POLITICS, ETIQUETTE AND THE FIGHT AGAINST HIV/AIDS IN KENYA: NEGOTIATING FOR
A COMMON FRONTBY
ZACHARY AROCHI KWENA
A PAPER TO BE PRESENTED
AT CODESRIA GENERAL ASSEMBLY
IN KAMPALA UGANDA
BETWEEN 8TH –12TH DECEMBER
2002Abstract
HIV/AIDS is the single most serious socio-economic and health affecting Kenya presently. The spread of the pandemic resulted from the failure of government to recognise it as a problem early enough and institute necessary measure to counter it. Today, there are efforts from various stakeholders to slow down the spread the pandemic. Some of these efforts have raised a lot of debates and controversies some of them taking political angle. This paper tries to assess the efforts and methods used in fight against HIV/AIDS in Kenya and the resultant debates and suggestions.
Introduction
HIV/AIDS is the single most serious problem that has been carried forward from the last millennium into this millennium. The pandemic has taken advantage of how people live their sexuality and puts a great caution to the number of sexual partners each person can have. It is apparent that having only one lifetime sexual partner is not necessarily possible or even desirable, but it is something everybody must take seriously in order to live in the current world bedevilled by HIV/AIDS.
HIV/AIDS pandemic is nowhere worse than Sub-Saharan Africa. Statistics show that out of the world’s 40 million people living with HIV/AIDS, 75% are from sub-Saharan Africa (Price, 2002). Last year alone, 2.2 million people died of AIDS in Sub-Saharan Africa and many more infected. Given these facts of HIV/AIDS in African in comparison to other continents such as Europe, North America and Asia, it is no longer tenable to claim that the disease ‘knows no boundary’. It is evidently visible that HIV/AIDS thrives well within certain socio-economic boundaries such as those found in Sub-Saharan Africa. Currently, of the 40 million people living with HIV/AIDS worldwide, about 730000 are receiving antiretroviral treatment. Out of this, over 500000 or 68% live in high-income countries of North America, Europe and Asia.
Similarly, of 2.2 million people who died of AIDS last year (2001) in Sub-Saharan Africa, only 30000 or less than 2% received treatment (Price, 2002). The lesson to learn from all these statistics is that HIV/AIDS is prevalent in poor economies that cannot raise money for prevention campaigns and those that can not manage to put AIDS patients on antiretroviral treatment. In this case, therefore, HIV/AIDS knows, and indeed, respects economic boundaries which in most cases coincide with political boundaries. In fact, over estimation of the number of people who had HIV/AIDS in Africa before the mid-1980s and the rapid spread of the virus in the region after that led many from the west to allege that HIV came from Africa (Schoepf, 1993). This baseless allegation was meant to not only revitalise racism and discrimination against Africans, but also cause heightened denial and delayed acknowledgement that HIV/AIDS is a global problem requiring global efforts to fight it.
Kenya, like other Sub-Saharan African Countries has inherited a huge junk of HIV/AIDS problem from last millennium. Sero-prevalence levels have risen from 2% in 1985 to well over 14% in the year 2000 (NASCOP, 2001). In fact, it is now estimated that one in every eight adults in Kenya is HIV positive and that at least 700 people die from AIDS or AIDS-related ailments everyday. At independence in 1963, Kenya pledged to fight three common enemies namely: poverty, ignorance and disease. In respect to this, Kenya rightly views good health for its citizens as the basis of socio-economic development. However, this expectation is threatened by high prevalence of HIV/AIDS that places heavy socio-economic burden in the country.
No disease or phenomenon, since 1960s, has had such a negative and devastating transformation on Kenya’s socio-economic landscape as has HIV/AIDS. The disease has nearly held economic development in the country at ransom and torn apart social structure and networks of the entire population. The pandemic has physically attacked and disabled people at their prime time of productivity and reproductivity (between 15-45 years). Although both urban and rural population is affected by the pandemic, the worst hit is the urban population (UNDP, 2001). This has, actually, meant low production due to absenteeism, high expenditure on settling medical bills and a budget set aside for prevention campaign (Hancock et al: 1996). In this regard, the pandemic is actually compounding the poor status of health in the country. Consequently, it is projected that the fight against HIV/AIDS will cost the country 5.5 billion in the next two years.[1]
Basically, the fight against HIV/AIDS in Kenya has gone through four broad phases. In the first phase between 1984-1987, the disease was not considered as a serious problem for the country and was described in the press and by policy makers simply as a ‘disease for westerners’. The attitude somehow changed when it became apparent that pandemic was affecting tourism, one of Kenya’s lead foreign exchange earning sector. For instance, in early 1987, the British army prohibited its soldiers from taking leave in Mombasa citing the threat of HIV among the commercial sex workers in the city. Following the HIV/AIDS scare, tourism drastically dropped as the tourists opted for other holiday destinations. This marked the beginning of the second phase between 1988-1991 where political leaders started giving AIDS a more realistic appraisal as a potentially harmful health issue. Even then the responsibility of managing the disease only remained with the Ministry of Health and as such, the public did not respond positively by changing their personal behaviour.
The third phase, 1992-1998, marked another significant change in Kenya’s policy in that for the first time data on HIV/AIDS was released and in April 1993 the first national conference on AIDS was held to deliberate on the problem. The Ministry of Health took the onus to declare that HIV/AIDS had become a national crisis. This, coupled with rising number of illnesses and death from AIDS across all population groups, provoked pressure from business, the media, NGOs and professional societies for clear policy directions from the government. The government was forced, in a number of its subsequent policy documents, for instance Development Plan 1994 - 1997 and in Sessional Paper No. 4 of 1997, to address the issue of HIV/AIDS in terms of its impact and setting out of general statements to guide the future action. However, this seemed to be public relations gimmick since no tangible efforts were visible on the ground. For instance, no backups accompanied the various proposals in the documents. The Ministry of Health’s budgetary allocation remained more or less the same.
The fourth phase (1999-2002), witnessed the president declare HIV/AIDS a national disaster and appeal officially to the international community, local organizations and individuals to assist in the fight against the disease. This created a stage for action from host of players that ranged from institutional research, NGO mitigations to individual efforts. Various initiatives, suggestions and approaches taken by these players in the fight of the pandemic have brought many issues for debate in terms of their effectiveness, legal, policy, ethical and human rights concerns. These debates have centred on a wide range of issues among them importation and use of condoms, introduction of sex education in formal schooling system, HIV test and confidentiality of the results, criminalizing the spread of HIV and efficacy certain drugs e.g. the Pearl Omega of Prof. Arthur Obel and Polyatomic Apheresis of Dr. Basil Wainwright.
In all these debates, the hand of politics has been quite conspicuous thereby greatly shaping people’s response to these issues. Political loadings of utterances on some of the interventions suggested have resulted into strong undercurrent of scepticism or downright opposition by the public without due consideration of the facts available. As such, the questions that this paper attempts to answer are: why did it take the government so long to recognize the perturbing existence of HIV/AIDS? What has characterised the fight against HIV/AIDS in Kenya? How have Kenyans reacted to various initiatives, approaches and suggestions on the fight against HIV/AIDS?
Recognition of Existence of HIV/AIDS in Kenya
The discovery of HIV virus by Prof.Luc Montagnier in early 1980s practically marked the beginning of the fight against the virus in some countries. The fight, in many instances, took the form of prevention of its spread and search for cure and/or vaccine. However, in other countries such as Kenya, the beginning of the fight against the pandemic delayed because HIV/AIDS had not been perceived as a problem in the first place and even if it were, they found reasons for not reacting to the problem as appropriate. It is fairly common knowledge that people only react in defence to a perceived threat. This justifies the kind of reaction Kenya, and many other Sub-Saharan African countries, exhibited towards the pandemic. It is only countries that recognized the existence and the potential impact of HIV/AIDS on their socio-economic structure that endeavoured to put in place programs, policies and legislation that aimed to contain its spread.
One possible reason why Kenya did not see HIV/AIDS pandemic as a serious problem was its adherence to WHO’s 1986 definition of AIDS for developing countries which underestimated the extent of the problem. The WHO’s definition was that for a person to be declared an AIDS patient, he/she must be diagnolised with at least two major signs and at least one minor sign of the disease and confirmed by exclusion criteria (Table 1). The WHO’s release of the HIV/AIDS definition was based on the fact that HIV test required a lot of funds that were not readily available in most developing countries and, as such, diagnosis of HIV/AIDS patients on the basis of symptoms/signs was the best option available.
Table 1: WHO’s 1986 definition of AIDS patients
|
Major signs |
Minor signs |
Exclusion criteria |
|
¨ Weight loss 10% ¨ Chronic diarrhoea for at least one month ¨ Fever for at least one month (intermitted or constant) |
¨ Cough for more than one month ¨ Generalised itching ¨ Recurrent herpes zoster ¨ Oro-phayngeal candidiasis ¨ Chronic progressive and disseminated herpes simplex infection ¨ Generalised lymphadenopathy |
¨ Cancer ¨ Severe malnutrition ¨ Other recognised causes |
Source: Fiala (1998)
The problem with this definition was that AIDS patients who were only diagnolised with one major sign and perhaps no minor sign were not counted as HIV/AIDS victims. This, consequently, gave a wrong low figure of the HIV/AIDS cases. The resultant erroneous low magnitude of the pandemic made the affected governments not to take the problem seriously. After what is described as ‘two lost decades’, Uganda redefined WHO’s definition to reflect a single-sign criteria such that a person showing one sign, for example, chronic diarrhoea for more than one month and the doctor is convinced it is AIDS was counted as a victim. This redefinition of AIDS enabled Uganda to get accurate statistics on the exact number of AIDS cases in the country useful for planning the campaign (Fiala, 1998). Tanzania also embraced the single-sign criteria adopted by Uganda. The two countries, as such, started their campaign against HIV/AIDS comparatively early. Both countries justified the single-sign criteria procedure on the basis that the WHO’s definition was too imprecise and that it had to be adapted to national circumstances. Kenya, on the other hand, made no efforts in adjusting WHO’s definition. This made the situation totally absurd that an infectious disease can give raise to different symptoms this side or that of an arbitrary political border.
WHO’s definition of HIV/AIDS notwithstanding, Kenya’s response to the pandemic was slow and unplanned (Rau et al., 1966). This initial lukewarm concern by the government resulted to rapid spread of HIV/AIDS. Many people today are left wondering why the government did not react promptly in an effort to contain the pandemic. A number of reasons, although hardly justifiable given the magnitude of the HIV/AIDS pandemic in the country, try to explain the government’s reaction. Sexuality in Kenyan culture, like in many other African cultures, is a hidden issue not openly talked about in public (Pool, 1997). HIV/AIDS as a disease is closely associated with sexuality that is a taboo to discuss in public. In Kenya, many things to do with sexuality were left to the affected individuals to discover for themselves. People who talk openly on matters of sexuality were seen as outcasts who lack respect. As such, the government was unable to find a socially acceptable manner in which to talk about HIV/AIDS to the public. The government, as result, reverted to silence hoping that the disease would not spread and would eventually disappear. However, this was an erroneous assumption since the disease neither stopped from spreading nor disappeared. Morbidity and mortality from HIV/AIDS forced the government and the public at large to start talking about the disease openly in various campaigns to check its spread.
When HIV/AIDS was identified in early 1980s, many societies especially those in developing countries thought the problem was far removed from them. In Kenya, HIV/AIDS was thought to be restricted to people with unusual characters such as those who practice homosexuality (gay and lesbians) and those who have close relationship with pets. These two groups, according to Kenyans’ mind were non-blacks. Since such risk groups presumably hardly existed in Kenya, it was assumed that HIV/AIDS would only spread within a small population. Even the press coverage of the issues of HIV/AIDS was always sensational and occupying a small space at the corner of a newspaper to the extent nobody took the disease seriously. The press did not come out clearly in sounding alarms and creating awareness of the pandemic among the public until much latter when the disease had grown out of proportion.
In the first decade of the pandemic, Kenya lacked strong political commitment in acknowledging the prevalence of HIV/AIDS fearing that this would cause panic among the public and potentially scare away tourists that country’s economy partly depend on. Unfortunately, even after the government kept quiet, the information about the prevalence of the disease reached some of tourist origins any way. To this effect, in early 1987, the British prohibited its soldiers from taking leave in Mombasa citing the threat of HIV among the commercial sex workers in the city (Rau et al., 1996). In quick response to the warning issued to would be tourists to Kenya, the Minister of Health at the time said:
“There is no scientific evidence that Mombasa and Malindi constitute a source of AIDS in Kenya…The Ministry of Health is satisfied that the known facts about AIDS in Kenya show that there is no need to panic. The foreign press is only out to distort the issue and create panic…” [2]
This reaction, as much as it was acting in best interest of Kenya’s economy, it was also doing exactly opposite in the long run. The truth of the matter was that the threat of the disease was real and spreading fast among the high-risk groups such as commercial sex workers and truck operators. Unfortunate thing is that after this kind of reaction from the government, people remained complacement and did not act to re-examine their risky behaviours. This explains why even after the government started taking deliberate steps such as creating National AIDS/STD Control Council and starting special programs to sensitise people on the pandemic, the spread still continued.
Politics of the fight against HIV/AIDS in Kenya
The use of condoms in preventing the spread of HIV/AIDS
The fight against HIV/AIDS in Kenya has been characterized with a lot of controversies on the methods used and approaches taken. Every method suggested has met heated debates from various quarters with hardly any compromise being reached. Sometimes what seems to be entirely on the prerogative of experts to comment on has been, in many instances, taken up by lay people thereby politicising the issue. The failure by the government to issue policy guidelines on the fight against HIV/AIDS early enough gave room for emergence of many suggestions and controversies.
There have been wide-ranging debates and controversies on the use of condom to fight the spread of HIV/AIDS. The main battle has been between Catholic Church together with some Muslim groups, on one hand, and the government on the other. The argument for Catholic Church has been that promoting use of condoms would encourage promiscuity among the youth. They, instead, advocate for creating awareness and understanding among the youth on the dangers of sexually transmitted diseases including HIV/AIDS and the need to abstain from sex. Although this method is morally good, it does not give an alternative to those who cannot abstain and want to have a chance to live. Hence, religious groups opposed to the use of condom have always been on the war path with politicians and other organizations and individuals who believe strongly that the use of condoms can help save lives that would, unnecessarily, be lost through AIDS.
During a-one-week symposium of Members of Parliament (MPs) at Continental Resort in Mombasa, MPs described the Catholic Church as being impediment in the fight against HIV/AIDS and other sexually transmitted diseases in Kenya. They noted that:
“The Catholic Church is undermining every effort being made by those fighting HIV and we want to know what the church stands to gain when millions of Kenyans are dying”.[3]
Arguably, those who advocate for the use of condoms and those that advocate for upholding moral standards and abstinence from sex are all fighting against HIV/AIDS but on different fronts. All they need is to harmonise their efforts focused on the common goal. President Moi himself has undergone impressive transition from advocating for the fight against HIV/AIDS from purely a moral perspective to a combination of morality and use of condoms. When the president started talking about HIV/AIDS openly in public, he was a strong believer in the school of thought of fighting HIV/AIDS from a moral standpoint by people abstaining from sex[4] Even at one point the president made a passionate appeal for Kenyans to abstain from sexual activities for at least two years to assist save their lives and money spend on importation of condoms[5]. However, in reaction to this appeal on one of the FM radio stations call-in-session, a caller described the president’s appeal as a joke because according to the caller if Kenyans abstained from sex for even a week, they will all go blind. These sentiments may be taken as a joke but they actually stand for what majority of Kenyans mean and believe. Therefore, the fight against the pandemic in Kenya need to move away from the use of one method approach to that that will actual use a composite of methods
President Moi as a head of state has been very keen on the spread of HIV/AIDS among the populace. This explains why he quickly changed his stand on how to fight the pandemic, as the situation got worse. He moved away from moral school of thought of fighting against the pandemic to the combination of use of condom and abstinence. The president came out strongly in support of use of condoms describing it as inevitable in fighting HIV/AIDS while officiating the 27th Graduation Ceremony of University of Nairobi. He argued that in today’s world, condom is a must to save the precious lives of young people being lost due to the pandemic. The president’s open support of the use of condoms led to the importation of 300 million condoms worth over Ksh.1.5 billion[6], act that was highly politicised. The argument was why import condoms worth that much when people were dying of hunger, hospitals had no drugs and the economy is at its knees. However, what the critics of the move failed to take note of was the fact that 700 Kenyans were dying every single day, 30000–40000 children are born HIV positive and that there were 1.1 million orphans resulting from HIV/AIDS[7]. This concomitant effects, obviously, is capable costing the economy more money that what was used to import condoms if they are used properly.
Many a times, the church has been strongly blamed for not doing enough in the fight against HIV/AIDS yet it is rightly argued that nobody or organization is in touch with the people like the church. It is only the church that has audience of the people at least once a week every week yet not much contribution seem to becoming from it. In the president’s address to the nation when he arrived from UN Summit on AIDS in New York, he accused the church for not doing enough to prevent their followers from the dangers of HIV/AIDS scourge. He demonstrated the church’s lax in tackling the pandemic by pointing out that although 80% of Kenyans are Christians, the spread of HIV/AIDS was continuing unabated. The president’s challenge to the church was that they should play their role by preaching abstinence and fighting to change people’s attitudes and beliefs. The church on its part accused the president of behaving like a proverbial man who pursued a rat from a burning house forgetting his immediate aim of salvaging his belongings. The urgent issue in the fight against HIV/AIDS in Kenya is for all stakeholders (government, church, NGOs and people) to work together to zero rate the spread of the pandemic before they start evaluating who did the most and who did the least.
It is not only the church that is opposed to and campaign against the use of condoms. Some anti-condom lobby groups dismiss the use of condoms, not on the morality grounds, but on the ground of their effectiveness in preventing HIV/AIDS infection. The lobby groups argue that HIV virus is smaller than the pores on the condoms and, therefore, there are high chances of HIV virus passing through the condom. But according to efficacy studies carried out by the Centre for Disease Control and Prevention (CDC) based in Atlanta, USA, condoms reduce the transmission of AIDS by about 85% (KEMRI, 2001). Condom, which is made of latex, if not damaged or degraded, is impermeable to HIV virus. The general prove is that if a condom cannot leak water, it cannot possibly allow the transmission of HIV virus unless damaged. In fact, the point made by the anti-condom lobby that condom pores are larger than the HIV virus is true. However, what is important to note is that the virus does not walk or fly across a condom but has to be carried in a fluid media (blood, vaginal secretions, semen etc) or a cellular medium such as blood cells. In this regard, therefore, the exchange of body fluids and not the virus size is the most important determinant of viral passage through latex
Use of condoms is, so far, the only known effective way of preventing the transmission of HIV virus. However, their use in Kenya like many other African countries is hampered by perceived discomfort, culture and superstitions people have towards them (Nasirumbi, 2000). There are people who find wearing a condom during sexual encounter uncomfortable to the extent that their pleasure is compromised. This explains why some people would wear a condom during the first sexual act and forget about it altogether in the subsequent acts. As mentioned earlier, sex in many African cultures is treated as taboo and an act that cannot be talked about in the open. As such, many people fear buying condoms across the counter where many people see them. Efforts aimed at finding a solution to this has seen the invention of a condom-dispensing machine where rather than a person buying condoms across the counter, he simply inserts appropriate coin in the machine and it dispenses condoms equivalent to the amount inserted[8]. The machines were supposed to be strategically placed near social places such as bars, nightclubs, discotheques, brothels etc and even in colleges. Unfortunately, this invention is yet to take root in Kenya.
There are also a number of superstitions concerning condoms. The popular one is that the condoms are treated with chemicals capable of making the users impotent or sterile. This claim is often illustrated by the fact that condoms are given free of charge in health institutions, local administration offices, quasi-brothels and in bars and other leisure joints. It is the nature Kenyans, to always become suspicious of items and services given free in an environment where almost everything is paid for in the name of cost sharing. For instance, people would not understand why they pay to get malaria treatment in a health centre and be given free condoms in the same institution. This, to them, looks ridiculous hence the room speculation.
HIV/AIDS medical research and efficacy of new drugs
Since the diagnosis of HIV virus, many research projects have been going on to search for a cure and/or vaccine, not only in Kenya, but through the world. A number of candidate drugs and vaccines have been tried since the first injection of an experimental HIV/AIDS vaccine in 1987 in United States, but none at all has been found to cure and/or immunize against HIV/AIDS. Some of the prominent drugs and/or vaccines that have been tried include:
¨ AZT drug therapy which reduces mother to baby transmission by about 51%
¨ Virodene PO58 described as a wonder drug
¨ Nevirapine that is an antiretroviral drug
¨ T20 that prevents HIV virus from getting into immune cells
¨ Kemron developed by Kenya Medical Research Institute (KEMRI)
¨ Pearl Omega developed by Prof. Arthur Obel
¨ Hydroxyurea (not new) used together with other anti-HIV drugs – cocktail is developed by Research Institute of Genetic and Human Therapy (RIGHT)
¨ Triple – drug cocktail of protease inhibition that sends HIV virus into a quiescent state in memory cells
¨ Cotrimoxazole – anti retroviral drug recommended for Africa by UNAIDS and World Health Organization (WHO)
¨ Polyatomic apheresis (Oxygen therapy) of Dr. Basil Wainwright.
At local level, Kenyan scientists, sometimes in collaboration with scientists from other countries, have been fully involved in research for HIV/AIDS cure and/or vaccine. Some of the drugs/vaccines have raised a lot of debate and controversies in terms of their efficacy. For instance, research on Kemron that had proved quite promising in its initial stages ended up failing in meeting efficacy test. A point worth noting about Kemron research is that the last stages of the research coincided with the time Kenyans were preparing to celebrate a decade of Nyayo Era. During the celebration, every sector was struggling to put something on the table to show the achievements of the era. Finally, a number of achievements were put on the table including Nyayo bus, Nyayo car, 8-4-4 system of education, Nyayo tea zones, and even the Kemron drug. However, eyebrows were raised by some scientists to the effect that the research on the drug was hurried through its final stages against the protocol guiding the research. Even if the drug would have failed efficacy requirements, the hurry to list it as among the achievements of a decade of Nyayo Era was ethically and procedurally wrong. Although the celebration organisers achieved their aim of using the drug to give political mileage to the Nyayo Era politicians especially as the country was preparing for general elections, the act was not friendly to the course of medical research, and more specifically HIV/AIDS research in the country.
Kenyan’s still remember well the debate and controversies that surrounded polyatomic apheresis that was developed and administered by Dr. Basil Wainwright. polyatomic apheresis treatment involved passing rays of atmospheric oxygen through the body of a patient. Dr. Wainwright claimed this could treat Cancer, HIV/AIDS and a host of other diseases. In a letter dated 30th of July 1996, Dr. Wainwright was cleared by the then Director of Medical Services Dr. James Mwanzia to conduct his research of Polyatomic apheresis on human beings. The letter in part read:
“It has been wonderful meeting with you and discussing early stages of what is likely to be a medical break through in Kenya and indeed East African region. The setting up of a polyatomic apheresis treatment centre in Nairobi is greatly appreciated by the government of Republic of Kenya. I would like to assure you of continued government support in assisting our fight against the many new, emerging and re-emerging diseases such as HIV/AIDS, Yellow fever etc...”[9]
Although the director had authorised Dr. Wainwright to set up a polyatomic apheresis treatment centre in Nairobi, Medical Practitioners and Dentists’ Board was totally opposed to the administration of polyatomic apheresis to patients. In search for support on their stand, the board had written to those in authority both at international and local levels. Following these efforts, United States Food and Drug Administration (FDA) wrote to the government of the Republic of Kenya cautioning it that polyatomic apheresis was not medically approved in the US (where Dr. Wainwright was before coming to Kenya) for treatment of HIV/AIDS and that Dr. Wainwright was a fugitive on probation violation. Consequently, about a year latter in 1997, Dr. Wainwright was banned from administering polyatomic apheresis any where in Kenya. In correspondence dated 24th September 1997, Dr. Mwanzia banned the administration of polyatomic apheresis noting that the government had information that Dr. Wainwright was a conman. In part the letter read:
“In view of the fact the unsuspecting public is being or is likely to be exploited. I have instructed the C.I.D. and Chief Drug Inspector to close down and seal all loopholes being used by Dr. Wainwright and take action on any criminal activities”.[10]
Dr. Wainwright saw hand of politics and corruption in the ban of his polyatomic treatment. He argued that it is the same Director of Medical Services who had allowed the administration of polyatomic apheresis who is now banning it hardly a year latter. This allegation is clearly depicted in his correspondence dated 22nd October 1997 seeking intervention of the then Chief Drugs Inspection, Mr. Juma in which he wrote:
“My family and I used to be great friends of Dr. Mwanzia and his family. Dr. Mwanzia’s very friendly stance changed negatively at exactly the same time when his business friend Paul Koinange ran into financial difficulties… If you feel, Mr. Juma, that you have a valid legal reason to close down any legal facility using this technology, then obviously you must instruct them accordingly …’’[11]
In the whole saga of polyatomic apheresis treatment, lack of clear government policy to guide medical research in HIV/AIDS and its enforcement is seen as an impediment in the fight against the pandemic. For instance, a decision of granting Dr. Wainwright permission to carry out research on human beings and stopping it within a year on the pretext that he is not a medical doctor and that he is a fugitive and, therefore, not be allowed to treat people is self-defeating. It is imagined that before clearing Dr. Wainwright to practice in Kenya, the authority ought to have sort to known his background. Again, the permission given to him was clear to the fact that he was not to start treating patients but to carry out his polyatomic apheresis research on human beings. To this effect, he must have had a protocol to guide the research, approved by Ethical Review Committee. Given this state of affairs, one then wonders how he jumped from research on human subjects to treating patients he was being banned from.
Pearl Omega invented by Prof. Arthur Obel is another HIV/AIDS candidate drug that took Kenyans by storm. Its ban met with a lot of criticisms from the public and some members of medical fraternity. According to Prof. Arthur Obel, since 1989 when he started administering the drug, more than 77000 patients have used the drug out of which 53000 were Kenyans[12]. Prof. Obel argued that since he started administering the drug on patients, many have deconverted to HIV negative and nobody was injured or killed by the drug. In indirect support of these facts, the then Assistant Minister of Health Basil Criticos noted that the government did not dispute the drug’s efficacy since no death had been reported. In addition, it is also aware of patients who were wasted but after having been on pearl omega, regained weight. The Pharmacy and Poisons Board went ahead and banned the manufacture and administration of the drug arguing that:
“Prof. Obel’s behaviour has been unorthodox and against all protocol and etiquette in a field where the rules are clear cut and heterodox procedure is not expected of researchers.”[13]
One of the unorthodox behaviours upon which Prof. Obel was dismissed was discussing his medical findings in newspapers instead of academic journals and conferences both locally and internationally where his claims could thoroughly be vetted by experts. To crown this, he refused completely to disclose Pearl Omega’s formula and its beneficiaries as required by the government
In what seemed to be the support of government’s stand on the ban of Pearl Omega, Kenya AIDS Society went to court to seek injunction to stop Prof. Obel from manufacturing, distributing and administering the drug. The society claimed that the drug was ineffective and that Prof. Obel was out to con HIV/AIDS sufferers. However, the court in its wisdom ruled that the society had no prima facie in the case and, therefore, the case was dismissed with costs[14]. Prof. Obel had a strong believe that the government was out to frustrate his efforts observing that:
“This is a intrigue at its pinnacle which is part and parcel of the power game to those who are initiated. The system has given me the opportunity to work as an industrialist in outside country”[15]
According to Prof. Obel, it was the end that was important and not the means. For the simple reason that the drug was in some instances effective, it is argued that the government would have looked for an alternative method to establish its formula and trace its beneficiaries rather than banning it altogether. The then Vice-chairman of Pharmaceutical Society of Kenya, Mt. Kenya branch Dr. Edward Kamamia and a leading psychiatrist Dr. David Ndetei came out strongly to criticise the way the government had handle the Pearl Omega issue. They argued that the manner in which the drug was banned was unprocedural and unscientific and was likely to ruin Kenya’s possibility of ever discovering a cure for the dreaded disease[16]. They accused the government of politicising the Pearl Omega issue observing that it was unethical for a doctor to disclose the identity of his or her patients as the government demanded. HIV/AIDS patients also protested the ban of the drug. They argued that the drug was their only hope and gave an analogy of a drowning man who tries to hold on everything in an effort to save his life and in the process he gets saved.
Although Prof. Obel was full aware of the statutory requirement under the Pharmacy and Poison’s Act that the contents and formula of drug is known before it is registered for use, he feared for his patent and intellectual rights being hijacked. This made him dismiss both the act and research protocol arguing that what was the standard approach to carrying out research yesterday may be totally obsolete today. Issues of protecting patent and intellectual rights that Prof. Obel held on so dearly has, in the recent past, been of great concern in HIV/AIDS research in Kenya. The best example for this is the on-going collaborative HIV/AIDS vaccine trials on commercial sex worker in Majengo between researchers from Oxford University, United Kingdom (UK) and University of Nairobi. Kenyan researchers on the team had been, technically, excluded from the list of beneficiaries of the proceeds of the research results. The researchers had to stand firm to be included on the list of beneficiaries with the conclusion that all the three partners would share equally research proceeds[17].
Although Prof. Obel was full aware of the statutory requirement under the Pharmacy and Poison’s Act that the contents and formula of drug is known before it is registered for use, he feared for his patent and intellectual rights being hijacked. This made him dismiss both the act and research protocol arguing that what was the standard approach to carrying out research yesterday may be totally obsolete today. Issues of protecting patent and intellectual rights that Prof. Obel held on so dearly has, in the recent past, been of great concern in HIV/AIDS research in Kenya. The best example for this is the on-going collaborative HIV/AIDS vaccine trials on commercial sex worker in Majengo between researchers from Oxford University, United Kingdom (UK) and University of Nairobi. Kenyan researchers on the team had been, technically, excluded from the list of beneficiaries of the proceeds of the research results. The researchers had to stand firm to be included on the list of beneficiaries with the conclusion that all the three partners would share equally research proceeds[17].
After debates, accusations and counter accusation about Pearl Omega certain issues remain obscure. Among these issues is why the drug was allowed on the market for quite sometime yet it was never registered under the Pharmacy and Poisons Act, which demand that the content of the drug is known before register. Prof. Obel in this regard, defied all laid down rules in medical research with impurity yet the government allowed the sale of an unregistered drug for many years. By the time Prof. Obel invented the drug, he was designated as chief government scientist (although the post was never gazetted) drawing his salary from the exchequer[18]. As such, it is not clear whether the KShs. 2 billion estimated to have been collected from sale of the drug went to the Exchequer or to Prof. Obel sine he was an employee of the government.
Antiretroviral drugs
Politics of antiretroviral (ARV) drugs is concern of many people in developing countries. Since their discovery in mid 1990s, antiretroviral drugs have proved highly effective at combating the voracious growth of HIV within the human body (Kuadey, 2001). The drugs are specifically important in controlling opportunistic diseases that come as a result of breakdown in the body’s immune system and reducing mother-to-child transmission. When HIV virus is not checked with medication (ARVs), it replicates with a fury, producing 10 billion copies each day. Even though ARV drugs are important in preventing virus replication, accessing these drugs, which are mainly in the custody of the large pharmaceutical companies such as Glaxo Wellcome, Boehringer Ingelheim is a big problem in terms of price to the poor majority. For instance, the cost of AZT treatment for mother and baby is about $1000. This is way beyond the purse strings of developing countries with health budgets of less than $10 per capita. As a result, multinational pharmaceutical corporations have been dandling these drugs to developing countries with a set of conditions such as having exclusive rights of supplying affected country with all or majority of its drugs requirement.
In Kenya, there have been debates on how to make generic antiretroviral drugs accessible to AIDS patients. Efforts contrary to achieving this end has greatly been criticised by the public. For instance, the then Minister for Health Prof. Sam Ongeri was widely criticised by the public and the then Chairman of Parliamentary Select Committee on Housing and Health Dr. Newton Kulundu for refusing free HIV/AIDS drugs offered by Boehringer Ingelheim of Germany. The Minister explained the circumstances behind his refusal of the drugs on the basis of exclusivity rights with which the drugs were attached. He consequently warned that politicians should stop politicising the issue of AIDS drugs noting that the government is ready to receive free drugs offer free from conditions[19]. The minister argued that if he accepts the drugs with conditions of exclusivity, he might be stranded when another company offers drugs because his hands would be tied.
The country’s commitment of availing its citizens with cheap generics of antiretroviral drugs was demonstrated when parliament passed Industrial Property Bill into Act amidst lobbying and canvassing against the bill. Unfortunately, the end result was an act without an essential clause allowing importation and/or local manufacture of cheap antiretroviral drugs[20], which had been mysteriously removed. The interesting thing is that shortly after the enactment, an anonymous MP emerged with miscellaneous amendment to the act not knowing the clause he wanted to amend had mysteriously disappeared from the act. The amendment was to effectively bar Kenyans from importing cheap antiretroviral generics except by express permission from the original patent holder[21]. However, it is common knowledge that no patent holder would willingly allow another person to import mimics of his drug that is cheaper. At the same time, Article 31 of the World Trade Organisation (agreement on trade related intellectual property rights) allows a country on declaring a national state of emergency to produce cheaper generic versions of any drug (Kuadey, 2001). This agreement, therefore, allows Kenya to produce cheaper drugs to treat its citizens. According to Dr. Kulundu, the aim of the anonymous MP was to corruptly give a certain manufacturing company the right to manufacture antiretroviral drugs and, therefore, did not want cheap generic drugs on the market. Actually, this is crime against humanity given this is happen at the time when an average of about 700 Kenyans are dying from AIDS and AIDS-related illness every day.
Introduction of family life education in schools
A proposal to introduce family life education in schools by the government contained in Sessional Paper No. 4 of 1997 met with resistance from a number of church organizations. The most outstanding opposing force came from the Catholic Church. The argument of the church was that the government was using that as a pretext of promoting the use of contraceptives such as condoms among the youth. The church, up to today, is adamant against the use of condoms claiming that they enhance promiscuity among the youth. After constant negotiations with other stakeholders, the church accepted to reconsider its decision and, therefore, allow introduction of family life education in schooling system on condition that they are not used as a pretext of promoting the use of contraceptives.
The government in collaboration with the World Bank and UNICEF has finally been able to launch the program and integrate it into school curriculum. The program aims at teaching the youth about HIV/AIDS and STDs prevention and control. This initiative resulted from the concern about the high numbers of adolescent youths that were contracting HIV/AIDS and STDs[22]. Apart from teaching the youths in classroom, they will also be exposed to films, poems and drama with messages on safe sex, control of contracting HIV/AIDS and other STDs.
Ethical and legal issues in the fight against HIV/AIDS
As has been the reaction to any epidemic, reaction to the outbreak of HIV/AIDS has been, in most cases, highly emotional. On panic, governments and organizations have instituted measures that are affront to human rights and the law (Rachier, 1996). Some responses have tended to disrespect confidentiality requirements and acted as a leeway for discrimination in employment and educational institutions. Kenya’s reaction to HIV/AIDS pandemic has tended to be greatly influenced by emotions rather than decisive steps to fight the pandemic. President Moi has, on at least two occasions, directed that deliberately infecting others with HIV virus be made a criminal offence. The first instance was in his speech declaring HIV/AIDS a national disaster and the second when he arrived from UN summit on HIV/AIDS in New York. The most conspicuous was, however, his public address on arrival from UN summit on HIV/AIDS in New York, where he directed that people who infect others with the virus should be hanged and rapists jailed for life. He argued that:
“We (Kenyans) have to make laws that restrict those who deliberately infect others because young girls cannot protect themselves from such criminals”[23].
The president was supported over his stand by among others Council of Imams and Preachers of Kenya (CIPK) and federation of Women Lawyers (FIDA), Kenyan Chapter. While it is necessary to pass down tough sentences to those who deliberately infect others HIV virus, such decisions need to be made with sober minds and not based on emotions. Such directives that are in contravention of the constitution are likely, in the long run, not to be implemented. The scale at which the pandemic has reached in the country can no longer accommodate time wasting on things that are not practical.
According to medical practitioners, the principle of doctor-to-patient confidentiality has been their biggest dilemma. In this regard, there have been a lot of debates on the issue of doctors disclosing the nature of illness of their patients to relatives or people who are likely to be affected. Some doctors have strongly advocated for the repeal of the legal and ethical guidelines prohibiting them from revealing their patients HIV/AIDS status[24]. For instance, Dr. Rosemary Okeyo who was then Kisumu Medical Officer of Health, in an area worst hit by HIV/AIDS pandemic, constantly advocated for relaxation of legal and ethical guidelines prohibiting them from revealing nature of illness of their patients. The argument has been that once the section is repealed, doctors are free to disclose to people who are likely to be affected by the HIV status of their patients. They believe that once this is achieved the malicious spread of the virus would significantly be reduced. Even the chairman of National AIDS Control Council (NACC) is on record of saying that one of the major frustrations they face as a council in tackling the HIV/AIDS pandemic over the years is legal constraints in respect to doctor-to-patient confidentiality[25].
A task force on legal issues relating to HIV/AIDS formed by Attorney General and chaired by Ambrose Rachier came up with a solid report that was to be eventually turned into a bill and enacted by parliament. Among the things the task force recommended were:
¨ Outlawing of mandatory HIV testing before employment, being given an insurance cover/mortgages or being granted refugee status
¨ Establishment of Employment Equity Tribunal and Trust Fund to cater for the interests of people infected with HIV/AIDS.
The general argument was that most of the people seeking employment are youths between the ages of 15-45 and unfortunately, they are the same ones most affected by HIV/AIDS pandemic. Discriminating them raises stigmatisation and the feeling of unworthilessness in society. In addition, they require access to antiretroviral drugs and need public trustee to intervene in cases of inheritance by or for orphans. The task force in its report argues that if these issues are not addressed can instigate further spread of the disease hence creating a sort of vicious circle.
Traditional and spiritual claim for cure of HIV/AIDS
Apart from efforts to get HIV/AIDS cure and/or vaccine from modern medicine, there have been allegations of cure from traditional medicine and spiritual power. By their nature, these claims have been abstract with no scientific backup. In Kenya, many claims of HIV/AIDS cure have been announced by herbalist but the most widely known is that made by Dr. S.K. Maingi. He claimed to have completed research on the drug he calls Blue Computer Drug (BCD) that is able to treat among other diseases HIV/AIDS, cancer and diabetes. Patients take the drug for only one week and they are cured[26]. Similarly, there have been claims of HIV/AIDS cure by spiritual power across the country. The most publicised in Kenya is the open air healing mass at the Holy Ghost Catholic Cathedral in Mombasa. Many people claimed to have been cured by prayers from Sr. Brioge McKenna, a Catholic nun believed to have powers to cure AIDS patients[27].
Claims such as these are not unique to Kenya alone but are found across Africa. For instance, Nigeria has quite a number of these claims including those made by people like Dr. Paul Amanya and Prophet Temitope Balogun Joshua (Udo and Aimiemwona, 2000). Dr. Paul Amanya who claims to be a holder of Ph.D. degrees in traditional Chinese medicine and pharmacology from Shanghai College of Traditional Chinese Medicine and Pharmacology claims to cure HIV/AIDS by his drug Kasa boom boom. He strongly believes that the jinx about AIDS has been broken except in the minds of those benefiting from huge grants for phoney researches. This is the same case with Prophet Temitope Balogun Joshua of the Synagogue Church of All Nations, Ikotun-Egbe who claims to cure HIV/AIDS patients by word of prayer. A known fact about HIV/AIDS pandemic is that many people across the world and more so in Africa are suffering. As a result, they are ready to spend any amount of to improve their health and as such quack medical practitioners and those who pose as so want to capitalise on this scenario to exploit the public. This explains the reasons why there are individuals and even institutions coming up with unfounded claims of certain concoctions being able to cure the disease.
HIV/AIDS as a national disaster
It took Republic of Kenya government 15 years to recognize the devastating impact of HIV/AIDS and consequently declare it a national disaster. President Moi declared HIV/AIDS a national disaster on 25th of November 1999 during a national symposium for members of parliament in Mombasa. While addressing MPs, the president noted that HIV/AIDS is not just a serious threat to social and economic development but it is a real threat to the very existence of people of Kenya and, therefore, every effort must be made to bring the problem under control[28]. To effectively tackle the disaster, a number of measures were, in fact, ordered to be taken. The measures ordered to be taken include:
¨ The immediate setting up of National AIDS Control Council to coordinate the fight against the pandemic
¨ Prepare children for the threat of HIV/AIDS and special lessons to begin in schools and colleges
¨ Set up constituency AIDS committees chaired by respective MPs to coordinate the fight against the pandemic at constituency/divisional level
¨ Chiefs and Assistant Chiefs to form committees of elders to produce solutions to cultural practices and beliefs that help the spread of the disease
¨ The age of consent marriage and maturity be harmonised to 18 years to protect young girls from infection by the older men
¨ Making illegal for any one to make any public announcements of HIV/AIDS cure or treatment without formal authority of the National AIDS Control Council
¨ National AIDS Control Council to regulate all biomedical research involving human subjects
¨ Making it a crime for anyone to deliberately or knowingly infect another person with HIV virus
¨ Making it mandatory for all health workers to inform family members of HIV/AIDS diagnosis and record the same in the death certificate.
Despite the declaration of HIV/AIDS as a national disaster and outlining a number of measures and programs to be implemented, tangible results are yet to be felt on the ground. The process of implementation of the measures is too slow, badly managed and in some instances non-existent altogether. Although the president recognised the vital role of MPs in turning around attitudes and mobilising people to play their role more vigorously in preventing the spread of HIV/AIDS as heads of constituency AIDS committees[29], their actual action on the ground has been more of seeking political supremacy than coordinating the fight against the pandemic. This has resulted to constituency AIDS committees formed to tackle the pandemic at constituency/divisional level being poorly managed to the extent that there have been calls for their disbandment. For instance, local council leaders from Machakos District and District Officers and social workers from Kisumu District have, separately, argued that constituency AIDS committees have been rendered useless because MPs were using them for their own political mileage and not to fight the pandemic. The local leaders claimed that the MPs appoint their stooges to the committees instead of more competent individuals at the expense of the noble work of the committees of coordinating the fight against the pandemic[30][31].
Although antiretroviral drugs are important in the fight against HIV/AIDS in the way of reducing mother-to-child transmission and prolonging patients lives, the casual manner in which the government handled the process of making them available at reasonable price is worrying not only to HIV/AIDS patients but to all Kenyans. This, to a larger extent, gives validity to claims by the chairman of Parliamentary Select Committee on Health, Housing, Labour and Social Welfare Dr. Newton Kulundu that the government was dragging its feet on the issue of antiretroviral drugs to allow a few favoured individuals to invest in the sector while 700 Kenyans die every day[32]. The amount of time the government has taken to operationalise the Industrial Property Act that was supposed to have a clause on the importation and/or manufacture of cheap generics of antiretroviral drugs is too long in tackling a disease that has been declared a national disaster. The act was enacted on 29th of May 2001 only to wait until 31st December 2001 to get presidential assent and to further wait until 1st April 2002 to be effective with mysteriously missing a clause on importation and/or manufacture of cheap generics of antiretroviral drugs. The Kenya constitution stipulates that in times of emergency, people shall be allowed to ignore rules in the process of resolving the crisis or disaster (Rachier, 1996).
Even with the legal permission to import and/or manufacture cheap generics of antiretroviral drugs, the staff and equipment of National Drug Quality Control Laboratory is ill-equipped to be able to test the efficacy of antiretroviral drugs to be imported and/or manufactured so that the concerned companies do not fill the market with placebos of the drugs. According to the National Drug Quality Control Laboratory Board chairman Prof. Gilbert Kokwaro, Kenya has no capacity to test AIDS drugs. The incapacity results from the fact that there are no chemical reagents to test the efficacy and toxicity levels of the antiretroviral drugs, which would be brought into the country when Industrial Property Act is fully implemented[33]. The problem is squarely due to budgetary constraints because out of the total amount they request from the Ministry of Health to purchase chemical reagents and other equipment, they only receive about 32%. As a result, they have a huge backlog of untested ordinary drugs in the store and this situation is likely to be compounded further by the requirement to test antiretroviral drugs. This shows that although there are measures and programs to suppress the spread of HIV/AIDS, such measures and program only exists in government documents but there is hardly anything on the ground. The implementation of the measures and programs is not supposed to be left to the government alone but for all stakeholders. This is definitely not the time to apportion blames or pursuing an escaping rat from a burning house but to act collectively on a common front.
Conclusion
The cases and rate of HIV/AIDS infection in Kenya are very high. The high cases of the pandemic resulted from the governments delay in instituting decisive measures to control its spread when the first case was identified in 1984. Until 1999 when the government declared HIV/AIDS a national disaster, there had been no clear policy guidelines on how to tackle the pandemic. This meant disjointed efforts by various stakeholders in the fight against the pandemic. The efforts to the form of education and creating awareness, advocacy for the use of condoms, HIV/AIDS medical research, criminalizing deliberate spread of HIV/AIDS and introduction of family life education in schools. Some the efforts, procedures and suggestions have raised a lot of debates and controversies from a wide spectrum of people about their effectiveness and etiquette. What is important nonetheless is to agree on a common front to pursue a common enemy-HIV/AIDS.
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