Not that the Economist has ever made a habit of ignoring tropical diseases. Far from it, the Economist as a British magazine is quite good at reporting on the Isles former colonies.
Here they’ve written on the issues of mass drug administrations as a tool in malaria eradication. Specifically, they focus on a Chinese group seeking to ramp up efforts to create a successful regimen of artemisinin and piperaquine to eliminate the disease by prophylacticly preventing infection, and interrupting the cycle of transmission long enough to eliminate the parasite entirely.
Dr Li’s approach is to attack not the mosquito, but the disease-causing parasite itself. This parasite’s life cycle alternates between its insect host (the mosquito) and its vertebrate one (human beings). Crucially, as far as is known, humans are its only vertebrate host. Deny it them and it will, perforce, wither away—an approach that worked for the smallpox virus, which had a similarly picky appetite. In the case of smallpox, a vaccine was used to make humans hostile territory for the pathogen. Since there is no vaccine against malaria, Dr Li is instead using drugs.
To date, the group has been running trials in the Comoros islands off the coast of Mozambique and had some success, but haven’t come close to full elimination. Elimination on islands surrounded by salt water (mosquitoes which transmit malaria breed in fresh water) should be a fairly easy proposition, but the issue of human mobility from the African continent guarantees reintroduction.
I’m personally involved in an island malaria elimination project in Kenya, but am under no illusions that results from an island are in the least bit generalization to the continent. Falciparum malaria is far too efficient and the lack of a winter renders transmission far too consistent to allow easy elimination. Add the issue of the intense mobility of Africans and one can’t help but be discouraged.
Dr. Li from the Guangzhou group seems to be optimistically under the mistaken impression that all it will take to eradicate malaria is the right combination of magic pills, but he’s gravely mistaken. The only thing that will consistently control malaria on the continent will be a full on, sustained assault using every tool known, along with intense economic development. The continent has only seen gains in malaria control during the 00’s, when incredible amounts of money and effort was thrown at the disease and, not coincidentally, when African economies finally started to take off. Eradicating malaria won’t be about a few pills.
More troubling to me are the ethical issues. Mass drug administrations require the participation. If even a small group of people refuse the medication, the entire effort might be for naught. Obtaining full, informed consent, however, is near impossible in these areas. While most people are willing to participate once the benefits are explained to them, the risks are often glossed over. Moreover, as communities will often follow the behavior of their neighbors or community leaders, it is difficult to judge whether people participate of their own volition or whether they are merely bowing to community pressure. Educational barriers might also compromise the ability to obtain truly informed consent.
Further, I don’t doubt the intent of the Guangzhou group, but I do wonder if Chinese institutions truly have the same level of ethical review and monitoring that United States’ institutions have (which isn’t even perfect and sometimes ill suited to developing countries). I’m sure that China would love to claim a success like malaria elimination, but I worry that a zeal for victory might lead to a violation of basic ethics and even a masking of failures, complicating the issue in the long term. I hope that I’m wrong.
It has been announced that Bangui mayor Catherine Samba-Panza has been appointed the Interim President of the near anarchic Central African Republic.
Her ascension couldn’t come at a better time. The Central African Republic, fragile even in the best of times, has been slowly sinking into chaos. No one really knows how many people have been killed in the fighting between Christian and Muslim militias (though this shouldn’t be read as a religious conflict), but reports last year pegged more than 1000 civilian deaths within a two day span. Experts have started using the g-word.
From the NYT:
The interim president selected on Monday at a raucous, five-hour session of a “national transition council” of rebels, rivals and politicians was Catherine Samba-Panza, a French-educated lawyer with a reputation for integrity and no ties either to the Muslim rebels or the Christian militia. Her selection was greeted with cheers in the assembly hall and dancing outside. That she is a woman — the third female head of state in post-colonial Africa — was especially welcomed by many people who felt that men had done nothing but lead the country on its vicious downward spiral.
Though encouraging, it’s too early to tell if Ms. Samba-Panza will be able to contain the bloodshed in the CAR. Certainly, Liberia gained much under the leadership of Ellen Johnson Sirleaf, but it’s hard to say whether there’s been a great transformation in Malawi under Joyce Banda. Rwanda’s female majority Parliament is vastly preferable to Kenya’s (or the United States’) overpaid and corrupt boy’s club, however.
The conflagration in the CAR has been troubling for a number of reasons. First, it represents a general pattern of instability just below the Sahara. Neighboring South Sudan, which just recently obtained independence, is now facing a conflict ridden humanitarian crisis.
Second, the conflicts in South Sudan, the CAR, Northern Nigeria, Mali and Somalia rage on compromise the positive narrative of a newly prosperous and economically viable Africa. The 80’s and 90’s were a stain on the continent. Though I don’t foresee a return to the extended civil wars of Angola and Mozambique (for example), general regional instability compromises the ability to sustain development over the entire continent.
Third, even if the CAR manages to suppress the violence, there are few viable options for the long term economic future of this landlocked and historically marginalized country. Without a long term economic plan chances are high that tensions will flare up once more, setting the country back again.
Every year, Bill and Melinda Gates release a letter on the state of the Gates Foundation and the current situation of global development and health. This time Gates set out to dispel three common myths on development, namely that poor countries are doomed to be poor forever, foreign aid is a total waste and that development will just lead to overpopulation.
The first is the most cynical, but even for us development/public health folks, it’s easy to be discouraged. Pessimism aside, the data don’t bear out the assumption that developing countries are entrenched in poverty. Just about all Sub-Saharan African countries experience consistent economic growth throughout the 00’s and have seen rapid improvements in just about all of the common health indicators. People are living longer, fewer kids are dying and they’re making more money to pay for school and health care.
Over the past five years that I’ve been going to Sub-Saharan Africa I’ve seen this change on the ground. Cars are in better shape, there’s more goods on the shelves, kids are better nourished and security has vastly improved. Does this mean that all of the problems are magically going away? No, there are still vast challenges to infrastructure development, access to health care and affordable medications, educational quality, gender issues and basic business development. However, these improvements do signal that Sub-Saharan African countries are reaching a point where sustained development is possible.
I have a hard time disagreeing with Gates here, but I did find his “before” and “after” pictures of Nairobi a bit bizarre. Though Nairobi is currently going through a construction boom, I fail to see how it would look any different in 2014 than it did in 1969 after more than three decades of stagnation.
Gates second point and the hardest myth to dispel is that of the alleged ineffectiveness of aid. Bill Easterly has made a career out of aid bashing, and, unfortunately, given cynical politicians looking for policy scapegoats a point to scream to their angry constituents. In a broader sense, the screaming over aid is really a questioning of developmental policies themselves. Certainly, there are development failures. The neo-classically informed structural adjustment policies of the World Bank and the IMF during the 80’s and 90’s were, on the surface, colossal failures (Read Beyond the World Bank Agenda: An Institutional Approach to Development by Howard Stein for a great analysis). On a smaller scale, we can easily cherry pick misguided but well meaning development projects or plans that simply went awry for any number of unforeseen reasons. The recent takedown of Jeff Sachs (The Idealist: Jeffrey Sachs and the Quest to End Poverty) and the massive problems of the Millenium Village in North East Province in Kenya is a great example of the challenges a development project can face.
However, in ever insular post Iraq America, the question that is most often asked is why we should even care and does our presence merely serve to make things worse. The truth is, and the point most often overlooked, is that most development projects are international collaborations. Many projects are conducted with partners in target countries and, more often than not, projects often make up for shortfalls that hobbled governments are unable (or sometimes unwilling) to provide. Health care is one example.
Jeff Sachs wrote a nice article this morning on how effective free insecticide treated nets have been in reducing malaria incidence and mortality in Sub-Saharan Africa. Nearly half a billion free nets have been given out worldwide as of 2014 and a lot of kids are alive today who would have been dead had they been born ten years earlier. Malaria is 100% associated with poverty. Wealthy people do not get malaria, even in malaria endemic countries. Though some of the decline in malaria incidence has been due to increased affluence and urbanization of African countries, a major percentage of this decline has been due to aid programs which provide bed nets and have expanded access to life-saving malaria medications. Certainly, not all aid works, but nothing works 100% of the time, particularly when humans are involved.
Which brings us to the most cynical and offensive of Gates’ three myths. Some people truly believe that saving African kids is a bad thing. One day there will be too many of them and they will suck up the ability for the world to sustain life. Honestly, this view couldn’t be more wrong.
The poorest parts of the world are the areas which are seeing the most rapid population growth. The average Malawian woman has 8 children in her lifetime, often starting when she isn’t even yet 15 years old. It has been said that if Malawi continues on it’s current trajectory, that it will have a population equivalent to that of Japan’s by 2050. Women in water and food constrained pastoralist communities can have ten or more children. The most affluent areas of Africa are the places with the slowest population growth.
Even more incorrect is the assumption that poverty is less harmful to the environment than development. Malawi is almost entirely deforested due to extensive use of charcoal for heating and tobacco cultivation. Deforestation not only robs the earth of potential carbon sinks, but also reduces need biodiversity and directly impacts precious water resources. Africa burns unclean fuels such as charcoal and coal for heating, and the poor condition of vehicles make it a major potential source of greenhouse gases. The air in Nairobi on any given weekday is so filled with exhaust that one can become dizzy just walking around town. It is, of course, unreasonable (and stupid) to deny Africans transportation and cooking fuel, but well meaning though poorly informed armchair environmentalists in the United States would happily suggest doing just that.
Which bring me to my final point. The case against development is one that assumes that the status quo is somehow preferable to anything that might come after. The assumption is that Africans were just fine without Europeans and their planet destroying ways. There is, of course, little data on what Africa was like before Europeans started extracting resources from the continent. We do, however, know a lot about underdeveloped areas of Africa. There is evidence to suggest that some do fine. There is however, much evidence to suggest that other simply do not. The worst parts of Africa are the parts which are the least developed. They are the areas where the market doesn’t function. The areas where there is little education, no access to health care, no roads, no economy, kids regularly die, where old people are a venerated since they are so rare, where there’s violence and instability and people are entirely marginalized from any level of political participation. While development likely will never solve the worst problems (like those in Somalia), there is no case to be made that the current state of the ultra poor is acceptable on any measure, even to the poor themselves!
Alright, off to bed.
Africa is an awful place to be gay, but, just as everywhere else, gay folks exist and do the best they can under adverse circumstances.
Happily, President Museveni of Uganda has stated that he refuses to sign a “anti-homosexuality Bill” sent to him from the Ugandan Parliament. It’s possible that he would have supported had he sensed that signing the bill would have benefitted him domestically, as Nigerian President Goodluck Johnathan (who’s luck seems to be running out) did just this week.
Wasting no time at all, Nigerian authorities have arrested and tortured dozens of people suspected of being gay. The methods are frightening:
Human rights advocates in Nigeria are reporting that dozens of gay men have been arrested under a new law that makes homosexual clubs or associations illegal. That law also criminalizes same-sex marriage. Gay men who have been arrested have reportedly been tortured into giving up the names of others. Michelle Faul with the Associated Press has been writing about this and she joins us now from Lagos.
And Michelle, why don’t you give us more details, what you’ve learned about these arrests and the reports of torture from human rights groups there.
MICHELLE FAUL: As we’re speaking, Melissa, we’re getting more reports in of more people being arrested in about six of Nigeria’s 36 states. I’ve spoken with human rights activists here who say this has not just happened since the bill was signed into law, but since there’s been noise about the bill. So the very idea of the bill has led to this persecution of people because of their sexual differences.
BLOCK: And in particular the reports of torture, what have you heard about that?
FAUL: That particular report comes from Bauchi State in the north of Nigeria, where it’s almost a case of entrapment. A law enforcer pretending to be a gay man went to a meeting where an AIDS counselor was speaking to men, who have sex with men, about how they could do this safely. He pretended to be gay, got the names of a couple of people, arrested subsequently one person, used their cell phone – this is illegal in itself for him to go through this person cell phone, contact another gay person and another gay person. Called them for a meeting, arrest them, take them to the police station and beat them up repeatedly and brutally until they gave up 168 names of people who were supposed to be gay.
But back to Uganda. Museveni has a thin road to walk. If he comes out on the side of Uganda’s very active gay rights movement, he risks losing crucial domestic support. If he would have signed the bill, he risks losing international support at a fragile point in Uganda’s development.
He plays it carefully, but offers a few bizarre ideas:
The President said a homosexual is somebody who is abnormal because the normal person was created to be attracted to the opposite sex in order to procreate and perpetuate the human race. He said, nature goes wrong in a minority of cases.
While in the Bill passed by Parliament there is no provision for killing homosexuals; the President said, “The question at the core of the debate of homosexuality is; what do we do with an abnormal person? Do we kill him/her? Do we imprison him/her? Or we do contain him/her?”
While the President said homosexuality is an abnormal condition that can be cured, he disagreed with the position of Western countries that homosexuality is an “alternative sexual orientation”. “You cannot call an abnormality an alternative orientation. It could be that the Western societies, on account of random breeding, have generated many abnormal people,” he said, adding that his acid test for rejecting Western position is that nature is purposeful.
The President said apart from the people who are abnormal, it seems there is a group of those that become homosexual for “mercenary reasons”—they get recruited on account of financial inducements. He said this is a group that can be rescued and that many of the youth fall in this category.
I’m not following his logic here. I seriously doubt Museveni does either. Though he says that homosexuality is a natural condition, he also tries to claim that young men become gay to make money. The former presents him with a problem. If homosexuality is to be considered an unfortunate genetic outcome, the state has no right to inflict punishment on the individual any more than on a person born with any other type of genetic defect.
The latter, I’ve heard before. NGOs allegedly come to Africa and recruit young men through promises of money and passports. There is no reason to discount the problem of prositution enabled by economic inequality. We’ve seen it elsewhere (a movie was even made about an Irish author’s disgusting sexual adventures in Nepal). Of course, the Ugandan and Nigerian Parliaments seem to be doing little to curb the much larger problem of female prostitution in Uganda and it’s difficult for me to understand how it’s at all relevant to the lives of people peacefully living their lives who happen to be gay.
And this is of course where the problem lies. Homosexuality makes for an easy target for Christian conservatives in Africa (often egged on by western missionaries and evangelicals). However, there is little outrage over extramarital affairs, child rape, and the buying and selling of women, an obviously greater social problem. But policy makers worldwide often like to pick on those who are unable to defend themselves.
How do the governments of Nigeria and Uganda have time for all this? In countries where half the population lives on a dollar a day, the problem of delivering food and health care would seem to be more pressing issues. Many people I know like to blame the West for all of Africa’s ills. Clearly, as these examples show, policy makers in Nigeria and Uganda aren’t in the least bit interested in the welfare of their people, preferring to weed out minor issues of “gays” than deal with important matters such as food, health and stability.