This article appears in the November 2002 edition of the Catholic Medical Quarterly
Kenya: A Country of Graves
AIDS has affected a great number of Sub-Saharan
African Children - 70% of those living with HIV/AIDS
are between 15 and 24 years
Twenty-one years ago, the first case of AIDS was reported. Since that time, AIDS has become the most devastating disease humankind has ever faced. The World Health Organization has estimated that, since the epidemic began, more than 60 million people have been infected with the virus. Of those infections, 80% have occurred in Africa, and 90% of these infections have occurred in Sub Saharan countries. HIV/AIDS is now the leading cause of death in Sub-Saharan Africa. World-wide, it is the fourth biggest killer.
About 70% of those currently living with HIV/AIDS are aged 15-24 years. Over 90% of the infected do not know they carry the virus. There lies the powder keg. Many millions more know nothing or too little about HIV to protect themselves and others against it.
The Epicentre of the Pandemic
In Sub-Saharan Africa, the epicentre of the pandemic, AIDS killed over three million people in 2001. The estimated four million new HIV infections in this region in 2001 mean that 40 million Africans now live with the virus. This translates into 1,000 infections daily or about 42 infections in one hour in Africa. In parts of Southern and Eastern Africa HIV prevalence rates have risen to alarming levels. In Swaziland HIV prevalence among pregnant women attending antenatal clinics in 2000 ranged from 32.2% in urban areas to 34.5% in rural areas. In Botswana, the corresponding figures were 43.9% and 35.5%. In South Africa s Kwa Zulu-Natal provinces, the figure stood at 36.2% in 2000.
In five West African countries - Burkina Paso, Cameroon, Cote d�Ivore, Nigeria, and Togo - all with relatively low HIV infection previously, national adult prevalence rates had risen to the 18% mark in the year 2001. This comparatively low prevalence may indicate a developing pandemic.
The true picture of this pandemic in Africa is still unknown. The figures available are estimates. Lack of the necessary infrastructure in terms of transportation, health facilities, trained data collectors and processors prevent deeper knowledge and understanding of the pandemic. These figures could be only the tip of the iceberg.
In 1984, the first case of this dreadful disease was identified in Kenya. A spirit of gloom now hovers over the entire country. AIDS has wrought untold sadness, sorrow, suffering, and devastation to our people. We have witnessed the infection of babies in the womb, at birth, during breast-feeding, of adolescents, parents, and even the elderly.
The young between 15 and 49 years are most infected. These are children in secondary schools, colleges, early employment, the informal sector, farming communities, and entering professions. These are the energetic, idealistic, and economically active group of our people. These are lives cut down at their most vulnerable prime.
We see them helplessly getting infected day in day out by this killer disease, walking lethargically, emaciated, and sick, supported on walking sticks by their 70 and 80 year old grandparents.
The social implications of this disease are frightening. The workforce is sick and dying. The already collapsed health sector has over 70% of all the available hospital beds occupied by people with AIDS-related diseases, leaving barely any other resources for the prevention and care of the myriad of ever present tropical diseases like malaria, typhoid, and intestinal worms. Diseases like tuberculosis, previously controlled, have now re-emerged with a vengeance. This tuberculosis is multiple drug resistant and has started killing in ever-increasing numbers, even those not infected with AIDS. There is increasing poverty as household incomes deteriorate. Life expectancy that had taken generations and hard work to rise to about 60 years has ruthlessly been reduced to a mere 46 years and still declining. Grandparents have to care for their orphaned grandchildren. AIDS is a disease that has affected every Kenyan, even those not infected.
The Current State of the Pandemic
The last National Population Census was performed in 1999. Then, our population was 28 million. The official estimates for those with HIV are three million currently. The more realistic figure is about four million infected with this doomsday virus.
Over 800 Kenyans die daily of AIDS. Since 1984, over 1.75 million of our people have already died. Last year alone over 260,000 were killed by AIDS. This year, we expect to lose over 300.000 people.
These are not just nameless, faceless statistics. They are human beings, people s children, mothers, fathers and brothers and sisters. They are the soul of the nation. The number of AIDS orphans currently roaming the poverty scarred Kenyan landscape is currently estimated at 1.5 million. These are children who will need care, shelter, education, guidance, love, affection, and upbringing but who are growing up without parental presence.
Many of them already roam the streets, scavenging from garbage bins for food. They have no shelter from the ravages of the unpredictable tropical habitat. There is no social system to take them in. Already, children 8-10 years old head many families. Child abuse and exploitation are rampant.
Though HIV can be transmitted in a number of ways, in Kenya, three transmission mechanisms are most important - heterosexual contact, mother-to-child transmission, and blood transfusion.
Heterosexual contact accounts for 80-90% of all transmissions in Kenya. HIV is thus mainly a venereal disease. The presence in either partner of other venereal diseases increases the risk of infection. Venereal diseases have a general prevalence rate among sexually active individuals of 55-60%. These include syphilis, herpes, genital warts, and thrush. All of these diseases cause genital ulceration, which facilitates HIV transmission.
Sex does not happen to people. It is not one of those calamities that strike communities because of poverty. To have or not to have sex is a decision people make. It is a choice.
About 1.2 million babies are born in Kenya yearly. Currently it is estimated that 25% of all mothers are HIV positive. About 300,000 babies are born to infected mothers annually. Assuming a 40% transmission rate, 120.000 infants are infected annually during pregnancy, delivery and breast-feeding.
Transfusion with infected blood is 100% effective as a method of transmission. Blood screening is still deficient for lack of equipment. With endemic anaemia due to malaria and malnutrition, pregnant mothers often need transfusions and are in real danger during childbirth. One shudders at the thought of being a victim in the daily ritual of road traffic accidents.
The national prevalence of HIV infection is currently estimated at 18% for rural areas and 22% for urban areas. There are some urban areas currently with prevalence rates of up to 40%. If this trend continues, rural prevalence will hit the 20% mark and urban 25% by the year 2005.
The number of those infected will then be over five million at the current rate of about 900 infections daily: 34 infections every hour in Kenya. The cumulative number of AIDS deaths will have increased from 1.8 million today to 3.5 million by 2005.
Without AIDS, the annual deaths in young adults, 15 to 45 years, would currently be 40,000 and rising to 46,000 by 2005. AIDS has dramatically increased that number to 300,000 currently and 360,000 by 2005.
HIV/AIDS affects all aspects of social and economic life in Kenya. People are the greatest re source of any nation. Already 1.75 million Kenyans are dead. Four million are infected and wait to die.
Over 800 die daily. In essence, over three million people will be reduced from the population in the next five years. What this means is that the impact of AIDS on population growth will be astounding.
Impact on Health Care
Doctors and nurses and other trained staff in healthcare are infected, sick, and dying from AIDS. The national health sector collapsed nearly two decades ago. What remains of the system is completely overwhelmed by the people seeking care due to AIDS.
70% of the available hospital beds are occupied by AIDS patients: waiting lists stretch to infinity. The majority of AIDS patients can t get admission to a hospital and are dying at home without care.
The cost of AIDS care is prohibitive. Families are selling all their assets including furniture to fund medicines and funerals. This is leaving whole families destitute even when only one member is infected. The other traditional medical problems are still with us and are now worse because of weakened citizens both physically and economically. Malaria, typhoid, pneumonia, intestinal parasites, and diarrhoea diseases, normally preventable and curable, are now major killers, because national and family resources are directed to AIDS-related problems.
HIV/AIDS and Tuberculosis
Tuberculosis was fairly well controlled in Kenya until the advent of AIDS. The TB, now so rampant in the country, is multiple drugs resistant. It is killing even those not infected by AIDS.
TB is transmissible by casual contact. The crammed slums in our cities, overcrowded transport system with poor ventilation, and lack of functioning health facilities, especially for the poor, is a recipe for disaster for the whole population.
In the absence of HIV, the number of new TB infections would be limited to about 1% of the population. This would result in 20,000-30,000 new TB cases each year. For the last 3 years, 180,000-200,000 new cases of TB have been seen. 90% of all the patients admitted to the National Infectious Disease Hospital for the last three years had both AIDS and TB.
The Economic Impact of AIDS
AIDS has severely impacted Kenya s economy. It has reduced the size and experience of the labour force, increased health care expenditures, raised the cost of labour, and reduced savings and investment. AIDS is different from other diseases because it strikes the productive age bracket and is essentially 100% fatal. The economic effect of AIDS is first felt by individuals and their families, and then ripples outwards to firms and businesses.
The economic impact is larger in some sectors like health care, the insurance industry, and the security forces. HIV/AIDS rates are very high among the security sector. These are young men, sexually active, and away from their families for long periods. Other sectors with a mobile workforce, including transportation, extension service, and banking, are severely affected.
When someone in the family is sick with AIDS, it is usually the women who care for that person. Young girls drop out of school to help their mother with the other children. The family then exhausts its savings paying for drugs. The sick person then dies, and they sell the land, if they have any, to pay for the funeral. Boys then drop out of school. The net result is that families become destitute, children�s educations suffer, and the convergence of all these factors activates the vicious cycle of poverty, child prostitution, more HIV infection, and AIDS.
Impact of AIDS on Factories and Business
The economic impact on factories and businesses is manifested by reduced labour productivity through AIDS-related deaths, absenteeism and loss of skilled and manual work force. Other effects include increased expenditures on staff recruitment and training, funeral expenses and medical costs.
According to projections of a World Bank Strategy Report in 1996, an average company in Kenya spends the equivalent of 45,000 US dollars on AIDS-related employee problems. This is close to 18% of the total company profits.
This year, the GDP is 15% lower than it would be without AIDS, while per capita income has dropped by 13%. There has been an 18% drop in savings.
Why the Pandemic Marches On
For the last 18 years that this disease has gradually devastated our people, a number of omissions and commissions have accelerated its spread. A fatal mistake was committed by our government, which misjudged the seriousness of this pandemic from the beginning. Policy formulation was delayed due to a misconstrued notion that denying the obvious was going somehow to protect the tourism industry. As the policy makers were prevaricating, useful time was irresponsibly wasted.
The medical profession refused to take the initiative and provide leadership in aspects of HIV/AIDS control that fell in their docket. The time-tested principles of communicable disease control were not applied at the beginning and are still not currently being applied. Despite irrefutable knowledge of the main transmission method, there was no routine testing of those at risk. Even when this was done and results known, contact tracing was not done. Neither the patients nor their spouses or others directly affected were given the results. The uninfected spouse is not informed of the infection of a partner, thus exposing them to the killer disease.
Despite the known causal association between HIV and promiscuity, the national media, be it print, radio, videos, TV, and films have irresponsibly promoted fornication and adultery. The media have not taken their social responsibility role seriously. They ridicule decency, modesty, and purity as backward. It is a very sad state of affairs.
From the beginning of the pandemic, erroneous assumptions were made that people cannot have sexual self-control and that they cannot change. For this reason, there were neither local nor international resources allocated to teaching morality and upright behaviour. The message saturating the media is that young people cannot abstain, that they are sexually active anyway, and that they will continue to be so.
HIV/AIDS has been commercialized at the expense of the lives of people. Foreign governments, through a network of NGOs, are allowed to make massive profits from sale of condoms. In 2001 alone, more than 150 million condoms were used in Kenya. In the same period, there was a 33% rise in the prevalence of HIV infection.
Poverty: A Major Catalyst
Poverty is a major catalyst in the spread of AIDS. Kenya suffers from endemic corruption, nepotism, bribery, economic mismanagement, and often outright theft of public coffers that has reduced our people to near beggars. Poverty has generated child prostitution, exposing them to infection with HIV.
The Way Forward
Though there is no cure or vaccine for this scourge of AIDS, much can and should be done for those infected. Patients should be cared for compassionately and spiritually prepared as the final days near.
The greatest hope lies in prevention. The path to tread is simply that of chastity for the unmarried and marital fidelity. This is not negotiable.
Perinatal transmission should be avoided. Antiretroviral drugs should be made available during pregnancy. Prenatal, intrapartum, and post-natal care for the babies should be designed to stop further spread. The ultimate goal must be to stop conception in the first place in those infected. They must be abstinent to protect others.
Blood transfusion must be avoided unless mandatory. Blood should always be fully screened. Screening should be affordable.
HIV testing should be encouraged. Children going to secondary school and university should be tested. All employees and those entering the security services should be tested yearly. Promotion should only be given to those HIV negative and meritorious. This may shock some of you but desperate situations demand desperate measures. To save a nation sometimes calls for drastic measures. Those marrying must be tested.
A vigorous campaign should be designed to debunk the myth of safe sex.
People must clearly be informed that condoms will not protect them from HIV. Condoms do not work as contraceptives for which they were created and will not work against AIDS.
Condoms are also promoted in Kenya as barriers against STDs. This is despite the countless STDs condoms cannot prevent. These include HPV, which causes genital warts and cancer of the cervix. This is a deadly cancer, very common in Kenya, especially among poor, malnourished, and disadvantaged women. Screening for this cancer is not practical because the health sector has been moribund for a long time.
Other STDs condoms cannot prevent include Chlamydia, which causes sterility, Hepatitis B and C which cause pain and liver cancer, Herpes genitalis, Chancroid, and syphilis. Most of these diseases are incurable: the consequences on those treatable are permanent. Condom users are not aware of these facts; those who distribute them dishonestly withhold this information.
Since condoms neither prevent HIV or STDs, those who promote them do so to make blood money as they sacrifice helpless uninformed Kenyans. How do you make informed decisions and informed choice without information?
When leaders pass the message that it is all right to be immoral as long as you use a condom, promiscuity increases and AIDS spreads. Asking Kenyans to use condoms is tantamount to sentencing them to death. But even if condoms were 100% protective, their use would still be illicit and below the dignity of the human person created in the image of God.
Teach Self Control
The teaching of self-control, marital fidelity, self-respect, and respect for others, purity of body and soul is not only necessary because there are many incurable diseases out there but also because it is the right, just, and moral path to tread.
The Kenyan government has demonstrated unbelievable irresponsibility. It has allowed itself to be coerced into subsidizing promiscuity. By giving free condoms to those who have chosen to be irresponsible, it is condoning the habit.
Children are dying in Kenya due to lack of simple cheap medicines. These children are forced to pay for life saving anti-malarial, pneumonia and diar rhoea drugs. Most of them die for lack of a few cents.
Women bleed to death in their huts during child birth because they have no money to pay for services, while the government uses the little taxpayers money available to give free sex to those who have chosen to be irresponsible. Sexual self-control, like all virtues, must be painstakingly taught through instruction and example. The government, under pressure from international donors and groups, has refused to promote chastity and fidelity to save the future.
In summary, we have here a young country in a drama of despair and death: a country where parents and their children are weary of unending funerals: a country where every home has one or more graves. An otherwise beautiful country is now in sadness and sorrow and moaning and death, all because of HIV/AIDS. This is my country. Kenya, a country of graves.
Dr Stephan Karanja, former secretary of the Kenyan Medical Association, is an obstetrician in Kenya.
Reprinted with kind permission from the Population Research Institute Review, Vol.12, No. 1, pp 1,4,5, 7& 10.