Three Days in Badistan

Earlier this week I was with a team tasked by the UNDP with fact-finding in an IDP camp. To be honest, it was chaos. I led the team in, and after some confrontation with the camp leader we had to leave again. After regrouping and better observation of protocols, we were asked to come in and meet with the camp inhabitants. A short time later, just when we thought we were making some progress, it all kicked off. Armed men entered the camp and went straight for the camp leader. They were not happy that he was colluding with the enemy, us. I overheard them saying that they were being paid to protect the camp, that the UN was the enemy and not to be trusted.

The one in charge looked at those around him, pointing his gun at each one of us with menace, and then he singled out a young lad from the camp. Calmly and quietly, all the more frightening, he ordered his comrade to shoot him. A deafening bang and the kid was dead. I kept my head down, trying to blend into the shadows and started looking for an escape.

The killer then took hold of one of our team, a young woman, and was about to take her from us – one of the possible scenarios that we had discussed when doing our risk assessment. Back then we had debated whether we would fight back or stay quiet, and one of our colleagues had stated quite simply and clearly that she didn’t want to be taken off and raped. The expectation of support hung heavy in the air, but I continued to keep my head down, trying to blend into the shadows and looking for an escape… this was not going to end well.

Then the bastard in charge grabbed the camp leader and ordered him and a female doctor out of the camp. As we watched them disappear through the gates two shots rang out, followed by haunting screams. Then silence.

After some time we started to stir, and a few of us headed for the gates. There we found the two alive, but badly wounded. I went to help the doctor, brought her back over to one of the benches, and using my newly acquired first aid knowledge, I attended to the horrible gunshot wound on her left hand.

Now I was staring to feel good, feeling useful again. At last I was meeting a need and making some difference. Short-lived.

She looked deep into my eyes and asked me why I had come, why we had brought all this trouble on them. I said that we were here to help, but she said look at what has happened because you are here. We need food, water, medical supplies, and you brought none of these. You brought only your stupid questions. Why did you come, aren’t there those in need back at home that you should be helping instead of coming here, to something you don’t understand, don’t know anything about and cannot help with? I felt hollowed out, unable to look her in the eyes, conflicted, and confused.

A baptism of fire in Badistan – a role-play training camp in the woods a few miles SE of Gatwick. An experience that was at once safe and yet disturbing, thought-provoking. Do we belong here, do we have a legitimate purpose, a necessary role, can we help make any difference – or shouldn’t we just stay at home and look to help there! Great questions.

Badistan IDP camp, one of several training scenarios organised by the ILS team.

Posted in Aid and Development

Impact of Abortion in Kenya

In Kenya, in 2012, the African Population and Health Research Center (APHRC) completed a study to assess the incidence of induced abortion and its impact. There is an informative 2 page summary of the findings here and the full study here.

Abortion in Kenya is highly restricted and most women resort to seeking services outside of the formal healthcare system (backstreet).

APHRC reports that in 2012 there were 465,000 induced abortions in Kenya, equating to an age-standardised abortion rate of 48 per 1,000 women of reproductive age (WRA). That is almost three times higher than the same measure in England and Wales, which was reported by the Department of Health as 16.5 in the same year.

According to APHRC, during that year nearly 120,000 Kenyan women were treated in healthcare facilities for complications arising from these abortions, and some 75% of these adverse events were recorded as either moderate or severe. This shows a complication rate of more than one for every four abortions. This is staggeringly high, 175 times higher than the same measure in England and Wales, reported at just one in every 700.

This shows the very significant impact of unsafe, unregulated, abortion on women’s health and the resulting strain placed on an already overstretched healthcare system.

Of those 120,000 seeking post-abortion care (PAC), more than 70% were not using a regular method of family planning prior to becoming pregnant. The Demographic and Health Survey in Kenya (2008-2009) found that 43% of births in the preceding five years were reported by women as unwanted or mistimed, reflecting significant, and multiple, barriers to family planning access and use.

Uncovering and responding to each of these barriers is complex, but something that programme planners must continue to work hard to achieve. We need to find better ways to satisfy any unmet need, and indeed to improve understanding and stimulate increasing interest in the use of long acting methods. If we can help to reduce the numbers of unintended pregnancies, that in turn will lead to a reduction in the numbers of induced abortions and the resulting harm from these.

Increasing provision of comprehensive abortion care (CAC) – which includes counselling, provision of safe abortion services, follow-up care and provision of the family planning method of choice – will be a key factor in harm reduction.

Posted in Sexual Reproductive Health | Tagged , , , , , | 1 Comment

Reach and Cost-Effectiveness of the PrePex Device for Safe Male Circumcision in Uganda

PLOS ONE Journal 0063134This paper was published at PLOS ONE on May 22nd, 2013.

(access here, or by clicking image)



Modelling, supported by the USAID Health Policy Initiative and UNAIDS, performed in 2011, indicated that Uganda would need to perform 4.2 million medical male circumcisions (MMCs) to reach 80% prevalence. Since 2010 Uganda has completed 380,000 circumcisions, and has set a national target of 1 million for 2013.


To evaluate the relative reach and cost-effectiveness of PrePex compared to the current surgical SMC method and to determine the effect that this might have in helping to achieve the Uganda national SMC targets.


A cross-sectional descriptive cost-analysis study conducted at International Hospital Kampala over ten weeks from August to October 2012. Data collected during the performance of 625 circumcisions using PrePex was compared to data previously collected from 10,000 circumcisions using a surgical circumcision method at the same site. Ethical approval was obtained.


The moderate adverse events (AE) ratio when using the PrePex device was 2% and no severe adverse events were encountered, which is comparable to the surgical method, thus the AE rate has no effect on the reach or cost-effectiveness of PrePex. The unit cost to perform one circumcision using PrePex is $30.55, 35% ($7.90) higher than the current surgical method, but the PrePex method improves operator efficiency by 60%, meaning that a team can perform 24 completed circumcisions compared to 15 by the surgical method. The cost-effectiveness of PrePex, comparing the cost of performing circumcisions to the future cost savings of potentially averted HIV infections, is just 2% less than the current surgical method, at a device cost price of $20.


PrePex is a viable SMC tool for scale-up with unrivalled potential for superior reach, however national targets can only be met with effective demand creation and availability of trained human resource.

Posted in Safe Male Circumcision | Tagged , , , , , | 1 Comment

Article In Press

Our paper exploring the cost-effectiveness of PrePex for male circumcision has been accepted for publication and, once released, will be posted here.

I will not be adding any new posts until then.


Posted in Safe Male Circumcision | Tagged

We Do Not Want an HIV Vaccine

My recent post about the “Cheating” poster campaign in Uganda has had some comments here and on facebook. Earlier today I read the comments posted on line at The Monitor in reply to its piece on the same hotly debated issue.

Up front I want to say that I agree, such messaging does need to be tested and the issues it raises are complex and multifaceted.

HIV prevention is a matter about which people quickly form strong views, often influenced by personal faith, world views and perspectives on morality. President Museveni often states how he would prefer Ugandans to either Abstain or Be faithful, and that he is not in support of HIV prevention campaigns that are focused on the promotion of Condoms or male circumcision,(this e.g. in The Monitor from his end of year message).

The argument made is that such promotion leads to increased infidelity and even promiscuity. So if I encourage you to use condoms, that mere encouragement will cause you to have more sexual relationships. It is the same argument that I’ve heard against providing family planning education to teenagers, because that will then lead them to start having sex, which they wouldn’t do if we didn’t mention family planning.

I think that such arguments are somewhat flawed. I agree that society could be healthier if more of us remained faithful to our life-long partner(s). I admire those that do so and would wish for more, but the reality is very different. Can one prove that increased infidelity, or promiscuity, has resulted from HIV prevention and family planning campaigns? If we take such an argument to its logical conclusion then we would not want to see an HIV vaccine developed, and made widely and freely available, because that would certainly cause all those vaccinated to become promiscuous.

So how should we balance the need to prevent the rising tide of HIV infections, more than 560,000 new infections each year, against the possible causation effect of increased infidelity and promiscuity? Public health policies are meant to consider good for society as a whole; I’m not so sure that we should be overlaying these with our individual faith and world views, but rather we should remain objective and evidence-based. I could of course be wrong and I would really be interested in reading any research that you know of that discusses how such campaigns influence behaviour, for good or for bad.

Posted in HIV/AIDS | Tagged , , , ,

Inequality Affects Health and Society.

When you hear ‘inequality’, do you first think about the relative differences between the West and the Developing World, or do you think about the differences between those living in your own country, or even within your own community?

In this TED Talk, Richard Wilkinson presents some of his research data from The Spirit Level, in which he shows that health and social problems are worse in those countries in which income inequality is largest. This is interesting because we may have thought these problems were worse in those countries with lower national average incomes. The data seem to tell us something different.

This first chart shows an index of various measures of health and social wellbeing against income equality; there is a significant correlation.


Whereas when the same index is plotted against gross national average income there is no discernable pattern or relationship.


Of course correlation does not necessarily mean causation; though there is something relatively intuitive about this that tells us life is better in a more equal society.

Posted in Inequality | Tagged , ,

Cheating? Use a condom.

A new billboard campaign is stirring further controversy in the ABC/Condom debate in Uganda. The issue is well discussed in this post on PlusNews (IRIN).


We know that HIV rates are rising in Uganda and it seems that more than 40% of new infections are occurring among those in long-term relationships. Multiple concurrent relationships (cheating?) are common, and the consistent, correct use of condoms is poor (less than 25%).

Given these data I think it is right and proper that public health campaigns promote the use of condoms, testing for HIV and knowing your partner’s (partners’) status.

I’m not at all convinced that promoting such a message is encouraging immorality and will lead to more people becoming unfaithful or promiscuous, I think those that will, are already being so. I favour this realistic and pragmatic public service approach, whilst at the same time agreeing with the detractors that, yes it would be better if we lived our lives faithful to our partners.

So if you cannot be faithful and are going to cheat, then please use a condom; and if you think you are being cheated on, then get tested and ask your partner to do so too.

Posted in HIV/AIDS | Tagged , , , , | 7 Comments

MMC is Cost Effective in Prevention of HIV

  1. Medical Male Circumcision (MMC) is a more cost effective means of HIV prevention than Treatment as Prevention (TasP). It is important to focus on programme implementation and we shouldn’t ignore the need to promote condoms and positive behaviour; ensuring a comprehensive prevention package.
  2. Comparison of TasP, ART and MMC value for money as interventions, concludes 1st scale-up MMC then ART: @glassmanamanda.
  3. @gregggonsalves @glassmanamanda, I agree, implementation is key and we need to learn more about what works and how to repeat it.
  4. MMC is significantly cheaper than TasP in terms of cost per infections averted – $1,096 versus $6,790: @cgdev
  5. MMC tends to polarise opinion, especially on Twitter and similar. There are some who
    consider this an assault, especially in the case of infant circumcision. MMC
    campaigns in Africa tend to be focussed on adult men and the procedure is voluntary.
  6. @BAIntactivists heterosexual transmission of HIV sets different context in E&S Africa compared to Europe and its voluntary. @glassmanamanda
  7. MMC campaigns are recommended for those countries in which HIV prevalence is
    high, transmission is mainly through heterosexual intercourse and the prevalence
    of male circumcision is low. In these respects Eastern and Southern African countries
    are different from those in Europe.
  8. .@KevinDTweets If the money spent promoting MMC were spent promoting condoms & positive behavior, it would have made a difference.
  9. @BAIntactivists condoms would provide better protection than MMC except usage is only around 20%. I agree positive behaviour would be best.
  10. HIV transmission rates would be very much lower if people behaved differently, used condoms on a
    regular basis and reduced the number of sexual partners; but until then MMC is
    an excellent public health intervention offering proven, cost effective
    prevention of HIV transmission.
Posted in Safe Male Circumcision | Tagged ,

Literature Review: Medical Male Circumcision

wad-ribbon158This literature review follows the logical and steady progress over 20 years of studies and research that led, in 2007, to the WHO and UNAIDS recommending medical male circumcision (MMC) as an essential element of a comprehensive HIV prevention package. Academic and programme modelling over the following four years led to PEPFAR setting targets and determining the required financial support for 13 countries in eastern and southern Africa to scale-up male circumcision (MC) programmes to reach and then maintain an 80% MC prevalence. Data released on March 2012 show that these countries have not yet been able to reach the necessary scale-up volumes. The review concludes with the recent WHO announcement of an innovative non-surgical device method, PrePex, which could potentially have a significant effect on enabling these countries to reach these scale-up targets more quickly.

Posted in Safe Male Circumcision | Tagged ,

Primary Healthcare in East Africa.


In December 2011, Dr. Nick Wooding kindly asked me to write a Preface for this book published by International Health Sciences University which discusses the many aspects and issues related to the delivery of primary healthcare in the developing world, and in Uganda specifically.

The Kindle version is now available at Amazon and the Preface can be read here.

Posted in Primary Healthcare | Tagged