Tag Archives: West Africa

Ebola, polio, HIV: it’s dangerous to mix healthcare and foreign policy

A polio worker brings vaccine drops to children in Peshawar, Pakistan. Using health initiatives as a cover for foreign policy can create suspicion of aid workers. Photograph: Fayaz Aziz/Reuters

A polio worker brings vaccine drops to children in Peshawar, Pakistan. Using health initiatives as a cover for foreign policy can create suspicion of aid workers. Photograph: Fayaz Aziz/Reuters

There are reasons to be fearful of the Ebola crisis gripping parts of west Africa: death; the risk of contagion; overburdened health infrastructure; and concern as neighbouring countries worry about what the WHO now admits is an international health emergency.

These difficulties are exacerbated by the population’s fear not just of the virus itself, but also of the health workers there to help.

While this fear is primarily related to contagion, there are other, more deeply rooted factors at play. Mistrust of outsiders, particularly western health workers, is bound up in the history of Africa and colonial medicine. When much of the continent was under colonial rule, great powers used these outposts of their empires as laboratories, and Africans as their test subjects.

Much work has been done through the years to counter this negative legacy: decentralised health systems, collaborations with local partners, training for African health workers, and partnerships between government, civil society and international donors.

The Ebola outbreak underlines how quickly such progress can unravel in times of crisis, and how the legacy of past mistakes by western powers can resurface to speed up that unravelling, to the detriment of health and security locally and globally. Frequently, particularly in the developing world, past failures re-emerge, complicating efforts at crisis management.

In this context, recent revelations from Cuba – where it was revealed that the US Agency for International Development (USAid) had used HIV prevention work as a smokescreen for fomenting political opposition – should ignite a debate about the necessity of keeping the work of public health agencies, security services and foreign policy separate. Where they converge, trust is squandered. And, as we are witnessing in west Africa, mistrust in times of emergency hampers the necessary work and efforts of foreign aid workers hugely.

The so-called “securitisation” of healthcare is not new. The outbreak of HIV set a precedent as the first health issue to be recognised by the UN security council as an explicit threat to international security. While HIV was a genuine global crisis, there have been recent examples in which foreign policy objectives have been cloaked by apparently innocuous public health activities.

In Pakistan, CIA operatives masqueraded as polio vaccinators to gain greater access to Osama bin Laden’s compound. Though the charade fulfilled its security intent, it later resulted in very damaging reversals in local efforts to eradicate the disease. The motive was disguised and trust was spent. Ultimately, the populace – and healthcare workers – suffered.

The ability of western governments and agencies to act as emergency providers of healthcare, and as honest brokers, will be increasingly reduced unless we agree that the provision of healthcare should be sacrosanct and protected from motives best realised by other means.

The “blue water” between global health and international security continues to narrow, as the UK foreign and commonwealth office encroaches further on the Department for International Development. Meanwhile, the US state department continues to treat USAid as an extension of its operations. Health has traditionally been housed in the international development agencies of western governments. However, as with the role and function of aid and international development, global health is increasingly seen as a part of wider international security strategies for protecting populations from threats such as bioterrorism and infectious diseases such as drug-resistant tuberculosis.

Tactical security objectives – however “successful” – should remain separate from international efforts to improve and protect public health. The Ebola crisis has posed incredible difficulties for health workers in west Africa – imagine how difficult it would be to deal with an outbreak where trust was absent at the outset. We are drifting towards a dangerous convergence of health and security policy, one that makes populations less secure and crisis management immeasurably more difficult.

Story via The Guardian

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Big Increase In Repeat Pregnancy Rates In HIV-Positive Women In UK & Ireland

Rates of repeat pregnancies among HIV-positive women in the UK and Ireland have increased substantially since 1997, investigators report in the online edition of the Journal of Acquired Immune Deficiency Syndromes.

In 2009 over a third of all pregnancies involved women who had at least one other pregnancy. Younger age and geographic region of origin were associated with having a subsequent pregnancy.

“A substantial and increasing proportion of pregnancies in diagnosed HIV-infected women are occurring in those who have already received HIV-related care in one or more previous pregnancy,” comment the authors. “The main demographic characteristics independently associated with repeat pregnancies were younger age…and being born in Middle or Western Africa.”

A large proportion of HIV-positive women are of childbearing age. However, mother-to-child transmission can be prevented in most cases with appropriate antiretroviral treatment and care. This low risk of transmission combined with the excellent prognosis provided by modern antiretroviral treatment means that HIV-positive women in resource-rich countries can realistically consider childbearing.

In the UK and Ireland the number of pregnancies in HIV-positive women has increased significantly over the last decade. A significant proportion of these women have experienced at least one other pregnancy while receiving HIV care. Given their often complex medical, obstetric and social needs, the care of this group of women can be complex.

Despite this, little is currently known about the demographics and health status of HIV-positive women who experience repeat pregnancies.

Therefore investigators from the National Study of HIV in Pregnancy and Childhood examined 20 years of data obtained from pregnant HIV-positive women in the UK and Ireland. Data from 1990 and 2009 were included in the study.

The investigators’ aims were to characterise the pattern and rate of repeat pregnancies and to establish the demographic and clinical characteristics of HIV-positive women with two or more recorded pregnancies.

A total of 14096 pregnancies were recorded in HIV-positive women during the study period. Just over a quarter (2737; 26%) were repeat pregnancies. This figure included 2117 women who had two pregnancies, 475 with three pregnancies and 145 with four or more pregnancies.

Outcomes were recorded for 13,355 pregnancies. In all, 11,915 (89%) resulted in a live birth, 121 (1%) in a still birth and 10% in either miscarriage or termination.

Both the number and proportion of repeat pregnancies increased significantly. There were 158 recorded pregnancies in 1997, and 32 (20%) were repeat pregnancies. By 2009, the total number of pregnancies had increased to 1465, with 565 (37%) being repeat pregnancies.

Further analysis of the 2009 figures showed that 28% were second pregnancies, 7% were third and 3% were fourth or subsequent pregnancies.

“The increase in repeat pregnancies over the last two decades is likely to reflect a combination of factors including the accumulation of diagnosed HIV-infected women who have already had pregnancy,” suggest the investigators. “Major improvements in quality of life and AIDS-free survival of people living with HIV, and substantial reductions in the risk of mother-to-child-transmission are also likely to have had an impact.”

Overall, the rate of repeat pregnancies was 6.7 per 100 woman-years.

The median interval between first and second deliveries was 2.7 years, with an interval of 2.3 years between second and third deliveries, with the same interval between third and fourth deliveries.

Analysis of the factors associated with repeat pregnancy was restricted to women who received care after 2000. A total of 11,426 pregnancies in 8661 women were therefore included. Just over a quarter (26%) were repeat pregnancies.

The probability of a repeat pregnancy declined significantly with increasing age (p < 0.001).

Women born in central African countries and West Africa were more likely to experience sequential pregnancies than women born in other regions.

“This pattern is likely to reflect a complex range of cultural, behavioural and migratory factors such as fertility patterns in women’s countries of origin and the demographics of women who migrate from different regions,” write the researchers.

There was no robust evidence that either CD4 cell count or health were associated with repeat pregnancies.

“The number of diagnosed HIV-infected women in the UK and Ireland having more than one pregnancy has increased substantially and is likely to continue to grow,” conclude the authors.

They stress the importance of understanding the characteristics of these repeat pregnancies. “Variations in the probability of repeat pregnancies, according to demographic characteristics, are important considerations when planning the reproductive health services and HIV care for people living with HIV.”

Original Article via Michael Carter at NAM

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