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13 Apr
Lately, I have Order Hydrocodone Online Canada inundated myself with a series of incredibly enlightening dispatches from TED Talks. Listening to Order Hydrocodone Online Canada them, especially those related to international health and development has been Order Hydrocodone Online Canada a wonderful respite from my undesirably excessive clinical workload. The one by University of Chicago economist, Emily Oster, who Order Hydrocodone Online Canada shared her work and ideas on HIV/AIDS in Africa at last year’s TED, however struck me as particularly, if unwittingly, poorly conceived. Her theoretical abstractions reveal in shameful detail how easily tainted the Order Hydrocodone Online Canada lens through which the developing world is seen from the outside, and Order Hydrocodone Online Canada the kind of thinking that underlie the misconceptions that inform the Order Hydrocodone Online Canada largely skewed global health priorities.
Emily Oster based her first argument on a Order Hydrocodone Online Canada shaky, if not completely false premise, justifying a claim that there was no Order Hydrocodone Online Canada behavioural change in response to the HIV pandemic in Africa by juxtaposing data from Order Hydrocodone Online Canada two radically different cohorts — homosexuals in the Order Hydrocodone Online Canada US and heterosexuals in Africa. High HIV prevalence within a population where Order Hydrocodone Online Canada there is widespread awareness of heterosexual sex as the predominant mode of transmission will result in increased rate of abstinence from Order Hydrocodone Online Canada sex or at least a modification of sexual behaviour as an Order Hydrocodone Online Canada evolutionary compulsion to preserve the species. Without elaborate public health campaign to Order Hydrocodone Online Canada promote abstinence, HIV prevalence would have reduced on its own. That is Order Hydrocodone Online Canada what you would expect, but Oster says it was not so in Africa. She compares data from Order Hydrocodone Online Canada gay men in the US in the eighties, (where Order Hydrocodone Online Canada the men that had more than 1 unprotected sexual partner within a Order Hydrocodone Online Canada month reduced from 85% to 55% in 4 years) with data from Order Hydrocodone Online Canada single men having premarital sex and married men having extramarital sex in Africa dropped by only 2%.
There are obvious flaws in Oster’s argument apart from Order Hydrocodone Online Canada cohort mismatch. Her homosexual cohort had a reduction in the number of unprotected sexual partners, whereas there was no Order Hydrocodone Online Canada specification as to the nature of sex amongst the African cohort: protected or Order Hydrocodone Online Canada not, homosexual or heterosexual. She did not give any idea of the Order Hydrocodone Online Canada HIV prevalence amongst the said African population(s), so we cannot possibly estimate the Order Hydrocodone Online Canada cost of sex among the population, and arrive at any predictable behavioural change based on that. We know though, that Order Hydrocodone Online Canada HIV prevalence among gay men was about the highest in America in the Order Hydrocodone Online Canada early and mid eighties.
However, even if Emily Oster’s two cohorts were by any chance or Order Hydrocodone Online Canada twist of logic comparable, and if there was indeed no behavioural change in response to Order Hydrocodone Online Canada HIV in Africa, her explanation for this — the Order Hydrocodone Online Canada cost of abstinence is so high that in the presence of low life expectancy, people would rather not bother to Order Hydrocodone Online Canada live healthy lifestyles, they’d rather prefer to Order Hydrocodone Online Canada expose themselves to the risk of contracting HIV/AIDS since they’re gonna die early anyway — is Order Hydrocodone Online Canada as unconvincing and implausible. Oster demonstrated that in places and within populations in Africa with high prevalence of malaria and Order Hydrocodone Online Canada high maternal mortality, there was no positive change in sexual behaviour in response to Order Hydrocodone Online Canada HIV. She did this, totally ignoring two huge, glaringly obvious confounding variables, poverty and Order Hydrocodone Online Canada lack of basic health services, leading causes of low life expectancy in Africa, together with lack of adequate sanitation and Order Hydrocodone Online Canada good water supply, which promote the presence and spread of diseases, and Order Hydrocodone Online Canada in themselves, inextricably linked to poverty.
This is actually where Oster’s greatest mistake lies, and Order Hydrocodone Online Canada unfortunately, it is what forms the main thrust of her thesis. M. Khan and Order Hydrocodone Online Canada colleagues in Burkina Faso, found that even within a developing country, the Order Hydrocodone Online Canada sex network within rural areas is denser, more closely interlinked than Order Hydrocodone Online Canada in urban areas, and the percentage of those who receive goods for Order Hydrocodone Online Canada sex is far greater in the semi-rural border area (45%) and urban area (31%) than in the rural areas (12%). This is Order Hydrocodone Online Canada easily explained. There is far greater homogeneity in relation to poverty in rural areas compared to Order Hydrocodone Online Canada urban or semi-rural areas, and so there are fewer people who Order Hydrocodone Online Canada are prepared to offer money or goods for sex. Poverty too breeds idleness, and Order Hydrocodone Online Canada it is easy to imagine that an idle man will easily have Order Hydrocodone Online Canada multiple sexual partners in a community where money is not given in return for Order Hydrocodone Online Canada sex. This explains why poverty may be associated with high levels of sexual activity. In these settings, there is Order Hydrocodone Online Canada high maternal mortality both from unsafe abortion, and because maternity care is Order Hydrocodone Online Canada not available. Where poverty abounds and Order Hydrocodone Online Canada basic health services are not there, mortality from malaria will be Order Hydrocodone Online Canada high. Where there is no access to basic health services like STI prevention and Order Hydrocodone Online Canada treatment and modern contraception, there will be poor awareness of the Order Hydrocodone Online Canada presence, reality and prevalence of HIV. Illness and death from HIV is Order Hydrocodone Online Canada attributed to other diseases, witchcraft, the will of God et cetera, hence diagnostic, prevention and Order Hydrocodone Online Canada treatment services, even if available will suffer low uptake in the Order Hydrocodone Online Canada absence of these basic health services.
Emily Oster however asserts that Order Hydrocodone Online Canada HIV prevalence rises with increase in economic activity and urbanization. She evokes the Order Hydrocodone Online Canada oft-quoted high HIV prevalence amongst truck drivers and migrants to support this Order Hydrocodone Online Canada claim. She also showed that the fall in HIV prevalence in Uganda was closely associated with a Order Hydrocodone Online Canada fall in the export price of tobacco, Uganda’s main export commodity. All of these are Order Hydrocodone Online Canada true, if only in part, but yet again, she misses the Order Hydrocodone Online Canada point. It is not wealth as an absolute quantity that encourages increase in sexual activity, hence HIV prevalence; rather it Order Hydrocodone Online Canada is the widening of the gap between the rich and the Order Hydrocodone Online Canada poor, increased contact between the rich and the poor, and the Order Hydrocodone Online Canada attendant dynamics, the differential power gradient, that characterises the relationships between the Order Hydrocodone Online Canada two classes. Much of extramarital and premarital sex is facilitated by an Order Hydrocodone Online Canada economic advantage of one party, often the male, over the other. With a Order Hydrocodone Online Canada fall in export price of tobacco in Uganda for example, the Order Hydrocodone Online Canada gap between the rich and the poor is less, there is Order Hydrocodone Online Canada less money available to maintain multiple sexual partners and visit commercial sex workers, thereby reducing the Order Hydrocodone Online Canada sexual network, and also, predictably, HIV prevalence, at least in part.
Marjolein Gysels and Order Hydrocodone Online Canada colleagues at the Medical Research Council Programme on AIDS observed and Order Hydrocodone Online Canada interviewed truck drivers and commercial sex workers at a roadside town in southwest Uganda. Truck drivers are Order Hydrocodone Online Canada a high-risk group for HIV due to their sexual networking and Order Hydrocodone Online Canada long periods away from home. They stop at towns along major routes to Order Hydrocodone Online Canada eat, sleep, sell goods and 94% of those interviewed would regularly have Order Hydrocodone Online Canada sex when they spend the night at the truck stop. Commercial sex work was found to Order Hydrocodone Online Canada be common but quite hidden and implicit in this setting and Order Hydrocodone Online Canada is centered around roadside bars; hence intermediaries are often involved in negotiations between drivers and Order Hydrocodone Online Canada commercial sex workers. However, in the wake of HIV/AIDS, the Order Hydrocodone Online Canada middlemen on whom truck drivers rely to find women have Order Hydrocodone Online Canada had an additional role, which is to identify HIV-negative women, and Order Hydrocodone Online Canada in spite of this, condom use was reportedly high, at 95%, in marked contrast to Order Hydrocodone Online Canada local men. HIV prevalence used to be very high among drivers and Order Hydrocodone Online Canada at truck stops. In the study town it was 40% in 1991; in the surrounding district it was 8% in 2001. The demand for Order Hydrocodone Online Canada casual sex however appears not to have decreased among truck drivers in the Order Hydrocodone Online Canada era of HIV, but there is a general awareness that this Order Hydrocodone Online Canada lifestyle carries the risk of infection. This shows indeed, that there has Order Hydrocodone Online Canada been behaviour change in response to the HIV pandemic in Africa; contrary to Order Hydrocodone Online Canada what Emily Oster will have us believe.
In 2004, 12% of children with malaria died as inpatients at the Order Hydrocodone Online Canada national hospital in Guinea-Bissau. Special drug kits for children with severe and Order Hydrocodone Online Canada complicated malaria were introduced, but this did not reduce mortality. In an Order Hydrocodone Online Canada award winning BMJ study in 2007, Sidu Biai and colleagues tested in a Order Hydrocodone Online Canada randomised trial of under-5 children admitted with malaria, whether removal of prescription charges, strict monitoring of patients, and Order Hydrocodone Online Canada financial incentives for doctors and nurses could reduce mortality. Mortality indeed came down to Order Hydrocodone Online Canada 5% in the intervention group and 10% in controls, reflecting the Order Hydrocodone Online Canada crucial role of poverty in mortality from malaria. The only difference between the Order Hydrocodone Online Canada two groups was that doctors and nurses were given financial incentives in one group and Order Hydrocodone Online Canada they were not in the other, which alone reduced the Order Hydrocodone Online Canada mortality by as much as 5%. Given, the Order Hydrocodone Online Canada drugs were free in both groups; maybe that explains a fall in mortality from Order Hydrocodone Online Canada 12% pre trial to 10% in the control group. Weigh this against the 5% reduction, when Order Hydrocodone Online Canada health workers were given added incentives. From this, it is clear that Order Hydrocodone Online Canada with just three simple interventions — i.e. if we could make basic health services available, if patients could afford the Order Hydrocodone Online Canada drugs and other services and if health workers were well remunerated — we could cut under-5 mortality from malaria by more than half.
It is Order Hydrocodone Online Canada much the same story with maternal mortality. Obstructed labour and Order Hydrocodone Online Canada ruptured uterus, eclampsia and other forms of hypertensive disease in pregnancy, obstetric haemorrhage mostly postpartum, puerperal sepsis, and Order Hydrocodone Online Canada unsafe abortion are still the main causes of maternal mortality. However, in the Order Hydrocodone Online Canada presence of accessible basic health services, they disappear as in Sri Lanka where Order Hydrocodone Online Canada maternal mortality ratio dropped from 550 per 100,000 live births in 1950-55 to Order Hydrocodone Online Canada 80 per 100,000 live births in 1975-80, and 58 per 100,000 live births in 2005. This was achieved by introducing a Order Hydrocodone Online Canada system of health centres all over Sri Lanka, and making quality maternal care services available and Order Hydrocodone Online Canada accessible to all including in rural areas. In Sri Lanka, 94% (1993) of deliveries are assisted by a skilled attendant, compared to 42% (1999) in Nigeria, with one of the Order Hydrocodone Online Canada worst maternal mortality ratios in the world (1,100 per 100,000 live births). This has Order Hydrocodone Online Canada been replicated in Cuba, where in 1970, the maternal mortality ratio was 73 per 100,000 live births, and Order Hydrocodone Online Canada in 2000, it had more than halved to 33 per 100,000 live births. In 1999, skilled attendants assisted every (100%) delivery in Cuba, after maternity care services were made available and Order Hydrocodone Online Canada free including accessible referral centres for complications.
Hospital wards in many developing countries are Order Hydrocodone Online Canada a heartbreaking, pathetic sight. The most basic and common place of materials, things you Order Hydrocodone Online Canada would otherwise take for granted, the most routine of investigations are Order Hydrocodone Online Canada often procured at great cost, from private pharmacies and laboratories that Order Hydrocodone Online Canada have clustered around government run hospitals over the years owing to Order Hydrocodone Online Canada the ineptitude of the hospitals to run efficient services. Worse still, these hospitals stock the Order Hydrocodone Online Canada drugs and have those equipments, but the regular story is Order Hydrocodone Online Canada that the equipment stopped working after a few months, the Order Hydrocodone Online Canada model is outdated, there are no staff to man them because they are Order Hydrocodone Online Canada off moonlighting or do not work during call hours or Order Hydrocodone Online Canada take weekend shifts, or even the bureaucracy of getting to Order Hydrocodone Online Canada buy the drugs or get the investigations done in the Order Hydrocodone Online Canada hospital is enough to push them outside. No matter how bad a Order Hydrocodone Online Canada patient is, no matter the emergency, the family usually has Order Hydrocodone Online Canada to pay for services and procure materials for treatment at the Order Hydrocodone Online Canada point of service. Usually, there are no provisions for emergency. These patients are Order Hydrocodone Online Canada also seen by poorly motivated health workers, who themselves are Order Hydrocodone Online Canada poorly paid. The distance from access, the prohibitive costs of hospital treatment and Order Hydrocodone Online Canada admission keep patients away, all contribute heavily to low life expectancy.
In sharp contrast to Order Hydrocodone Online Canada this, some new structures are also sprouting in hospitals or Order Hydrocodone Online Canada around them. They are highly efficient units, dedicated to single disease programmes, often HIV/AIDS, provided and Order Hydrocodone Online Canada funded by external donors. An AIDS orphan who lives with siblings in squalor without access to Order Hydrocodone Online Canada insecticide treated nets and artemisinin based combination therapy for malaria, whose sister does not have Order Hydrocodone Online Canada access to specialised obstetric care in pregnancy, gets antiretrovirals for free at these units. Those with more rou¬tine diseases receive poor care and Order Hydrocodone Online Canada still have to pay. Hospital staff who are supposed to be Order Hydrocodone Online Canada at their duty posts seeing patients that they were trained and Order Hydrocodone Online Canada being paid salaries and allowances to see are often busy running those units, with extra remuneration often in hard currency, often surpassing their salaries, at great expense of the Order Hydrocodone Online Canada system. This is the newest brand of internal brain drain in sub-Saharan Africa.
Single disease priorities generally weaken health systems. Of all, spending on HIV research, treatment and Order Hydrocodone Online Canada prevention activities is the most notorious example of this prodigality. In 2006, although Zambia’s entire Ministry of Health budget was only $136m, the President’s Emergency Plan for Order Hydrocodone Online Canada AIDS Relief provided the country with an HIV targeted budget of $150m. This unbalanced distribution of health funding occurs across sub-Saharan Africa. Making HIV into a Order Hydrocodone Online Canada pivot, raising it to the status of the zeitgeist of the Order Hydrocodone Online Canada times has indeed skewed health priorities at both national – in many developing countries – and, most importantly at global levels. There is Order Hydrocodone Online Canada only so much we can achieve, with HIV at the Order Hydrocodone Online Canada centre of our planning and initiatives. We cannot move ahead while we ignore so much. What more evidence do we need, than Order Hydrocodone Online Canada that with all the spending on HIV, much too little is Order Hydrocodone Online Canada being achieved.
Healthcare and Order Hydrocodone Online Canada development are so interlinked that it would be grossly wrong to Order Hydrocodone Online Canada interpret data without due consideration for the whole picture and connections that Order Hydrocodone Online Canada are not immediately apparent. It is not enough to have epidemiological data, without the Order Hydrocodone Online Canada insight to interpret them and discern underlying trends. Poverty and the Order Hydrocodone Online Canada lack of basic social and health services is at the centre of what Order Hydrocodone Online Canada defines developing countries, and that is really where our attention should be Order Hydrocodone Online Canada focussed in trying to find solutions to problems in these countries; any thinking that Order Hydrocodone Online Canada as much as puts these as second to any other priority is Order Hydrocodone Online Canada ultimately bound to fail. Until these form the crux of both local and Order Hydrocodone Online Canada global public health interest and policy, much of our effort will only continue to Order Hydrocodone Online Canada result in the proverbial one step forward, two steps backward.
*This is the first in a series of posts from guest bloggers.
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Seye Abimbola is Order Hydrocodone Online Canada a medical doctor in Nigeria. This article is an abridged version of an Order Hydrocodone Online Canada article that will be published in the Spring edition of Perspectives on Global Issues Buy Clonazepam Online Pharmacy.
