Tag Archives: United States

Ever Lost A Parent? Losing A Child Is Twice As Painful.

Just over two years ago, I lost my dad and saw the world crush in my eyes. I have a rather low threshold for tears, of joy or pain, but I had (and have) never cried as I did then. A heavyset seven- footer athlete, my dad had been battling hypertension quietly for preceding two years. He was on medication, watched his diet and had a regular fitness schedule at home and away. It was his problem and he had never made it an issue to the rest of the family except for the occasional mention that all was fine. In the month prior to his demise, he had visited his Physician more frequently. Dosages were adjusted, tests done and new instructions given.  All would be fine, the doctor hoped.

This optimism did not last. One fateful night, dad woke up in the middle of the night paralysed waist down. By morning, he had no function of all limbs. At the hospital that morning, he slipped in and out of total memory loss, then coma. In exactly 24 hours since he was last fine, dad was no more.

I had been away in Los Angeles for an exam. After my paper, I suddenly went off moods. I was sullen, withdrawn and disinterested in everything for no good reason. We had planned an after party with the rest of my colleagues but I opted out. I was just not in the mood. Little did I know dad was battling a war back home that he would soon lose. My phone had gone off after the battery drained during the daylong exam. I did not have a charger with me until over 600 km away in San Francisco where I was staying for the duration of this trip. However, when I turned on my phone, it came on briefly and I listened to a voice message from dad asking me to call him. I did and he sounded in his usual element for the first few seconds then went of a tangent in his speech. Someone from the rest of the family spoke to me and gave me an account of the events. Dad, in their assessment had made as remarkable an improvement as the deterioration had been. They hoped to leave the hospital in hours.

I was not convinced. My heart raced, tears welled and a drop fell to my phone. I was in a trance. The world seemed to spin slower by the minute and curtains were drawing! I had a strong feeling my dad was not going to come out of such a major stroke. I saw him on a wheelchair, sagging facial skin, drooling saliva and having all his activities of daily living tended to by others. An athletic man full of vigour and with an ever commanding presence reduced to a toddler all over again. I could not hold back my tears. I cried like a burst dam. I knew he faced certain disability or probable death.

We embarked on our road trip back to SF. All the beautiful stops that had made us opt for 6 hour road trip over a 2hour flight made no sense to me or the rest of the party. A few friends cried with me; the rest just slumped into their seats and drowned in their own thoughts. By the time we arrived, dad was in a coma. It was seven o’clock in the evening, about midnight in Kenya time. Nearly 6 hours later, he was no more.

To date, I have never known what words to tell anyone who has lost a loved one. I was told all manner of kind words but they made no meaning to me. The feeling of loss at that time was beyond any words or acts of consolation. Nothing made meaning if my dad would remain dead. I cried all night. My friends embarked on searching for a flight back to Kenya. They were crying between words as they spoke to the airline contact. She cried with them too on learning why I needed a flight in such a short notice. She put me on the next available flight that would connect to Nairobi quickest. I was grateful but my tears would not stop. I arrived at SFO in tears and after a couple of ‘dry’ quick connections in Chicago, JFK, Heathrow and JKIA, the reality dawned on landing at Kisumu.

I had flashbacks of moments when my dad would pray for us every night before he went to bed long after we had been in bed. The moments of quiet counsel. The moments of harsh punishment. The school visiting days. The gifts. His corner at the church and in the house. His mere presence in our minds even when we were not physically together. I have never really overcome his absence. It gets lighter with the passage of time but no one can condole me for this life changing loss. Perhaps quietly known to us as a family, we never tried to condole each other. I could not describe my loss and I knew my mum and siblings could not describe theirs either. We just mourned together undisturbed.

Looking back, I now think it was fair my dad died before any of his children; it is only fair that way. I cannot imagine what my dad would have felt to be the one mourning my death. The loss is much bigger. I have a nearly-two-year-old daughter with whom I have already made so much attachment. Her death in my life would devastate me. This is why even though I cannot pretend to comprehend Raila’s loss at Fidel Odinga’s sudden demise, I know the loss for him and his wife is beyond description.

The Bible captures the demise of King David’s seven-day old new-born in moving detail in 2 Samuel 12:18-23. King David fasted, wept and did not speak to his servants as he immersed himself in prayer for the life of his ailing new born. When it died on the seventh day, the servant could not muster the energy and courage to break the sad news to the King.

19 But when David saw that his servants were whispering together, David understood that the child was dead. And David said to his servants, “Is the child dead?” They said, “He is dead.” – 2 Samuel 12:19

King David grieved solemnly. He had cried enough, fasted and sulked in prayer while the baby ailed. For Raila and spouse, there was no luxury of time. They just woke up to a dead son. The devastation is beyond any words of consolation. No condolences will make meaning. They will grieve in their own way and live with this loss for the rest of their lives. The loss of a child by a parent is an unnatural event. It deflates and nearly takes meaning out of all you worked for and hoped for your child and their future. It puts a sudden stop to what ought to be a lifetime journey. It kills a parent’s soul. I can only wish them and all other parents in their shoes the strength that God gave King David.

23 “But now he is dead. Why should I fast? Can I bring him back again? I shall go to him, but he will not return to me.” –2 Samuel 12:23

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RIP Fidel Odinga

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Do These Lives Count for a Thing?

On the morning of September 11 2001, the United States of America woke up to what remains one of the most atrocious acts of terror on civilians. In a span of minutes, nearly 3000 people lay dead following the multiple airline hijackings and suicide crashing. That day is immortalized in history.

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Aftermath of 9/11 at the World Trade Centre

Even more enduring are the changes that occurred in the wake of the attacks. Not only has airline transportation practise changed worldwide, internal national US security, immigration, banking finance, foreign policy and military practise have all been affected in one way or another.

Two months after the attacks, the Transportation Security Administration (TSA) was established with the core mandate of securing US transport systems; focussing on air transport. This mandate was later emboldened through the establishment of an entirely new Department of Homeland Security one year later. Twelve years on, airline and passenger safety in the US is a near-impregnable multi-layer behemoth system that spans the globe. There has been no repeat of the ignominious events of 9/11.

In achieving this feat, new laws were crafted and zealously implemented. New institutions were established with the mandate and wherewithal to achieve their specified objectives. Investment in new technology, training of personnel and public education have all been components of an all-out commitment to prevent, pre-empt and manage the next 9/11.

The raison d’être for these sweeping changes would be the sanctity and value of human life. There is no greater wealth to any nation than the lives of her people. Indeed, people are to a nation what good health is to an individual. The loss of a single life anywhere invariably shatters many other lives. Children are orphaned, spouses are widowed, parents bereaved and friendships cut short. The direct loss of productivity of the deceased and their grieving social circle cannot be quantified. Attendant expenses in emergency response, treatment, rehabilitation and funerals only make the pain and cost of avoidable death unbearable.

In Kenya, we live through a 9/11 on our roads every year! I have never lost a close relation in a road accident but lost my own dad to a fatal stroke. The sudden emptiness that engulfed the entire household remains palpable one year on. Each time the now regular road crashes grab the headlines; I cannot help but feel the pain, agony and anguish the families of the victims bear. It baffles me how the authorities charged with road safety live with their conscience through crash after crash to an annual tally of well over 3000 Kenyans! Thomas Jefferson’s words that, “The purpose of government is to enable the people of a nation to live in safety and happiness” ring hollow in these circumstances.

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An accident scene in Kenya

Unlike in the US where the loss of 3000 lives marked a turning point of global significance, our departed kin die in vain year in, year out.  Are we just numb to the sheer pain of fellow citizens? Or are our own goals in life too grand for us to care about them? Alternatively, is it lost on us that this untamed beast will come calling on us or kin sooner rather than later? Still, are our lives of lesser value even before our own eyes?

We still grapple with (and lose invaluable lives in the process) the same old failures that make our roads unsafe. The number one determinant of all road fatalities remains speed yet the enforcement of the law on this single factor remains in limbo. Driver aptitude is roundly recognised as equally significant but we have not made even baby steps in reforming training, empowering and educating current drivers or even consistently punishing errant behaviour. Whenever we flex some muscle, it is usually an uncoordinated, limited and short-lived reflexive jolt in response to the latest tragedy. A common spectacle in those moments is the inspection of public service vehicles by the roadside. One wonders how such inspections appraise components like brakes, lights, wipers, emissions and so on. Pointedly, the focus is usually on licences, body paintwork, extra passengers, tyres and other such easily apparent failings. The irony is that in a spectacular misapplication of technology, drivers whose vehicles are found at fault are instantly fined, pay their fees on the spot and proceed in their death shells!

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An impromptu roadside vehicle inspection in Kenya

The ‘hero’ medal in today’s airline safety goes to the passenger (especially in the US). Even before one’s flight, one could already be on a ‘flight watch-list’.  Then there is the ever growing list of prohibited items to check. Even those items allowed must be in certain quantities and packaging. A one hundred per cent baggage inspection means baggage must bear special or no locks lest they be broken into for one’s own safety. At the airport, traditional terminal car parks are now replaced by drop-off zones. Armed and uniformed military personnel are at hand and cameras record entire termini. Then there is the full-body scan by x-ray machines and so-called pat downs by TSA officers. Meanwhile, shoes get a dedicated x-ray session as one tugs on barefoot. As if that were not enough, the person on the seat next to you could be a trained security officer planted there for your safety.

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A typical full-body airport x-ray scan image.

Such is the seriousness with which life is guarded. Many passengers do not exactly love the ritual that air travel has become in the wake of 9/11 but they neither do they loathe it. Instead, most see it as necessary inconvenience whose dividends are too valuable to wish away. This understanding has partly been achieved not only by complete and constant communication with passengers, but also by co-opting passengers as stakeholders in the safety/security war. Even more important, a legal framework ensures everyone in the process plays their bit professionally and efficiently.

Back on our Kenyan roads, while passengers generally understand the basic safety regulations like seat-belts, non-speeding and safe loading, there has not been a demonstration of a compelling commitment on their part to these requirements. Too often, passengers board full buses for the selfish (nay foolish) expediency of saving time. In hospital beds, passengers recount tales of speeding or otherwise reckless drivers whom they did nothing about.  Our losses on the roads have continued to be directly borne only by those immediately affected. As a result, a pervasive tolerance to this carnage has made sure the rest of us do not do our part in transportation vigilance until it is our turn to bear the loss.

The authorities need to empower passengers to report safety abuses by acting decisively on all reports. While the police have a particularly heavy legal responsibility to instill discipline on errant road users, we citizens bear the ultimate responsibility. If the police will not do their part, we should be selfish enough to demand better. Our safety is for the most part for our own individual good. It is now obvious not one of the numerous public officers whose job is to enforce road safety looses sleep over a road crash. At least you should give your safety a second thought and ultimately some action. It’s your life!

Michael Bane writes in his book Trail Safe: Averting Threatening Human Behavior in the Outdoors, “Risk is the increased consequence of failure.” We have made our roads risky by that which we fail to do. As a pedestrian, maintain your wits about you while by the roadside or crossing the road. As a passenger, ask the speeding driver to slow down and do it over until you feel safe. Other passengers may find you a nuisance but make no apologies for being safe. Wear your seat belt if provided. Do not board when there is no seat for you. Be selfish and jealously take guard of your life. Should you be the driver, common sense, traffic rules and courtesy should be your mantra behind the wheel. Even if you believe in an after-life, your family and loved ones cherish your presence more in this life. Should you fail to honor your duty to safety, like the over 3000 lives lost on the road in Kenya this year, your life will be lost in vain.

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An accident victim in a Kenyan hospital

Social Inequ(al)ities will Drown Us All: Rich or Poor.

In Kenya today as in just about every other part of the world, we face a multitude of threats to human development and co-existence. Every country bears unique difficulties whose solutions are without saying, equally unique. However, on a general assessment, a number of challenges have been surmounted by solutions that appear quite similar overall if for a tweak here and there. Specifically, we face significant challenges in internal security, road safety and public sector services and utilities (health, education, housing, electricity and water). Given, a few Kenyans enjoy first-rate quality of these services but majority of the nation still live in low quality dwellings lacking the most basic utilities.

A dichotomy exists in which state-run services targeted at the masses are invariably inferior to their privately run counterparts targeted at those able to pay market prices. This is most evident in the health and education sectors. In other key public sectors like transport and the utilities, state divestiture is now mature with only regulatory functions and minimal shareholding left over. Even then, the entirely private road transport sector is one of the most chaotic and inefficient sectors. It is therefore apparent that ownership – state or private – is no panacea to inefficiency, rather policy and management.

According to the UNDP, the Human Development Index (a composite of three factors: education, income and life expectancy) is a fair measure of the quality of life and potential in a nation. Western European countries have consistently topped the world HDI rankings with Norway coming first 8 times in the last decade. Save for a few, nearly all the highly developed countries have programs that attempt to guarantee every citizen access to quality health care, education and decent employment. The hand of the state is heavy on these sectors in terms of both investment and regulation. In addition, these countries have social safety nets that encourage nearly all citizens to achieve their individual potential. Public transport for instance runs as the economic engine that it is: delivering workers to their jobs across the country efficiently – in comfort, safety and on schedule. Regulation and enforcement of fair employment practices on the other hand guards against poor pay, unfair working conditions and the vagaries of unemployment. The goal of these programs is to transform individual needs and aspirations into national goals to which everyone contributes according to their ability and enjoys according to their need.

In contrast, our undoing in Kenya is entire systems, institutions and sectors whose singular goal is to achieve the best interests of a select few at the expense of the public. Like the colonialists, many of our leaders see their positions as an elevation above the masses and therefore an entitlement to special benefits and treatment. It is the reason we spend more on chase cars, outriders and elite police for a few persons and leave the rest of the public at the mercy of police officers lacking the most basic crime deterrence and quick response tools! For the same lack of a public focus, we have set the minimum wage at a sorry $100/month when a few public officials draw $1000/sitting as allowances for meetings that are part of their regular work. Even though we know most road deaths occur among pedestrians and cyclists (70%) partly because they have to share the highways with high-speed motor traffic, we still build the same types of roads with no considerations (special lanes, crossings and footbridges) for this most-vulnerable majority. Food remains the major budgetary expenditure for most households due to the lack of concerted efforts at helping farmers produce cheaper and better food. Until recently, major highways would be shut down for hours for the president who would not show up after all!

Whatever the justification, these scenarios reinforce inequalities and limit the number of Kenyans actively participating in national development. These lopsided choices further hinder the achievement of individual aspirations of the majority and therefore keep the whole country in a perennial state of insecurity, increasing poverty and dwindling quality of life. It is high time focus shifted from ‘big man’ first to ‘common man’ (read everyone) first.

When we make our public schools the best schools, our public hospitals the best and develop a public transport that actually works, we shall be firmly on the path to real economic growth. Assuring every citizen a chance at proper education, health and an enabling environment to earn an income are probably the reasons for the existence of government. As of the moment, an unacceptably large swathe of the population is labeled as informal. Their children attend low quality public and shadowy private schools, they go to backstreet private clinics or the constrained public ones, they earn inhuman wages, they can barely afford good food and they are a security risk to everyone else including themselves. On the flip side, a much smaller number of citizens under the guise of state officers are feted and pampered at every turn. They do not care of a public transport system because in addition to their state-issue limousines they can choose which of the other two or three cars to use, they have their health insured, their children attend exclusive private schools and the walls around their homes are too high for any peeping Toms. Unfortunately, this class of Kenyans – the policy makers, political leaders and social elite – is like the dog running away from its own ugly tail. Their penchant at eating the state is a risk unto themselves and everyone else.

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To improve the quality of life in our country, we will have to focus on public good. The letter and spirit our policies will have to seek to impress the public rather than a select few. A focus on common good will achieve benefits for everyone while a focus on individuals will leave those same individuals exposed to the very ills they attempt to escape. The elite and middle-class have their place in every society but that place is really small and uncertain if the rest of society has no place.

Rather than each build walls round our homes and grab 5 or so officers to keep guard, it would be safer for us all to have the police equipped with the skills and tools to not just deter crime, but also apprehend nearly all criminals every time. We may have the option to take our kids to the best private schools but at the end of it all, those who miss a good education in the public schools will still be our collective problem to face. And however healthy one may be … complete with a private health insurance, doctor and all … the health problems of the rest of the public are as much your own as they are theirs. The minister who can halt all traffic and have his way to the office in time achieves nothing if the rest of the workers remain held in a gridlock.

While true leaders would naturally focus on satisfying the aspirations of their people rather than themselves, it is also a civic duty of citizens to demand of better from their leaders. In a situation where both leaders and citizens have sat on their laurels, the consequences are dire: continued depravation and disempowerment of the masses as leaders plunder and amass ever more wealth. In the long term something gives: a revolt by the masses due to difficult and poor living conditions may force a reformation of leadership. The leadership on the other hand may be forced to transform itself for better when the effects of their actions (and inaction) begin to bite them.

We can have a voluntary leadership reformation and put everyone (and the nation) on the path to sustainable economic success. Kenya is in the company of only a handful of nations in which public service is the most lucrative economic activity. For most developed countries, public service is a dedication and commitment to serve – the benefits of which are nowhere close to those of for-profit operations. Remuneration in the Kenyan public sector today does not reflect expertise, experience or value. If it did, doctors, teachers, police and nurses would not be the lowest paid in spite of the fact they offer key professional social services. It cannot be lost to policy makers that the services of medics, teachers and the police are so key to a sustainable economy and that there can be no meaningful development in the absence of security, good health and proper education.

As the name suggests, public goods achieve good for everyone; those who pay for them and those who do not as well as those who use them and those who do not. The outlay costs for most are prohibitive but in the long run, the efficiency and multiplier effect on individuals, economies and nations are worth every penny spent. When everyone has the opportunity to participate in nation building, the task of nation building becomes lighter, faster and better. Every one of us should focus on the greater good at whatever activity we engage in.

Celebrating Kenya @ 50: Who’s Hosting?

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In colonial Kenya, long before I was born, the government was a foreign entity only domiciled in Kenya. It came with its structures and practices from yonder and paid little courtesy to what the locals felt or thought of its ways. If anything, the government’s goal was to subdue locals so the protectorate could advance the Queen’s agenda. That is how the fertile highlands were settled by the rulers and not the locals. To ensure the locals remained on their knees, the government decided what activities anyone could do. For instance, locals could not grow coffee or tea; Kenya’s black gold back then. If a local got within the white man’s circle, it was for their role in keeping their fellow black man subdued. We therefore had chiefs and askaris who were meaner to African Kenyans than the supposed-oppressor White rulers were.

At independence, for some strange reason liberation carried with it the animosity that existed between the privileged few and the masses. The police continued to be agents of torture and repression. The average public servant was not accountable to the ordinary citizen but to the new black “white” man. Colors changed but the relationships did not. Citizens were liberated but were still supposed to remain in their pre-independence clothes. The rulers meanwhile conveniently grabbed the white man’s wardrobe and did not care to turn out in the white man’s best attire.

Today, 50 years later, your average public officer will easily lose their job if they went against the grain of the establishment. Even when their action was in public interest! We still cherish the GSU for their ability to reign terror on fellow citizens. We still clothe our tribal demigods in the colonialist’s garbs; irreproachable, benevolent and with a free will to tread over us as they may please. The ordinary citizen has remained at the same spot he was at independence; unwilling to upset the leadership with uncomfortable questions, unquestioning when called to vote and always sorry for his own sad plight.

In the last week, two events got me thinking of how stagnated our society has remained in leadership and accountability. On Wednesday 14th, former Congressman Jesse Jackson Jr and his wife were both sentenced for what in Kenya would be called corruption. Jackson was sentenced to 30 months in jail for stealing Ksh 65M of public funds. While that may not be big news in Kenya, the news is that these public funds were donations by the public to Jackson’s election campaign kitty. Now that would get most Kenyan politicians and citizens in serious thought trying to contemplate what the offence was! And as if that were not strict enough, his wife got a sentence for falsifying tax returns to hide the theft. The Jacksons were condemned and chastised for what in Kenya would never be known in the first place. A man once touted as potential president climbed down the public moral altar in disgrace courtesy of greed and public accountability.  Jackson displayed a kind of greed we are not strange to in Kenya. He spent the money on a Rolex watch and few other little luxuries at a time when his family’s combined annual earning was over Ksh 26M. In essence, Jackson stole money he already had to spend on things he did not need. The Kenyan public sphere is replete with supposedly honorable men who steal money they have for things they do not need but get away with their impropriety. Sadly and oddly, the ordinary citizen is firmly stuck to his colonial mindset; not asking questions and worse, swearing support when tribe is appropriate.

The second event was in Germany. An 8-year old boy was bitten by a turtle while swimming in a small lake. The boy sustained an injury but nothing life threatening. However, what followed is unimaginable in Kenya. The entire lake was drained and residents and firemen searched for the single 40cm turtle in the mud all weekend.  Such is the value of human life. And such is the epitome of public accountability. It saddens that we lose thousands of innocent productive citizens in Kenya in such senseless ways as road accidents yet nothing is done about it by the responsible public officials. The idea of public officials serving the public is still a far cry. The colonial mentality of serving a boss has held our leaders from recognizing the dignity and potential of our own people. Instead, all decisions must conform to the interests of the establishment first before those of the citizenry.  This is why we will still cherish the GSU for their batons, fear the police for their handcuffs and hold leaders in awe for their positions. In the meantime, nobody will move to fix the carnage on the roads, the want in hospitals and the disarray in schools. All this while, the public remains firmly seated in their role as subjects rather than employers of the leaders. The few who try to make a difference are just that, few.  In Mandela’s words, it remains a long walk to freedom.

Preventing HIV Using ARV’s; The Feasibility.

In theory, behavior change that leads to total non-exposure to HIV would halt the further spread of the virus. This would entail complete abstinence from all sex or remaining totally faithful to a mutually faithful partner and at the very least, always correctly using condoms in all other sexual encounters. The reality however, is much different; behavior change responses need to be sustained and widespread to have any impact. In any case, behavior change strategies (the oldest tool in the prevention of HIV transmission) cannot stand alone in the control of HIV; they work best in complement to other strategies. Similarly, it is my opinion that Treatment as Prevention (TasP) is not the silver bullet in the control of transmission of HIV and will only have relevance in some limited contexts and not others.

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It needs no emphasis that HIV as a global epidemic has exacted an unwarranted toll on humanity since it was described slightly over thirty years ago; the statistics speak for themselves. Every viable effort against the epidemic will remain welcome and worth consideration. To date in addition to Anti-Retroviral Therapy (ART); male circumcision, condoms, microbicides, donor-blood screening, voluntary testing and behavior change strategies are all interventions in use against the spread of HIV/AIDS across the world. Variable successes have been noted with each or combinations of these strategies in different contexts. To this arsenal, the World Health Organisation (WHO) has since late 2010 recommended universal treatment as a preventive measure. By WHO’s definition, TasP is the prescription of antiretroviral (ARV) drugs to all persons infected with HIV as early as possible and irrespective of their CD4 cell counts for the rest of their lives. This definition excludes ARV microbicides and pre-exposure ARV prophylaxis. It is noteworthy that only the United States of America (USA) offers TasP as defined above in its national program so far.

Worldwide, majority of the HIV infections are acquired by heterosexual contact. These infections occur predominantly in low-income countries of sub-Saharan Africa and parts of Asia. Other modes include use of contaminated blood products and needles, mother-to-child and homosexual sex between men. The epidemic has a different face in different regions: generalized in Africa, concentrated among homosexual men in the USA, female sex workers in Thailand and injection drug users (IDU’s) in Russia. With these epidemiological differences, successful control strategies thus need to be context-specific and locally-adapted for most impact. The principle of TasP is based on knowledge from the experience with anti-retroviral drugs (ARV’s) in the management of HIV; particular for prevention of mother-to-child transmissions (PMTCT) and between sero-discordant couples. Properly administered, ARV’s progressively lower viral load in blood to near non-detectable levels; concomitantly lowering the risk of virus transmission. It is this benefit that on a population-level scale is postulated to slow if not halt the further spread of HIV.

The Proximate-determinants Conceptual Framework of infectious disease transmission requires the interaction of 3 key biological determinants; i) exposure, ii) duration of infectiousness and iii) efficiency of transmission of the infectious agent to propagate, halt or reverse the disease transmission process. An intervention on any one of these biological factors is important in any preventive strategy.

Multiple studies have demonstrated that viral load is a principle factor in the efficiency of transmission of HIV; the higher the load, the higher the likelihood of transmission between sexual partners. It is also known that viral loads are highest in the acute phase of infection; TasP therefore aims to start treatment as soon as possible after infection unlike regular ART. However, the efficiency of transmission is also influenced adversely by other factors like the presence of other sexually transmitted infections, sores, nature of sexual acts, circumcision and condom use. In addition to lowering the transmission efficiency, TasP also has an effect on the other two biological determinants of transmission; duration of infectivity and exposure to infectious material. By lowering viral load, ART greatly improves patients’ quality of life and as a result, they generally live much longer than they otherwise would. When the use of ART begins early in the course of the infection as in TasP, the additional length of healthy life provides a longer period upon which infection of others could potentially occur. On to the third determinant, certain studies have noted increased risk behavior in persons infected with HIV once treatment was widely available and quality of life greatly improved; the phenomenon of risk compensation. This has an influence on exposure; with more risky sexual encounters, there is a greater risk of (re)infection of oneself and partners.

It is noteworthy that the evidence basis for TasP has mostly been collected from observations of cohorts of sero-discordant couples on ART and small populations of generally high HIV prevalence (concentrated epidemics) of male homosexuals and injection drug users. A population-based cohort in British Columbia, Canada was the first major large scale study of the effect of increased ART coverage on a population. The results of this study, later mathematically extrapolated on computer models, have been a strong evidence basis that widespread ART coverage could potentially lower both individual and communal viral loads and thus halt or even reverse the spread of HIV by making transmission less efficient.

Despite the impressive mathematical models demonstrating the turnaround effect TasP can have on HIV incidence, these projections are yet to be demonstrated in large population-level treatment programs in generalized epidemics. In the United States (US), high treatment coverage for heterosexual HIV infected individuals has not resulted into significant decline towards elimination as predicted on some of these mathematical projections. Even worse, certain models have shown a potential rise in incidence if TasP is not accompanied by appropriate behavioral change. Further, key assumptions made by these models (100% of the population is tested and there are no financial or other barriers to initiation and sustenance of treatment) cannot be wished away in real life. To be successful, a TasP program would need to maintain three conditions: ART coverage of the population needs to be significantly high (>75%) and sustained, patients’ ART adherence rate needs to be high (>80%) and sustained, and lastly, treatment must be initiated at the earliest time since infection (healthy individuals).

Besides biomedical interventions like TasP; improved quality of life, female education and empowerment as well as support for the vulnerable of society (orphans, the poor) have been shown to have greater impact on the long-term sustainable control of the spread of HIV. Such interventions, when complemented by programs that strengthen existing local health systems and infrastructure, create effective and long-term systems for HIV control. It thus appears that keeping HIV in control would involve the engagement of other sectors and other strategies that address the underlying determinants in an integrated system.

The efficacy of ART and its role in lowering the efficiency of transmission of HIV is not in doubt. This has been demonstrated in the PMTCT programs and among sero-discordant couples in studies referred to above.  If adopted universally, TasP carries the promise of eradicating HIV or at the least significantly slowing its rate of transmission. This promise is however bound by lack of experience with TasP on a large-scale in generalized epidemics and the fact that the benefits are largely the product of mathematical projections of current observations. These may not be guaranteed to replicate as projected. On another note, achieving ART coverage of above 75% (a requirement for TasP) would be a huge leap forward in meeting unmet treatment needs for those who currently need ART and lack it. Only 47% of those who need ART have access to it in the low and mid-income countries. However, achieving this high level of coverage may be a mirage considering the fact that in the over one decade of availability of ARV’s, only half of those who need them can access them in some regions. Scaling up coverage to include those who are healthy and not in immediate need of these drugs would thus be a formidable challenge.

As mentioned before, initiation of ART needs to begin at the earliest opportunity upon infection. This portends a double challenge; finding newly infected persons and keeping them adherent to treatment for life despite their being asymptomatic and relatively healthy at the beginning. HIV infected persons are most infectious in the acute phase of the infection (up to first 6 months) during which most are generally healthy and unaware of their status. On average, these persons are up to 10 times more infectious than they will ever be at any other time in the course of the infection and will often continue with risky sexual behavior. Current universal testing practices have failed and large groups remain out of reach of the health system. Ethical considerations have also meant that testing remains only voluntary. This presents a major challenge to TasP programs of diagnosing asymptomatic infected individuals who remain the most infectious. Further, providing ART to persons who are healthy for the communal good comes with the risk of poor adherence as well as raises ethical and equity concerns. Poor treatment adherence coupled with long periods of ART would lead to the widespread development of resistant strains; a catastrophic situation in the absence of new drugs. Equity demands that those most at need of treatment get it first hence raising programmatic concerns for resource limited countries. To further complicate the matter, some patients develop a false sense of security in ART and may actually practice riskier sexual behavior once on treatment.

Finally, focus on TasP would take away much needed attention, focus and already-scarce resources from other interventions that would make a bigger impact on the incidence of HIV. Combination approaches to HIV prevention promise better and sustainable prospects at containing HIV. These programs are wholesome and encompass prevention, treatment and empowerment of the vulnerable members of the society. Termed as ‘Highly Active Prevention’ by Prof Holmes of the University of Washington School of Medicine, these strategies go beyond the medical realm into the underlying determinants of the HIV epidemic. This approach to HIV control takes advantage of strategies known to work directly in preventing the transmission of HIV (behavior change, treatment, circumcision) while addressing conditions that expose individuals to infection with HIV (poverty, poor education, gender disparity). It involves community participation in collaboration with their leadership to develop locally appropriate and sustainable solutions. This approach attempts to address health inequities, gender disparities and social injustices that make certain individuals vulnerable to exposure to HIV infection. I share the opinion that this approach is the surest way forward in the management of HIV particularly in the low-resource generalized-epidemic context. In concentrated epidemics, TasP may have a role particularly if those populations can be reached in totality and financial and other barriers to access to treatment be eliminated.

In summary, TasP is a novel concept with a noble cause whose prospects are yet to be agreed upon by various researchers as generally feasible. It presents challenging logistics in implementation as well as raises serious ethical and financial concerns. Curbing the spread of HIV will invariably involve concerted efforts that approach the problem from both the prevention and care perspectives. Even more importantly, improvement of the general quality of life for populations; including access to better quality education and employment will lay the foundation upon which health-sector interventions will make an impact. Health interventions (like TasP) on their own stand on shaky ground and may not hold long in the absence of programs that address the underlying determinants.

Is Universal Health a Public Burden in Africa?

The WHO has a long convoluted definition of health as is typical of most organizations of its stature and mandate. To the average person, African or not, health is subjectively defined in simpler terms; a state of wellness and ability to cope with the daily demands of life. The similarities end here. What counts for normalcy in Western Europe and North America is literally worlds apart from the same in Asia or Africa. While the per capita annual spend on health in the US is about $8000 and $3000 in Western Europe, every African individual spends only about $85 towards their health annually! This comparison, at face value, is damning. Indeed health care in the West is highly specialized and commensurately expensive; in great contrast to the African context where healthcare largely involves basic primary care. The expenditure gap is therefore a result of the size of the health ‘shopping cart’. This cart is significantly small for most of Africa with just a handful of goods while our American/European counterparts have a large cart bursting with goodies. Looked at differently, the African public sector is unable to push the ideal health cart and has chosen to keep only as few goods in it as it can push. This beggars the question; is health a public burden in Africa?

KIDCART

In his book ‘Why Africa Is Poor; And What Africans Can Do About It’, prolific author, researcher and international expert Dr Greg Mills goes at great lengths to demonstrate the central role the health of any nation has on its ability to grow from poverty to prosperity. Health is the very foundation of productivity and growth. A population afflicted by disease and illness spends less time in the production of the goods and services it needs. Complementary to good health is education; the skills to produce, and leadership; the organization of priorities. All developed economies have had to make deliberate provisions for the health and skills of their people to be where they are today. Other factors are subsets of these three pillars. Is it thus plausible to argue that leadership is wanting in Africa for it not to have prioritized the health of her people? The statistics all point to a sector in wanton neglect and crying for attention; life expectancy at birth of 56 years (against 80 in developed countries) and unacceptably high all-cause mortality and disease rates. Viewed against investment in health and other social services, these grim figures are proportionate to the dismal investments in these sectors. However, Africa is a vast territory of 54 nations; each unique in its own right and internally very diverse. A sweeping statement like this may not fly but remains valid for the most part. Analyzing individual countries paints a more accurate if grimmer picture than these continental averages.

Take Kenya for instance, a country with a per capita GDP (PPP) of  just under $ 2000 spending a meager 4% of her GDP on healthcare. Two thirds the citizens live on less than $ 2 a day and predominantly rely on the state-run health system for their health needs. The health system is mainly funded by central government taxes (direct and indirect) in addition to co-payment into a largely voluntary national insurance scheme that covers nearly two million of the 40 million citizens. Those not covered, an overwhelming majority, are expected to share costs with the state in the form of user fees at points of care. These direct fees amount to 60% of all the national health spend. There is no explicit provision for the care of the worst-off in the society; the elderly and the extreme poor. Where provisions exist, like for children under five, free treatment is often negated by a lack of an assortment of supplies including drugs which patients routinely have to buy out of pocket. In addition to the direct costs of healthcare, majority of the population bear disproportionately high indirect costs in accessing health. Transport costs are highest in the rural areas where physical access is lowest and poverty highest. The opportunity cost of time in seeking care also tends to be higher for the worst-off of the society; they make no income when sick and have to pay to get back on their feet. As though not already overburdened, the poor further face a silent hidden cost: counterfeits and illegal practitioners. Illegal practitioners take advantage of the unmet health needs of those disenfranchised by the formal system. It is here where counterfeits are passed off for genuine drugs and overall quality of care much lower than anywhere else but at a fraction of the direct monetary cost. This situation is not unique to Kenya: across Africa, millions of poor peasants have to make the choice between their health and food or work. While it is obvious that productivity is lost with every episode of illness, most African governments have failed to embrace this rather simple fact that a good health status is the basic unit of productivity; even ahead of education/vocation.

A sad irony is that while majority wallow in poor health, a small middle class in Kenya (like in other African countries) has access to fairly comprehensive employer-financed health covers tenable at some of the best health facilities around the country. These people do not lose much income (if at all) for their sick-time and do not have to pay for their health costs at the point of care. This sad state of affairs ensures that only a small subset of the nation enjoys good health and subsequent productivity and therefore carries the resultant burden of the sick and less productive. This further widens inequalities and keeps entire nations stuck in poverty, disease and underdevelopment; a reality so prevalent across Africa and within nations.

On the contrary, Germany spends 12% of its GDP on healthcare with direct private fees amounting to only 25% of the total health spend. The health basket in Germany is certainly larger but it is important to note that the bulk of the financing for health is prepaid. Public funds shoulder nearly one quarter of the health budget with the rest covered by prepaid compulsory universal health insurance into which employees and employers contribute. Further, the government makes payments for those out of employment or otherwise unable to make an income. This single feature creates a system in which ability to pay is not a determinant of access to health services. Efficiency and collaboration between private and public players in financing, service delivery and research into healthcare is high and the overall result is a system that meets the health needs of all citizens including the less fortunate. Needless to add, the dividends of a healthy nation are self-evident; greater productivity, longer lives and greater quality of life.

However, a good national health service is not by itself a guarantee to improved national health status. The health service is only one of a retinue of factors that determine the health status of individuals. Commodities like food security, water and sanitation, education, clean energy and social cohesion achieve greater health benefits and savings than the health service itself. It takes leadership to define programs that integrate these individual components into a system that delivers health to the nation. This demands an awful amount of political capital and ownership for any meaningful success. Africa must begin making homegrown decisions for her people. The introduction of user fees in hospitals and state divestiture from several key public sectors (including water, electricity and transport) can be remembered by all to have been a top down condition by the Bretton Woods institutions in the infamous Structural Adjustments Program era of the 80’s. Today, fragmentation of healthcare in most African countries amongst disparate donors with as many interests has made sure that only modest gains have been made in the improvement of healthcare. The presence of these programs if for nothing else is testimony to the fact that our health systems are not functional as presently constituted. A conscious effort must be made to ensure the attainment of universal population coverage as the first step in achieving universal health care. To ensure a meaningful health package, the financing of health – as a necessity – needs to be prepaid rather than at the point of service. Mechanisms must also be placed to ensure the most disadvantaged of society are not disenfranchised from the health system by way of fees. And more importantly, there must be efficiency at every level; collection and pooling of funds, purchasing of health goods and services, management of the health workforce and research. This calls for closer mutual public-private partnership and for emphasis; leadership. Only then shall we begin to have a healthy enough population that can engage in production and economic and social development. Fortunately, these developments are already taking place in countries like Ghana, Rwanda and Burkina Faso with steady and remarkable results. It must remain alive to us that universal health is a public burden; not to be shunned, but one to be borne by everyone in a way that especially seeks out the most disadvantaged in the society.