Tuesday, September 28, 2010

The Choppy Logic of HIV Politics

"Circumcising infant boys could become part of Kenya's voluntary male circumcision programme...if an ongoing pilot project in the western province of Nyanza recommends it." Can infant boys become part of a voluntary program? Perhaps the author meant that parents could choose to have their infants circumcised, which is quite a different matter.

The pilot project is looking at the ability of medical staff to run an infant circumcision program that is acceptable to parents and safe for the infants. At least, that's how I interpret this rather garbled account. Words like 'successful', 'promising' and 'viable' also occur in the article (though some of the optimistic words are later qualified by words like 'reasonably', 'variable' and 'comparatively'), though the program hasn't finished yet.

The people being trained, apparently, are clinical officers and nurses, not doctors and surgeons. Kenya doesn't have anywhere near enough doctors or surgeons to take care of existing health problems, let alone get involved in tens of thousands of additional operations and follow-up care. Not that they are oversupplied with nurses or clinical officers, either.

The whole exercise involves what is sometimes referred to as 'task-shifting', whereby less well qualified, even completely unqualified people, are trained to do work that in wealthier countries would only be carried out by a highly qualified person.

Task-shifting may be safe enough when it involves doling out drugs and the like (though that also has its risks), but carrying out operations? I can't see it being popular in a Western country. There are hairdressers who have more training than some clinical officers but no one is suggesting that hairdressers should circumcise anyone.

The article suggests that infant circumcision is 'preferable' to adult circumcision, for various reasons, including being more cost-effective. But does that make it ethical to decide on behalf of infants that they should have an invasive and potentially dangerous operation, rather than waiting till they reach an age where they can give their informed consent? And purely because it may give them some protection against HIV?

Does the fact that parents make the decision on their behalf make it ethically sound? What sort of information are the parents being supplied with in order to make the decision? This operation may, the argument runs, reduce the risk of the children being infected with HIV when they become sexually active, but the evidence is slim and needs very careful manipulation to make circumcision sound like a good idea.

Even if circumcision were guaranteed to protect against HIV, or give a high level of protection, I would still question the ethics of carrying out such an operation on infants. They could decide whether or not to have the operation when they are adults. After all, there are many things these children will face, most of them preventable or curable and many of them deadly.

Up to 20% of the children will die of water-borne diseases and another 20% of respiratory problems. The majority will suffer from some form of intestinal parasite, possibly all their lives, and a large percentage will endure various forms of malnutrition and vitamin deficiency, the effects of which will almost definitely last for the rest of their lives (if they live). Most will, at some time, suffer from malaria and a host of other controllable diseases.

Indeed, quite a large number will be infected with some disease or other, hepatitis B, hepatitis C, possibly even HIV, as a result of their contact with a health facility. Some will even die from the disease, or suffer severely compromised health as a result. Health resources are not just scarce in Kenya, they are also potentially dangerous. The risk of HIV and the protection that circumcision may give seem quite diminished compared to the realities of Kenyan health care.

The trend towards 'treating' healthy people with drugs and other procedures is extremely worrying. Health is not just the absence of disease. Although sick people need drugs and other things, healthy people do not. Especially in a country where the most basic needs, clean water, sanitation, food, housing and education, are lacking. If the country doesn't have the wherewithal to treat all its sick people, why do some appear so anxious to use up scarce resources on those who are not sick?


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