here at Edendale we're not celebrating ....

TB is one of the oldest diseases known to man (HIV is a merely new kid on the block comparatively .... although a rather uppity ambitious one at that) .... and is the second leading cause of infectious deaths worldwide (about 2 million deaths a year ... second only to HIV inevitably) .... one person is infected every second ..... and about three quarters of all people with HIV here in Africa are co-infected with TB ... its the ultimate double whammy sick joke ....

And although we know how to treat it and treat it well (ie cure it) .... we still don't manage to ... and like HIV it is ravaging through populations both here and in the West ... taking evil advantage of inequitable health systems, poverty and apathy ... and is now totally outwitting our rather feeble attempts to bring it to heel ....

And the scary thing is ... this disease knows how to fly ....

A Very Un-Valentines Day

This country has a horrible way of biting you in the bum .... just at those moments when you start thinking that a corner has been turned and that there is hope for this country after all ....

I spent yesterday schlepping around hospitals, clinics and GP surgeries in rural mpumulanga (province of SA where Kruger national park is) .... following up on patients, training doctors, etc etc ..... and i suddenly realised quite how much had changed here since a year ago.

At my first training session in this area over a year ago - only three patients turned up, they bolted the doors of the hall and were clearly terrified of being seen there and hence "outed" as being HIV positive ... they wouldn't even leave the room at the same time and certainly wouldn't be seen with any of us foreigners - a sure-fire sign of having AIDS (the only outsiders that come to these parts are do-gooders) ...

A year on - we have to barricade ourselves into the room to avoid the huge mass desperate to to get onto ARVs .... having wider access to treatment and witnessing others in their community actually getting better has definitely reduced stigma and given them hope .... the message has trickled through that knowing whether you are postive is no longer an immediate death sentence and so more people get tested ... and the numbers needing ARVs keeps rising ....

And so it was a rewarding moment realising that a year of our programme had made such a difference to a community .... and importantly to see the patients who had been so pitifully ill just a few months before actually job-seeking and looking well ....

I returned home to my B&B feeling as though I was finally doing something worthwhile .... and over dinner with two of my colleagues we earnestly talked about things getting better for this country after the twin scourges of apartheid and HIV .... and so in between courses we got up to get some fresh air and walked onto the front street ... to be greeted by the sight of a gaggle of young girls all dressed up to the nines ....

This sadly was not some asbo-inducing fest of fourteen year olds gathering for valentines day and just hanging out on the street .... instead these girls were flashing at the passing truck drivers (this being a big timber region and transport route with lots of trucks) ... and if any of them stopped at the traffic lights ... they would clamber onto the bonnet shouting to the driver all the things they could offer him and the price ....

Horrified and yet somehow also fascinated - we ran down to the nearest girl to ask her why she was doing this ... and it was just wrist-slittingly depressing to hear that it was the only way any of them could make money and that often they were sent out onto the street by their families ....

We asked her if she'd ever heard of HIV (of course she had ... there's not a a soul here under the age of 50 here who hasn't) .... and if she used condoms (of course she said she did .... note to all doctors about people telling us what we want to believe ...) ..... and sadly like the good HIV doctor I am - I was of course NOT carrying spare condoms to dish out to all and sundry on the street ....

But within a few minutes - she had a client .... who said that for sex without a condom he'd pay her three times the going rate (about 300 rand - less than 30 quid) ... she looked at us and shrugged her shoulders ... it had been a quiet few days and she wasn't going to turn him down - she needed to eat .... we tried to plead with her and even offered to match the money ... but in a flash she'd hoisted herself up and the driver was shouting obscenties at the interfering foreigners about trying to make him eat sweets with the wrapper on ....

I looked up and noticed he didn't have a seat belt on .... and so here's the rub ... how do you get a nation to start using condoms and avoid a fatal threat which will affect them 5-10 years on ... when you can't even get them to wear a seatbelt to protect against an immediate threat? How do you get people to value their lives when they have so little to look forward to at age 14 that they sell their bodies and potentially their long term health for under 50 dollars?

Another hope bites the dust .....

I feel a bit sheepish since i've been meaning to write about microbicides ever since the Toronto conference last summer (and yes i DID do more than just accessory shop there). I even had a snappily titled post all set up in my head in honour of Gates and Clinton, the chief celebs that i followed around star struck ... although admittedly rather typically never got around to actually writing the post ...

But to summarise post haste - the overwhelming themes at the conference were:-

1) that the face of HIV globally is now the face of a woman (especially a poor black or asian one)
2) that the funds committed to provide ARV treatment to all that need it are never ever going to suffice (despite the best efforts of Gates, Buffet and dare i say George Bush) .... and
3) that the pendulum needs urgently to swing back to prevention efforts (as opposed to solely treatment advocacy) .... BUT a very different kind of prevention this time ...

Stephen Lewis (possibly the greatest Canadian ever) made an impassioned speech regarding the fact that funds such as PEPFAR, originally the largest fund donated to a single disease are now already woefully inadequate for the current state of the pandemic, much less for the projected numbers in a few years time .... three by five might would need to be fifty by ten at this rate .... an inconceivable burden of disease ....

But the one positive message that shone through was that finally sisters might be able to do it for themselves ....

We all know that condoms don't work (correction: condoms could work if only men could be persuaded or even volunteer to wear them) .... and that vaccines are still the same ubiquitous 20 years away that they were 20 years ago .... but microbicides were presented as the possible salvation of every woman in the developing world wanting to protect herself surreptitiously .... (the other breakthrough touted was that some ARV drugs could be taken on a Friday night to protect someone having unprotected sex until sunday night .... a whole new take on "something for the weekend - sir" and not unsurprisingly top of the agenda for the MSM contingent at the conference .... speaking of which I had never seen such a circus at a conference ... there sections for grannies against aids, prostitutes, transvestites, transsexuals, multisexxuals ... frankly anything went and had a stall or an advocacy group .... ).

So it is with great sadness and disappointment that we learned earlier this week that the trials into microbicides had been universally halted in all research centres across Africa because the provisional results showed that women who had used the gel actually had higher rates of infection than women who used the placebo gel .... bloody typical ....

Now it could be because women with the microbicide took more "risks" with the confidence of the gel whereas the placebo group somehow managed to make their men wear condoms or even that the gel candidates were somehow placed at greater risk through some other means (barrel scraping) ... but it does look like the great white hope of a female-centric method of protection has bitten the dust .... a disaster for women on this continent ....

I've just got home from a day in an antenatal clinic in Kwa-Zulu Natal where 80% of all the expecting mums are HIV positive ... someone pass the Prozac and quick ....

Canadia - The Land of Niceness

So despite the terrorists trying really really hard to stop me .... i finally managed to arrive in toronto on saturday night ... albeit several hours late .... but despite having been travelling for almost two days without a break .... like the trooper i am ... i still managed to go out for late drinks with my lovely friend Jay's fiancee (the very lovely and beautiful Bindee) .... just to acclimatise of course you understand ...

And so i was introduced to this land of utter niceness .... everyone here is nice to the point where you think something MUST be wrong ... the cabbies don't speed and give way to pedestrians .... no one crosses the road when they shouldn't ... and everyone goes out of their way to help you ... they apologise if they knock into you ... and everyone smiles - all the time .... they are all so nice - it can't be natural .... either that or there's something to that maple syrup ....

Sunday was spent preparing for a week at the AIDS conference .... mimosa brunch .... shopping for shoes and bags (BCBG dahling) ... and then many yummy martinis on sunshine-y patios .... yes - its a hard life this saving the world lark ..... so its obviously vital to have fabulous accessories as one does it ....

Pot loads of cash .... Thank you Mr Buffett

Warren Buffet. What a very lovely man.

Many of you may have heard - Mr Buffet, multi-gazillionaire, owner of Berkshire Hathaway (and hence half the world .... including a good part of Tescos, McDonalds, Coke etc) .... and apparently stock-market investor to God .... has donated almost all his personal fortune to charity .... the great bulk of which will be given to the Gates Foundation and its fight for improved global health and education. Apparently he and Bill play bridge together ...

The exact amount varies according to who you read ... and will definitely vary long term since it's all stocks/shares related ... but essentially its estimated at somewhere between $30 and 40 billion on current valuations.

On of the largest donations ever made by an individual.

In addition he has given several billion to other eponymous charities - which are pro-choice and promote family planning.

And his generosity in one fell swoop elevates the Gates Foundation into being the wealthiest and probaly the most influential player in the game of international health .... not least due to the fact that the charity must spend the amount donated per year within that year .... essentially they must give away over $ 1.5 billion a year .... greater than the GDP of a good few African nations ....

As I have alluded to before - Bill Gates is thankfully unencumbered by ideological chains .... but it is worrisome that the alpha male funding body of the international health world is entirely subject to one man and his wife's idiosyncrasies. It is rather ironically - very unhealthy.

Now I don't want to post yet another polemic about a funding source .... but it does make you think about the role of traditional multilateral funding organisations, and the rise of such personal foundations to fill the gaps.

Perhaps this is inevitable after the self-interested and bungled development packages of the 70s, 80s and 90s. Mistrust is high. At least with such charities - to a greater degree - what you see is what you get .... and the fewer strata you have to deal with ... the less opportunity for "leakage" and the more for accountability. But .... it is worrisome if we keep having to rely on the Bill Gates and Warren Buffetts of this world ...

ABC .... easy as 123?

Last week - I attended the PEPFAR (President's Emergency Plan for AIDS Relief) annual conference (in Durban - so - sadly no sexy international business trip for me) .... an event showcasing the achievements so far in fighting the AIDS pandemic in the 16 recipient countries.

PEPFAR (as many of you already know) is the US initiative established by President George Bush in 2003 .... pledging $15 billion over 5 years to a global crusade against HIV/AIDS ..... in essence the largest amount ever pledged by a single country to combat a single disease .... thereby making it one of the most influential programmes in international health today .... (as well as funding my own current employment - thank you Uncle George) .... for more background info - check - http://www.avert.org/pepfar.htm

There are of course a myriad of reasons why President Bush would choose not to put this huge bolus of cash into a multilateral organisation such as the Global Fund - not least the ability to stipulate branded drugs and accommodate the interests of Big Pharma .... and it certainly allows him to state that the American People have put 560,000 people on ARV treatment within 3 years and enabled testing for many millions more .... as well as helping to prevent mother-to-child transmission of HIV to four million women .... which no one can deny is a monumentous achievement .....

But perhaps the most controversial reason is the ideological motivation behind the ruling that PEPFAR funds must be divided as follows:

1. 55% for the treatment of individuals with HIV/AIDS
   
2. 15% for the palliative care of individuals with HIV/AIDS
3. 20% for HIV/AIDS prevention (of which at least 33% is to be spent on abstinence until marriage programs)
4. 10% for helping orphans and vulnerable children

Now most of us have heard of the ABC approach to preventing HIV (Abstinence/delay having sex, Be faithful and Condomise) ....

But PEPFAR has developed its own definitions for ABC ..... namely Abstinence for youths until marriage, Be faithful in marriage/monogamous relationship and Condoms for those who practise high risk sex ..... (and all this on a background of the global gag rule and the prostitution loyalty oath)

And so - many PEPFAR-funded prevention programmes are limited to providing condoms only for "high risk groups" .... and the only message available for young people is that of abstinence until marriage .... and this in countries where the reality is that kids start having sex in their early teens because there is little else to do .... where early sex is often violent .... and where young girls have little choice or decision-making capacity over what happens to their own bodies ....

In addition - whilst the guidelines insist that a third of all the prevention money is spent solely on promoting A and B .... the reporting system for ALL the PEPFAR prevention programmes (well - in South Africa at least) requires them to submit stats only on their A/B achievements (but not C) .... so even if you do distribute/preach condoms .... you're not given any credit for it ..... and there's no incentive to really make an effort to provide them .... given that A/B targets are the only results that will get you refunded ....

The EU on World AIDS Day 2005 openly distanced themselves from this policy .... advocating instead for a comprehensive approach to prevention and treatment ..... and the GAO reported earlier this year .... that some countries receiving PEPFAR money had needed to divert resources from efforts to prevent mother's transmitting the virus to their children and for ensuring clean blood banks .... in order to meet such A/B targets set for them .......

The Lancet published an editorial accusing PEPFAR of being " ill-informed and ideologically driven" .... noting that almost a quarter of such US funding was being chanelled through faith-based organisations .... and concluded that "Many more lives will be saved if condom use is heavily promoted alongside messages to abstain and be faithful".

And yet .... some organisations still believe that PEPFAR's efforts to influence the HIV world are not profound enough ..... "Casting the first stone: the US Christian right’s war on the Global Fund"

So obviously ..... this has formed the basis of many a wine-fuelled-late-night-indignant discussion here ..... but surrounded as i am by liberal heart-bleeding ngo types .... i was taken aback when asked by a friend that ..... given this current american administration was elected not once but twice - then why can't the US spend its dollars in a manner that its citizens would approve of, advocate for and most importantly vote for?

Indeed at the end of the day .... if we ignore the prevention agenda .... PEPFAR has proved incredibly successful in rapidly putting people on treatment .... often in creative and innovative ways .... and so ..... whilst it calls into question the motivations behind such donor aid (should the US be allowed decide who can use a condom or not - even if sex is the major cause of HIV spreading?) .... realistically this is the nature of development ..... and we will have to weigh up how nefarious it really is to use such bilateral aid agreements to ensure the success of our own pharma companies or religious organisations ..... as long as the job gets done - especially when no one else is putting up the cash ....

Lets just be thankful that Bill Gates thinks that religion isn't time efficient ....