Circumcision: Non-Paternalistic Public Health is Possible in Africa, Isn't It?

After holding out for a while, apparently the Malawian government has now had a change of heart about male circumcision and has caved in to pressure from the international HIV industry to include the operation in its HIV 'prevention' strategy. There were good reasons for holding out: prevalence is a lot higher in the Southern part of the country, where almost everyone is already circumcised. While the headline figure is 'up to 60% less likely to be infected', there are many countries where men are more likely to be infected if they are circumcised, aside from Malawi (see table of HIV infections in circumcised and intact men).

The country claims to have circumcised 5,000 men already but they plan to circumcise another 245,000 by 2015, despite the conflicting evidence about the effectiveness of the program. It is also revealed that only 4% of the country's medical staff have been trained to carry out the procedure. That's extremely worrying in a country where there is such a shortage of medical staff, regardless of what they know about circumcision. Other research in Malawi has shown that living close to a health facility is a serious risk factor for being HIV positive. But I don't expect that to be mentioned in the evangelical literature.

The last sentence in the article is particularly badly phrased: "people still had to be reminded that male circumcision alone is not 100 percent safe". The sentence aims to express the idea that male circumcision on its own will not protect against HIV and the 'up to 60% protection' requires the use of condoms (which is why some people ask if the circumcision is even necessary). But sadly for Malawi, figures suggest that HIV prevalence is far lower among both males and females who never use condoms than among those who ever use them.

Another reason why the sentence is unfortunately phrased is that it sounds like it means the operation itself may carry risks which, ironically, is true. In addition to many unexpected HIV infections in male and female virgins, where prevalence was similar to or higher than that among non-virgins, there have also been questions raised about mass male circumcision programs, where some of those circumcised might have been infected as a result of the operation itself. In countries where health facilities are in such bad condition that they may carry as high or even higher a risk of HIV infection, mass male circumcision sounds like an extremely dangerous HIV prevention strategy, particularly in Malawi.

Meanwhile, Uganda claims to have already circumcised 600,000 men since 2009. Uganda has had quite a few probable healthcare associated HIV outbreaks, including during the Rakai circumcision trial, which is supposed to show that circumcision is a viable strategy for HIV reduction. There, the aim is to circumcise 4 million men, until HIV prevalence "reaches zero", which will be a very long time from now at the rate things are going. Notably, despite evidence for healthcare associated HIV transmission in Uganda, the ridiculous claim about 80% of transmission being through heterosexual contacts is still being made (and elsewhere it is claimed that almost 20% more is from mother to child transmission).

The article also claims that 768,000 men have been circumcised in Tanzania, against a target of 1.3 million. Strangely, it is also claimed that Kenya has only circumcised 76,000 men against a target of 860,000 men by 2011. Other claims have put the figure in the hundreds of thousands, against a far higher target, and that was just among the Luo tribe of Nyanza province, a few million people. Another country where circumcised men are more likely to be infected than uncircumcised men is Rwanda, and it is stated that they have already operated on 415,000 men, out of a target of 900,000.

Paternalism behind African 'public health' programs funded by Western countries is questionable enough, but can't these circumcision evangelists at least wait until the more dubious arguments been re-examined and until there is stable and convincing evidence for carrying out what is probably an unnecessary and clearly an unsafe operation on more than 20 million people? Jacques Pepin (in The Origins of AIDS) has shown the sort of damage that resulted from public health programs carried out in colonial days (motivated by a desire to maximize profits);  we now know far better than to carry out mass male circumcision programs, but it seems we're still going ahead with them anyway.


[For some of the less well publicized details about the three circumcision trials used to advocate for mass male circumcision, see the Don't Get Stuck With HIV website and blog.]