Friday, June 26, 2009

Health Related Political Footballs

It seems like a short time since the issue of mass male circumcision (MMC) became a political football and it is not even the latest issue to have that status any more. But articles about it still appear every now and again and there seem to be a handful of genuine projects aiming to roll out MMC in some countries.

The Integrated Regional Information Networks (IRIN) has a recent article on the subject and lists the countries that have made some progress towards rolling out MMC. I notice Kenya is not on the list and not much progress seems to have been made in the eight countries in the list. Most sub Saharan African countries suffer from a lack of capacity and this seems unlikely to change in the near future.

On the one hand, a country could approach HIV as if it was just one disease of many and build up their overall health services. But most donor funding goes towards a handful of diseases, the main one being HIV. Very little funding, if any, goes towards building up health services in general.

Alternatively, countries could extend the capacity of existing health services to accommodate some kind of MMC programme. The latter approach might be like the attempt to test people for HIV (in the form of voluntary counselling and testing clinics) and the attempt to distribute treatment to as many infected people as possible. But after many years and extraordinary amounts of money being spent on these areas, these efforts have had limited success.

It’s important to note also that there are still many questions about the benefits of MMC and precious little discussion about the downsides. This is worrying and gives the impression that MMC is being promoted without taking into account the welfare of the people who will be involved. Of course, that wouldn't make MMC much different from development projects in general.

But the aim of MMC, ostensibly, is to reduce HIV transmission. It is believed that circumcised men are far less likely to become infected with HIV than uncircumcised men. The level of protection offered by circumcision is a matter of debate. I hope the debate is comprehensive and well informed because any measure that could reduce HIV transmission should be welcomed.

That is, any measure that has substantial benefits and few, if any, adverse effects. And circumcision may have quite a number of adverse effects. Rather than rehearsing the possible adverse effects here, I recommend the Male Circumcision and HIV website.

But my objection to MMC is slightly different. Given that I would argue that if Kenya had good health, education and other social services in the first place, HIV would never have spread as it did and would be easier to fight now. Therefore I see little point in piecemeal programmes that address one small factor in HIV transmission at a time.

Men are becoming infected because they don't know enough about safe sex and they don't have a high level of sexual health. Women are becoming infected because they have, in general, even poorer levels of health and education than men. There are employment, infrastructure, legal, lifestyle, tribal and many other reasons why men and women continue to be infected with HIV.

All of the factors in HIV transmission need to be addressed, not just the one or two factors that seem most attractive at a given time. Why MMC seems so appealing is really not that clear but ask yourself this question: would you go to a clinic to be circumcised if you knew that 1 in 5 operations resulted in some kind of adverse effect? Would you allow a clinic to circumcise your children?

Who in their right mind would advocate a programme of MMC in a country where tens of thousands of women die giving birth or shortly after giving birth, where tens of thousands of children die of diarrhoea, acute respiratory conditions, malnutrition or other easily curable or treatable diseases or where a substantial number of people will never have access to a qualified doctor in their whole life?

Kenya needs good health services, education and other social services. I know I keep beating on about it but these other political footballs are just distractions. I guess they are supposed to distract but we shouldn't forget the problems that Kenyan people face: they relate to day to day issues, such as food shortages and high food prices, unaffordable health care, appalling educational facilities and standards, political unrest, corruption and many other things.

Tackle the issues that face people on a daily basis and the problem of reducing HIV transmission will be a whole lot easier, whatever measures are deemed most appropriate in the end.



Hugh7 said...

Bravo! Great article.

Too many pieces about circumcision and HIV present it as some kind of magic bullet that will wipe the epidemic out in a decade or two - never mind the many, many circumcised men and their partners who will die of HIV on the way. They suggest that every other preventative measure should take second place, because now circumcision is here to save us all!

Kenya happens to be a country where more of the non-circumcised men happen to have HIV than the circumcised, but that may have nothing to do with circumcision - in at least seven other African countries the reverse is the case. What is more likely is that the difference has something to do with the other customs of the tribes that do not circumcise, such as having more parters at the same time. Having only one partner at a time ("Zero grazing" as they called it in a very successful campaign in Uganda) is one important way people can protect themselves.

Babies, boys and youths are circumcised in many places in the world - but hardly any men, because men usually know what they would be losing. It is done for hundreds of different reasons, having nothing to do with each other. That suggests that the real reason is something else.

One thing is certain, circumcised men tend to want other men to be circumcised, to reassure them that they are not missing anything. For that reason alone, men should beware of people who try to talk them into getting circumcised.

Simon said...

Hi Hugh
Thanks for your comment. Yes, there are so many things that could have been done over the last thirty years, before HIV was even recognised, to reduce the health, education and other social problems facing people in developing countries. It seems strange that some parties are hell bent on MMC in countries where they have pig-headedly ignored basic health services.