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Thursday, November 21, 2013

Hepatitis and HIV ... a preliminary exploration


Hepatitis and HIV

The worlds of HIV and viral Hepatitis are similar, but different.

In Australia, HIV largely impacts gay men. Viral hepatitis, on the other hand, disproportionately and largely impacts Aboriginal and Torres Strait Islander people, people who are imprisoned, ethnicised communities where hepatitis B is endemic in countries of origin, and young people.

In other words, the people who are impacted by viral hepatitis in Australia are, on aggregate, less politically enfranchised than the single group most affected by HIV, gay men.

Another way of framing this, in an Australian context, is that viral hepatitis largely impacts on poor people and disenfranchised people.




More comparisons

Why, on aggregate, are the communities who are affected by HIV so different from those affected by hepatitis?

In Australia, HIV is largely transmitted through unprotected anal intercourse between casual partners of unknown status. At the same time HIV was identified about a half a decade sooner than hepatitis C (which was once known as “non-A, non-B” hepatitis).

Also, there is a “neatness” to HIV and the way it is understood which is not so true for hepatitis.

For example, you either have HIV or you don’t. You are either HIV positive or you are HIV negative. If you have it, you will not clear it, either on your own or with treatment. There is no vaccine.

On the other hand, there are 5 known types of viral hepatitis, known as hep A, hep B, hep C, hep D, and hep E. Each of them has different window periods, differing forms of transmission, different courses of treatment, and different possibilities for clearance as well as reinfection. Some of them can be vaccinated against (hep A & B, which can impact also on D), and others you cannot (hep C and E).

Further examples: Hepatitis B is easily cleared by most people (95%) if it is contracted when you are an adult. However, if you got it when you were a child from your mother, you are more likely to have it for the rest of your life (chronic hep B). Hep B is treatable with antiviral medication, but, like HIV, you have to take the medication for the rest of your life.

Hep C, on the other hand, has a lower rate of clearance when contracted as an adult. Unlike hep B or HIV, treatment for hep C can effectively cure you of the virus (i.e. you can become hep C negative after having been hep C positive). Still, you can also get it again.



In terms of transmission, hep B in Australia is largely transmitted from mother-to-child during childbirth, and is sexually transmissible as well from having penetrative sex (vaginal/anal) without a condom, and is also moderately transmissible through unprotected oral sex. Hep C, on the other hand, is not classified as sexually transmissible unless there is direct blood-to-blood contact in the context of sex play. The highest rates of transmission of hep C in Australia is through sharing injecting equipment.



There is so much more to learn.



While HIV theoretically has two forms (HIV-1 and HIV-2), worldwide when one says “HIV”, we are most likely to refer to HIV-1, because HIV-2 is mostly isolated to West African regions.

Yet: All the various viruses that are collectively known as viral hepatitis are also quite different from one another in their structure. For example, hep B is DNA, whereas hep C is RNA.

Hepatitis viruses are also found in diverse prevalence around the world. For example, hep A, which is transmitted through oral contact with contaminated fecal matter, is primarily found in countries with low standards of food hygiene. It is quickly cleared by most people (i.e. there is no chronic hep A), and once cleared, offers immunity, and thus tends to occur more sporadically and epidemically (ubiquitously in a time-limited way) in populations.

One the other hand, hep B is more likely to be found endemically (ubiquitously and indefinitely) in certain countries. At the same time, unlike hep C, both hep A and hep B can be vaccinated against, which means that they are largely preventable without having to engage in any significant behavioural change. Indeed, in Australia, at this point children born in Australia are vaccinated against both hep A and hep B. This means that hep A has been largely eradicated in Australia (given that it has been vaccinated against and is quickly cleared without treatment, even when contracted), while hep B will be largely seen in communities that trace themselves to hep-B endemic migrant communities (e.g. the two largest groups with hep B in Victoria are Chinese and Vietnamese communities).

As there is no vaccine for hep C, and it is blood-to-blood transmitted, we largely see it in significant proportion among people who inject drugs who share injecting equipment, plus a significant minority of people who get hep C from contaminated tattoo equipment (e.g. home-done tattoos with poor infection control).


Prevention
Whereas the introduction of needle and syringe programs (NSPs) in Australia led to rapidly lower rates of HIV among people who inject drugs, the same outcome has unfortunately not been true for hep C. The reasons are complex. They are related to how the use of NSPs were encouraged, and the sorts of health promotion messages that were encouraged.

“Don’t share fits” (i.e. don’t share needles) is a fantastic message for preventing the transmission of HIV through injecting drug use. However, this does not work quite as well for preventing hep C transmission. My understanding of this includes that HIV does not live very long outside of the body compared to hep C. In other words, if there was a bit of HIV-infected blood left on the tourniquet or the communal water used to rinse needles, etc., this would be less likely to lead to seroconversion. However, if there was a bit of hep C-infected blood left on the tourniquet or the communal water used to rinse needles, etc., this would be enough to lead to the spread of hep C among people who inject drugs, even if the needles themselves were not being shared.

Health promotion and hep C prevention messages, therefore, had to expand to become about not sharing any injecting equipment whatsoever, thus moving away from a focus on needles and needle-stick injuries, and into more information about standard infection control procedures for all people who might come into contact with any blood of this nature.




Strategy

In a sense, the coalition of workers around HIV makes a particular sort of strategic sense; in Australia, the AIDS Councils have evolved over time to include many aspects of broader gay men’s health. The NSW-based one (the AIDS Council of NSW), where I used to work, has evolved in its brief to include a broader commitment to the health of all gay, lesbian, bisexual and transgender people, who have a visible enough commonality to one another (in our non-normative diversity of gender and sexual practice/expression) that this coalition makes a particular type of political sense.

However, it is more difficult to see what this means in doing hepatitis work.

Because of the huge differences culturally between communities who are impacted by hepatitis, it seems difficult to imagine what sort of coalitionary practice would make the most sort of strategic sense in moving forward in this field. Viral hepatitis seems infinitely more intellectually challenging and politically fraught when compared to HIV.

It is striking that, by numbers alone, hepatitis impacts on 9 times more people than HIV, and is the cause of the fastest preventable form of cancer in Australia (liver cancer).



In considering the relative political strength and resource-density of HIV work in Australia that I have been involved in (at the AIDS Council of NSW), I want to propose a number of strategic decisions and political commitments that we could make in the field of hepatitis that might be of similar weighty import. I admit that my bias, given my professional background in health promotion, is in the social justice aspects of health. I believe any work in health promotion is necessarily incomplete without a proper consideration of the many broad justice issues which impact on access to testing, prevention, and treatment of disease.

There are a few positions I believe are worth exploring, therefore…

Just as in HIV, we know that people who are living with viral hepatitis experience stigma around their experience. People with HIV have historically borne the brunt of stigma for being too sexually promiscuous, or for homosexual deviance. Similarly, people with hepatitis (C, especially) are stigmatised for their association with injecting drug use.



We need to speak out against the pathologisation of all drug use.
We need to be more mindful about the ways in which skin penetration is associated with a particular intensity of illegality.

i.e. We need to support the decriminalization of ALL drugs, with a strong evidence base to indicate how this will lead not only to better health outcomes for people who currently use drugs (who will be less afraid to seek support), but may well actually reduce the frequency of drug use (just as the decriminalization of homosexuality is highly correlated, internationally, with the proper controlling and managing the rates of HIV seroconversion).



We need to speak out against the injustice that is the existence of colonially-brought prisons on Aboriginal land, which have led to the disproportionate incarceration of Aboriginal people in this country, and the introduction of this institution which is an independent risk factor for the spread of disease. Correlated issues include speaking out about Aboriginal deaths in custody from correctional neglect and abuse, the privatization of prisons which turns the detention of racialised people into a product for profit, and the strategic targeting of prison guard unions to educate on the evidence for introducing NSPs into prisons all across Australia as a way to minimize the spread of all blood-borne viruses within prisons.



Furthering this, it is important for us to become more cognizant and participatory in all immigrant justice work, including looking into the exploitative conditions that students and skilled migrants are brought into Australia, who may well become entrenched in systems which rely on employer-driven visas (like 457 visas) for international recruitment, driving down wages in Australia, impacting on Australian employment conditions, subjecting these visa holders to an overattribution of blame for these diminishing conditions, as well as problematic routes (or lack thereof) to permanent residency status, thus compromising on the health of all Australians due to the relative lack of health entitlements of these workers.

Another form of immigrant justice would be to take a less paternalistic stance on the health of culturally diverse communities, particularly the highly racialised communities who bear the disproportionate brunt of hepatitis B in Australia (Asians, Arabs and Africans). This is not about “blaming” Anglo-Australians nor our existing health system for the failure to address this inequity (for indeed, many communities with hep B have had hep B prior to contact with Australia), but rather about imagining what sort of country we want to be and to be serious about the accountability for the health and wellbeing of all human beings who find ourselves present on this land.

This means increasing our commitment to overt anti-racist work, and, from a bureaucrat’s perspective, the support of community-driven responses to health inequity, health literacy and political empowerment.



On aggregate, we also see that viral hepatitis, compared to HIV, affects people who are on the lower socioeconomic end of the population. As a determinant of health then, we must also speak out about the widening gap between the rich and the poor in this country, which is, in itself, a sort of spiritual tax on the “liver” of society, the seat of vitality and strength. By disenfranchising a relatively larger and larger number of people within our society, we are complicit in maintaining the economic conditions which propel people to risky behaviours. There is evidence to show that it is not only poverty alleviation, but the narrowing of the wealth-poverty gap within societies, which is highly correlated with better health outcomes for ALL people across the board, both the rich AND the poor.


Thursday, November 14, 2013

on Atheist Fundamentalism

Here's why atheist fundamentalism is problematic.

1. It is potentially colonising of Aboriginal spirituality (at the very least through a blanket denial about the legitimacy of uniquely Aboriginal ways of apprehending or sacralising phenomena)

2. It is rooted in its own improvable metaphysical and ontological faith-claims
(e.g. that all of reality is encapsulated by and reducible to the material sphere and the rationally cognizable)...

3. Denying teleology requires a teleological presupposition that the capacity to make this very denial is a superior proposition than its less sophisticated predecessors

4. What is not fully apprehended cannot either be properly denied.

Wednesday, November 13, 2013

in Defence of Inaccessibility

Of course I have been inoculated with the aspiration of egalitarianism, equal access to opportunity, social relationships, a healthy and happy sexuality, and so on.

Then also there is its shadow virtue... that of Inaccessibility 

Also known pejoratively as elitism
or perhaps more "sacrally", as esotericism



And So What?

There are the implications of such an assumption that the intentionally inaccessible is/can be elitist... The implications being that we assume many other things about elitism too. A web of words and fantasies of ways of doing or being with regard to the world that evoke often negative impressions, negative feelings.

The implications of the latter assumption that the intentionally inaccessible is/can be estoeric... This connotes more of a sense of mystery or wonder about what is kept inaccessible... There may be a vigour in the pursuit of this inaccessible thing, a fetishistic pursuit of inaccessibility itself, where the chase is as much a part of the goal as the goal is in itself.

And so this is the point, for me... That the inaccessible may actually potentiate a state of rebellious possibility... a sort of "larrikinism" where the mere suggestion at the inaccessibility of a thing motivates an indignant chase, a letting go of the bliss of ignorance into a state of desirousness, passion, Truth-seeking.

When I stumble upon some roots of a Truth,
I can sometimes see how it can manifest itself in the simplest of forms...:
The calm satisfaction of a broth of perfectly brewed noodle soup, brimming with warm silky nutrition
The unselfconscious sigh of a lover you know you have been deeply pleasing with your touch
The breath of fresh blue sky breeze and the smell of the Eucalypt trees that leave soothing trails in the insides of my forehead...

The ways that Truth can be so simple,
yet sometimes also simplified, diluted, diminished
through a person's refusal to linger upon the encounter in contemplation, digestion, rumination

The ways I know in myself, when I have been too eager to explain the value of a thing or a thought, the value of an insight or imagining... When I have been to quick to interpret what I have not long taken the time to get to know...


And So What?

The Mystery implicit in any Truth itself, or any encounter with Truth hereafter...
The Mystery that suggests that language is the first colonist... In the beginning was the "word" and the whole Mystery of the world became "settled" by homeless wanderers, the first differentiated and self-identified splices of consciousness... Wandering here and there, carving boundaries upon the face of sublime chaos, of perfect pure potential, and then Naming it. Turning it/them/ourselves into things, utilities, clothes and pots and pans and silk and sex toys.

The Mystery that sees a tree and imagines wood,
that builds houses and then, just as quickly, razes them,
that sifts the sand from the ash,
 calls the former debris, and the latter our ancestors,

The Mystery that elucidates and encloses and enlightens and destroys
The Mystery that carves out pieces of reality which come in various degrees of accessibility to any given person in any given moment
and yet refuses to ever allow itself to be "Known" in any linguistic sense of the Known...

In one of my Sanskrit classes when I was studying at the University of Sydney, we learned from my Professor Andrew McGarrity that there is some evidence to suggest that words like
"Knowledge" (English)
"Gnosis" (Greek)
"Jnana" (Sanskrit)
evolve from a similar ancestral root... We can tell their common ancestry by their similarity of meanings in their respective languages to one another, and also in their commonality of an awkward combination of consonant sounds (K-Nowledge ... G-Nosis ... J-N-[y]ana)

started to take on different meanings as they differentiated themselves from the root possibility of the "knowing" of something, the apprehension of a thing.

In English, for example, to have "Knowledge" of something means to have information about it, often acquired through some material source such as a direct physical encounter, or a conversation with another person.

In the English language use of the term "Gnosis", however, we seem to inherit it from its use in a more Christian and religious sense of the term, to refer to insight (seeing from within), or a knowledge which may have come from contemplation, rumination, perhaps interaction with a non-material Being, such as, in Christianity, God, or in Buddhism perhaps, resting in a calm Knowing which is its own Subject. The Sanskrit term "Jnana" might mean similarly, and is commonly paired with other words which would denote certain facets of spiritual knowing, usually based on direct empirical evidence... a "6th sensual" knowing.

Relatedly, the negation of the Gnosis and the negation of Jnana take on similar meanings...
To be Gnostic and practice Gnosticism may be to be especially inclusive of contemplative or meditative practice as a way of "knowing" phenomena
To be Agnostic and practice Agnosticism may be to be less inclusive of cotemplative of meditative practice as a way of "knowing" phenomena... In English, of course, the term agnostic would suggest an ambivalence about the truth claims of a practices and worldviews that may be generated or inspired by states of contemplative expression, such as improvable concepts like "God" or "Buddhanature" for which I am sure there would be many other linguistic equivalents in various world religions...

This would be true also of a term like "Ajnana", suggesting agnosticism, often with connotations of being in a state of ignorance. Linguistically, then, Jnana would be normatively more of an aspirational form of knowing, rather than a way in which you and I would normally have knowledge about the world.

And what way is that?

The way which co-evolved with how we pronounced the word...
The loss of the double-consonant sound... The loss of the "K-N" in "know", and its correlative connotative simplification...

We simply "noe" something like we "know" something.


And So What?

All of this analysis is, of course, biased by the fact that this interpretation is the result of my own limited encounters with speakers and fluent writers of these languages aside from English. Without having primary sources upon which I can base my analysis as above, all of this is just speculation.

By confessing my being "just speculative", I have confessed my reverence for the possibility of "inaccessible" knowledge. I have consented to a worldview which agrees that there is a hierarchy of "ways of knowing" and "things worth knowing", and that my current understandings and methodologies will necessarily always remain somewhat disconnected from the phenomena I am attempting to describe.

Yet, without the possibility of this Mystery, for me, I might not even have begun this challenge of Seeking Truth, of being a Truth-Seeker.

Seeking Truth gives me vitality and strength. It challenges me to accountability and honesty, and it keeps me accountable and honest.
Avoiding Truth mires me in habit and fearfulness, or in addictions and cowardice, and it keeps me unaccountable and dishonest.

I am a Human Being.
My understanding of a Human truth, perhaps one of the universal truths that cross human cultures, is that we all have the innate orientation to both Seek Truth and to Avoid Truth.
To Seek Truth, some of us study, contemplate, converse, travel, make love
To Avoid Truth, some of us study, contemplate, converse, travel, make love.


And So What?

There are no answers until there are questions. There are no questions until there is uncertainty. There is no uncertainty unless there is forgetfulness. There is no forgetfulness unless... I have forgotten where I was going with this.

Sunday, November 3, 2013

Cranberries

I have been listening to the Cranberries again a lot recently. In particular, their first album:

"Everybody Else is Doing It, So Why Can't We?"

Bringing back memories of being in my air conditioned room, aged 13, playing computer games and feeling very special indeed. The super-saturated intense world of child Me, colours more intense, the will to wander great indeed.

7 of Pentacles

7 of Pentacles
Alert and contemplating the fruits of my labour
of what has sprouted and bloomed
and what other seeds I have sown that may soon take root

I wait and imagine the sky, ready to receive more inquiry and wonder
and Awe

I allow myself the grandeur of pride
in my work well done
my garden well made
my home ready, waiting for me to arrive
each day

There is work yet to be done, this is sure ready,
but in the meantime I look forward
to working on my harvest

Asylum

as in... Madness
that spurs move, forced and chosen dislocation, exile
both "self-"imposed as well as
from gargantuan Other;
Tyrant so sick
He permanently burrows himself into all further generations'
responsibilities for Healing.

Oh... young people. Young people who are people who are
all Youth and perspicacity
chaotic sharpness, incendiary and relentless
or else; all too easily defeated
reposed in bed, without glory nor the Will to it

Asylum, as in
sought, chosen
as in, Madness
as in some midnight sky of dangerous noises
inspiring departure

I feel pain, and know asylum
I sought refuge and now see asylum
I speak because I choose to reclaim all metaphor
from the co-optation of government
rendering other humans as the parts of ourselves
that we are unwilling to face