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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.

Via Negativa: the way to low HIV prevalence?


Wajir is a city and county in Kenya’s former North Eastern Province. From a HIV perspective, the county stands out for having the lowest prevalence of all Kenya’s 47 counties, currently estimated at 0.4%. The next highest counties are Mandera (0.8%) and Garissa (0.9%). Wajir, Mandera and Garissa make up what was the province, formerly a part of Jubaland, in Southern Somalia.

Homa Bay is a town and county in the south west, formerly part of Nyanza Province, and the number one county for HIV prevalence, 26%. Indeed, the only counties with prevalence above 10% are Siaya (24.8%), Kisumu (19.9%), Migori (14.3%) and Homa Bay, which (along with Kisii and Nyamira) made up Nyanza. That accounts for one third of all HIV positive people in Kenya.

The question of why HIV prevalence is so high in certain parts of Kenya is usually answered, implicitly or explicitly, with half baked notions about ‘African’ sexual behavior, ‘African’ mores, ‘traditions’, sexual practices, ‘unsafe’ sex, promiscuity. In a word: sex. It’s all about sex, and in the worst hit counties experts have persuaded the US to part with hundreds of millions of dollars for mass male circumcision programs.

A lot less seems to be written about the extremely low HIV prevalence found in the north east. Look up Mandera, Garissa or Wajir on PubMed and you will only come across just over 300 papers altogether, compared to thousands for other locations (and almost 50,000 for Kenya as a whole). But it would be interesting to know how HIV prevalence has remained as low as in many western countries in the north west of Kenya, yet it has risen as high as the worst hit countries in southern Africa in the south west of Kenya.

Sex happens in north eastern counties too. In fact, condom use is generally lower in these counties. Polygamy is more common, as are intergenerational sex and marriage, phenomena the HIV industry sometimes insists are risks for HIV transmission. Knowledge about HIV transmission and how to avoid it tends to be lower in these counties, too. Birth rates are higher than in other parts of the country.

Circumcision is said to be widespread in a number of counties, not just in Wajir (and Mandera and Garissa) but also, for example, in Kilifi. But HIV prevalence in Kilifi is a lot higher, at 4.5%. The populations are predominantly Muslim in both counties, so circumcision is not likely to be the full explanation, nor is religion. There are commercial sex workers and men who have sex with men in every county, with no evidence that these practices are less common in low prevalence counties.

The north eastern counties are, in fact, very different from the rest of Kenya. Kenya was divided up on ethnic lines by the British, which is why the territory once called the ‘Northern Frontier District’ became one province: it was, and still is, populated by ethnic Somalis. They are geographically isolated, in the sense that there are few major roads. Much of the north of Kenya is arid and sparsely populated. Even the Somalis who live elsewhere in Kenya, such as in Nairobi, tend to live in predominantly Somali suburbs.

A similar kind of isolation, albeit on a much larger scale, can be found in northern Africa. The Sahara is sparsely populated and there are few major roads traversing it. HIV prevalence is low in all North African countries. In fact, HIV arrived relatively late in North Africa, and analysis of the common subtypes there suggest that the epidemic spread to a large extent from southern Europe, and to a lesser extent from West and central Africa.

The most common HIV subtype in Kenya is type A, followed by D, with a small proportion of type C. But the most common subtype in the north east of Kenya is type C, this being the most common subtype in southern Africa, Ethiopia and a number of other countries. So the former province really does seem to have a different epidemic or ‘subepidemic’. Type C is known to have evolved later than A and D, so the former North Eastern Province’s subepidemic is newer, like those in North African countries.

But it is still unclear how the above features of certain epidemics and subepidemics are associated with very low prevalence. Instead of looking for phenomena behind very high prevalence in some south western counties, are there certain phenomena that are absent in the north west (and in North Africa)? Isolation doesn’t mean less sex, nor even less ‘unsafe’ sex, and sexual behavior is very poorly correlated with HIV transmission.

We don’t know much about Wajir, Mandera and Garissa because not much research has been carried out there, and it’s not surprising that little HIV research has been carried out where there’s little HIV transmission. But what about other healthcare research? I notice almost all the articles on PubMed are about HIV, and were published in the last 20-30 years. So the area has been isolated from research for a long time.

Now, if there are few roads and limited infrastructures, is healthcare infrastructure similarly limited? It could be expected that access to healthcare facilities is poor and that many people rarely or never go to a hospital, or see any kind of health professional. The majority of women probably give birth at home, coverage of mass drug administration programs, including routine immunizations, is probably lower for these and other more isolated counties.

Borrowing Nicholas Nassim Taleb’s ‘via negativa’ in his book ‘Antifragile’, perhaps HIV prevalence in the north east of Kenya (and in North Africa) has remained low because of infrequent contact with healthcare facilities. This is not to say that healthcare facilities are unsafe in the north east, although it does suggest that they are unsafe in high prevalence counties. Also, it is suggested that HIV is circulating in health facilities, more in some than in others.

Many (including Taleb) like to repeat that ‘absence of evidence is not evidence of absence’. There is a possibility that HIV has been, and is still circulating in health facilities in Kenya, and may account for a significant proportion of infections, perhaps the majority of infections. Little research has been carried out to estimate the relative contribution of healthcare associated HIV transmission. We will never know until the evidence is sought: does limited contact with healthcare keep HIV prevalence low in the north east of Kenya?