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Tag Archives: Lisbon Declaration

Via Negativa and ‘First do no Harm’

I am in favor of routine vaccination, for my children and for children in my care. I always take children to a doctor when there is something that won’t go away on its own, or that I don’t recognize, and I would do the same for myself. So I am certainly not advocating ‘doing nothing’ as a response to medical problems. I write as a layperson, with an interest in healthcare and development.

But all healthcare must also be safe healthcare; people should be granted their right to know everything they need to know in order to make the best choices for themselves and their dependents, in accordance with the Lisbon Declaration on the Rights of the Patient, along with other instruments relating to patient safety. I feel that people, especially in developing countries, are frequently denied these rights, and that the results of this can be fatal.

In his guest post for this blog, Helmut Jager discusses the example of the infection of millions of Egyptians with hepatitis C (HCV) through unsafe healthcare, resulting in the highest prevalence of the virus in the world. Jager states that the “causes of the infections [globally] mostly are: bad medicine or intravenous drug addiction”.

The ‘bad’ medicine Jager refers to is a program intended to reduce infection with schistosomiasis (bilharzia), caused by a waterborne parasite. This program involved the use of syringes, needles and perhaps other equipment that were not always sterile. Under such conditions bloodborne pathogens, in this case, HCV, can be transmitted from patient to patient.

The medicine Jager describes is ‘bad’ because conditions in healthcare facilities are unsafe, instruments are being reused without adequate sterilization, etc. Rising numbers of people with HCV in the population eventually visiting health facilities meant increasing numbers of healthcare associated transmissions, also called ‘iatrogenic’; a vicious cycle.

Jager is not suggesting that healthcare facilities should do nothing about schistosomiasis (or any other condition) in order to avoid the risk of iatrogenic transmission of HCV or other bloodborne pathogens. He is recommending that unsafe practices be eradicated, practices such as the reuse of injecting and other equipment and processes that involve piercing the skin, or even come in contact with bodily fluids, such as speculums, gloves, etc.

Reducing unnecessary medicine is another of Jager’s recommendations. The WHO estimates that 16 billion injections are administered globally every year. In some countries up to 70% are probably unnecessary. About 37% were said to involve reused injecting equipment. Therefore, reuse of other skin-piercing equipment may also add substantially to the problem.

Jager’s blog is about the high cost of Gilead’s ‘sofosbuvir’ and the damage this does to programs aimed at eradicating the virus. Sofosbuvir has been recommended by the WHO for the treatment of HCV: it is unaffordable for people in poor countries, who make up the bulk of those living with the virus, at risk of suffering serious illness from it, and of dying from it. Jager cites a source reporting that “treatment costs in the US are US$84,000 and in the Netherlands €46,000. The production cost of the drug is estimated not to exceed US$140.”

There are two man-made disasters here: first, there’s the raising of the Aswan Dam in the 1960s. The dam was intended to control the flow of the Nile in order to improve irrigation provision and generate hydroelectricity; this damaged ecosystems and led to an increase in schistosoma infestations. The second was the massive outbreak of HCV caused by unsafe healthcare procedures, employed to address the schistosomiasis endemicity, that affected millions of people.

Apparently environmental impact assessments evolved in the 1960s, but it is likely there was something similar before the specific phrase was adopted. After all, it was known that introducing invasive species of fish to Lake Victoria would cause huge and irreversible problems early in the last century; the invasive species were introduced anyway, because certain parties wanted them to be (the colonials wanted to introduce sport fishing to the lake for their enjoyment). The fragility of ecologies has been recognized for a long time.

Whether either or both these disasters could have been avoided 50 or more years ago, strategies to eradicate schistosomiasis sometimes seem to concentrate on a quick technical fix (there’s even a vaccine in development now), such as mass administration of Praziquantel. Praziquantel works, up to a point. It cures patients, and reduces the infected population, which promotes herd immunity and helps interrupt the life cycle of the parasite. But it is less effective in eradicating the parasite when used on its own.

Research in Lake Victoria finds that the population affected by schistosomiasis also needs access to safe drinking and domestic water supplies, reduced contact with contaminated water, adequate waste disposal (which can interrupt the life cycle of the parasite), etc. In other words, the first disaster Jager alludes to, schistosoma infestation in the waterways, affects a much larger population than those who live close to and depend on the waters of the Nile.

This is a larger and more general problem, because all massive infrastructure projects risk destroying ecosystems and environments. And the medical treatment people need once their water supply is infested can be too little; but possibly not too late. It’s too little because those affected will still need access to safe water and sanitation, but some of these issues can be addressed, bearing in mind the counsel of ‘first, do no harm’.

Water and sanitation provision is vital, as is promotion of good health related information. Gilead are unlikely to scale back their profits much unless they are compelled to do so; yet, intervention would not be unprecedented. Unsafe healthcare can be eradicated, much more cheaply and efficiently than mopping up the victims of unsafe healthcare. And unnecessary healthcare can also be reduced, substantially, which will further reduce unsafe healthcare.

In my previous post I speculated that counties in Kenya with very low HIV prevalence, such as Wajir, Garissa and Mandera, may have escaped high levels of transmission through unsafe healthcare by having very low levels of healthcare provision of any kind. I also speculated that high HIV prevalence in counties such as Homa Bay, Kisumu, Siaya and Migori may be a result of greater access to healthcare facilities and health programs whose practices are not particularly safe.

So those four counties on the shores of Lake Victoria, with fishing as one of the most important activities, must have very high rates of intestinal parasites (and other conditions; Eileen Stillwaggon sets out this argument in Aids and the Ecology of Poverty). If use of health facilities is high, the chances of a pathogen such as HIV contaminating medical equipment, which is then reused without adequate sterilization, must also be high.

Where healthcare is unsafe, carrying the risk of exposure to bloodborne pathogens, such as HCV, HIV and others through reuse of skin-piercing instruments, it’s best avoided; via negativa is the best counsel, even if most avoidance is a result of poverty at the moment. There is still the option of ‘doing no harm’, but only if the contribution of unsafe healthcare to HIV epidemics so far is thoroughly investigated. If that’s not done, people would be better off to stay away from healthcare facilities.

Mandatory HIV Tests: Shouldn’t Zambians Decide?

The Lancet has an article by Andrew Green about the recent decision of the government of Zambia to introduce mandatory HIV testing in all government health facilities; if they visit a clinic, they must agree to be tested. Green urges against mandatory testing, using the often heard claim that people will be reluctant to go to health facilities if they think they will be compelled to take a HIV test.

It is argued that people could feel ‘stigmatized’ if they are found to be HIV positive, or perhaps even if they are just tested for it. Indeed, the orthodox view of HIV is that it is almost always sexually transmitted in African countries, and that there are excessively high levels of ‘promiscuity’ (in case you were wondering where the stigma comes from). Popular supporters of the orthodoxy, write: “Unprotected heterosexual sex drives the Zambian HIV epidemic, with 90% of new infections recorded as a result of not using a condom”.

Zambia ranks 7th in the world by HIV prevalence, around 13%, and 9th by number of people infected with the virus, about 1.2 million. The epidemic in Zambia probably started before the 80s because it had already reached 9% prevalence by 1990. Prevalence has stood at over 10% for about 25 years. It peaked in the mid 90s, so it has only dropped by a few percentage points in the past two decades. Population growth would suggest that new infection rates have not dropped at all.

Health Minister Chitalu Chilufya told Green “We can’t continue doing things the same way and hope that things will get better”. Chilufya is a doctor, not just a politician, and it’s hard to disagree with his response. What has been done so far has failed. The epidemic has remained ahead of the HIV industry, with 60,000 new infections a year, far outnumbering the 20,000 deaths from AIDS. Maybe it’s time to do something different?

Green cites the World Health Organization as an authority for the view that testing should not be mandatory or coerced. But where does the view that people will stop going to health facilities come from? Is there any country that has made testing mandatory, and found that people stopped seeking healthcare of any kind? Perhaps people are more reluctant when it comes to HIV because they know that it is seen as an indication that they have been ‘promiscuous’. Might they be more willing to be tested if WHO drops their mantra about sexual transmission?

Cuba is an example of a country that has taken a very different path from almost every other country when it comes to HIV, and healthcare as a whole. Most countries are heavily influenced (dominated?) by the WHO, or by US funding and HIV ‘policy’. But things in Cuba couldn’t be more different from Zambia, and sub-Saharan Africa more broadly, with one of the best controlled HIV epidemics in the world.

The UNAIDS current ditty is ‘90-90-90’, at least 90% of HIV positive people tested, at least 90% of those found positive on medication and at least 90% with an undetectable viral load by the year 2020. So, what is their strategy to achieve this, aside from assuming that everyone should continue to copy all the failed strategies of the US, hoping that things will be different for them?

Targeting people thought to be at risk of HIV purely on the basis of their perceived levels of ‘promiscuity’ means those infected non-sexually, or at risk of being infected, will be missed. Unless they start to estimate non-sexual transmission sources, and start to reduce transmissions of this type, untold numbers of Zambians will be infected, and can go on to infect others, directly or indirectly.

If the orthodoxy are confident that 90% of HIV infections are sexually transmitted, they have nothing to lose by tracing people’s contacts, sexual and non-sexual. This doesn’t violate anything. HIV positive people have a right to know how they were infected and HIV negative people have a right to know how to protect themselves from risks. But if Zambia ‘returns to the flock’, and keeps all testing voluntary, what rights might this threaten?

If contacts are not traced, many people won’t know what the risks are, and therefore how to protect themselves. HIV positive people won’t know for sure how they were infected. According to the Lisbon Declaration on the Rights of the Patient, people are entitled to be informed of things like this by their health facilities, by healthcare personnel. People are also entitled to accurate health information and education. Where is this accurate information to come from if health facilities don’t collect it, or if it is never analyzed or followed up?

People have a right to know about hygiene, safety and infection control in health facilities, and similar information. It would be obtuse to argue for a right to health or healthcare, but against ensuring safe healthcare. In any population, including Zambia’s, there are unexplained transmissions. Examples include HIV positive virgins (who were not infected through mother to child transmission), HIV positive people who have never had sex with a HIV positive person, HIV positive people whose only sexual partner has tested HIV negative, HIV positive infants whose mother is negative, etc.

Green seems to be arguing on behalf of an orthodoxy that is afraid people will realize that there are non-sexual risks, as well as sexual, and that people have been systematically denied their right to this information. He seems to want to help cover up the fact that possible non-sexual infections that may point to unsafe healthcare, for example, have never been investigated in high HIV prevalence countries, or any countries whose HIV strategy is entirely dominated by the WHO, CDC, UNAIDS and the like.

Rather than challenging opposition to mandatory HIV testing, perhaps Zambia could investigate possible healthcare associated transmission of HIV. There is no violation involved if non-sexual contacts are traced, such as unsafe healthcare, traditional practices, or even cosmetic practices, such as tattooing. If Zambia doesn’t do something different, the epidemic could follow the Lindy Effect, lasting another 40 years. But the matter should be decided by Zambians, not by The Lancet.

Lisbon Declaration: Scare Stories about Sex Cost Lives

Why would women in an African country fear being diagnosed HIV positive, refuse to take part in a treatment program that would keep them alive, and probably prevent them from infecting others? After all, the virus has been around for over 30 years and treatment has been available, free of charge, for more than a decade. We know how it can be spread, we just haven’t agreed on which are the most dangerous modes of transmission. But a study has found that women believe their husbands and families will reject them, perhaps divorce, disinherit, physically attack or even kill them because of their status.

Well, it’s not quite clear why Measure Evaluation felt the need to ask women why they were afraid, given the role of the HIV industry in stirring up that fear. Do the researchers think anyone would like to be diagnosed HIV positive and have to go home to their partner and explain how they were infected with a virus? The HIV industry insists HIV is almost always transmitted through sexual intercourse in African countries. It’s different in European countries, where people are not assumed to be ‘promiscuous’ just because they test positive.

HIV has long been presented as being primarily sexually transmitted among heterosexuals, in African countries. People who are infected tend to be told that they were almost certainly infected by having sexual intercourse with a HIV positive person. However, many people who have tested positive have objected that they have not had sexual intercourse at all; or they know that the person (or people) they have had sex with are negative; or they took adequate precautions, etc.

In non-African countries, such as the US, the largest group of people infected with HIV are men who have sex with men. The next largest group is injecting drug users. Therefore, many would ask why heterosexual sex appears to be so much more risky in some African countries than it does in non-African countries. Prevalence among certain groups, such as young women in parts of South Africa, has approached 50%, even higher sometimes. Prevalence is over 20% in some southern African countries (although not in any non-African country).

UNAIDS, WHO, the US Centers for Disease Control (CDC) and other parties have tied themselves in knots trying to explain away the glaring racism implied in the claim that up to 85% of infections in African countries are a result of unsafe sex. When non-African people say that they could not have been infected through sexual intercourse, the matter can be investigated. Otherwise, their own statement of their risks is accepted, and they are not branded as some kind of sexual deviant.

I’ll quote Catherine Hankins, formerly a senior officer at UNAIDS, expressing her views on ‘African men’: “Take a middle-class African businessman. He has had five women – nothing excessive. But the pattern we find is that he has a wife. He also has an on-off affair with an office colleague. He also has what the French call a ‘deuxième bureau’ – a mistress who might have a child. And once a year he goes back to his home village and has sex with his original village sweetheart. Then he gets HIV from a bar girl on a business trip.”

Hankins and her fellow scientists may see this as a reasonable explanation for extraordinarily high rates of transmission, usually in relatively clearly delineated pockets, in high prevalence African countries. But if that’s what ‘African’ men tend to be like, you might expect HIV prevalence to be relatively high in almost every ‘African’ country, in all cities, and in all densely populated areas. You could also be forgiven for wondering whether Hankins believes that all women are similarly ‘promiscuous’, or if they are mostly victims.

The reality is quite different: HIV prevalence is highest in a handful of southern African countries; next highest are parts of East African countries, such as the area around Lake Victoria and one of the southern districts in Tanzania; Nairobi, Kampala and a few others places were also hard hit by the pandemic (with low prevalence elsewhere); but in central African countries, even West Africa, prevalence is much lower, and in North Africa rates are lower than in many western countries.

In fact, prevalence is often high among wealthier people, employed people, people with access to better road infrastructure and better access to healthcare. ‘Promiscuity’ (perhaps not as rich as Hankins’ scenario) occurs everywhere, not just in a handful of southern African countries, in cities or in diamond and gold mines. You could say it is fairly widely distributed, in Africa and elsewhere. Some people are ‘promiscuous’, but most are not. So unless you accept redneckery like Hankins’ (which is something of an industry standard), HIV should also be much more evenly distributed, at least in African countries around where the virus seems to have emerged.

The patterns of HIV transmission suggest that there are additional modes of transmission aside from heterosexual sex. These may include unsafe healthcare, where skin piercing equipment is reused without sterilization, unsafe traditional practices that involve skin piercing, even unsafe cosmetic practices, such as ear and body piercing, tattooing, etc. But the patterns of transmission do not suggest levels of unsafe sexual behavior that would be beyond most people, in inclination, energy, even time.

So instead of asking why women are afraid to be diagnosed as HIV positive, or why ‘African’ men are angry (especially HIV negative ones), the international HIV community should ask how they have allowed themselves to be fooled by such tired old myths, such as those about ‘African’ sexuality or typical behavior of ‘African’ men. The HIV industry is still happy to test people and send them home, so they can tell their HIV negative husbands and partners that they have a sexually transmitted virus. They then have to persuade their family and community that they are not ‘promiscuous’. If the HIV industry didn’t believe them, why would their family or community?

The World Medical Association’s Declaration of Lisbon on the rights of the Patient states that: “Every person has the right to health education that will assist him/her in making informed choices about personal health and about the available health services. The education should include information about healthy lifestyles and about methods of prevention and early detection of illnesses. The personal responsibility of everybody for his/her own health should be stressed. Physicians have an obligation to participate actively in educational efforts.” Failing to inform people adequately means they take risks they needn’t take, are stigmatized because of their HIV status and are much less likely to accept treatment that keeps them alive, and reduces the risk of infecting others.

Of course people are afraid and angry, they are being told lies about HIV, about the people closest to them, and about ‘Africans’ and their superhuman ‘promiscuity’. UNAIDS, WHO and the rest know that heterosexual sex cannot account for levels of HIV in certain areas in Africa. So no more lies about concurrency, ‘traditional’ sexual practices, predominant ‘mores’, migratory patterns and the like. HIV can be transmitted through heterosexual sex, but it is much more easily spread through unsafe healthcare and other bloodborne modes of transmission. If people are not informed, they will continue to avoid diagnoses, life saving drug programs and anything else to do with HIV.