Thursday, March 22, 2012

It Isn't the Science That Counts, It's What You Do With It

It doesn't often seem to happen but an article questioning male circumcision as a means of reducing HIV transmission, entitled 'Africa: Circumcision in HIV Fight Questioned', has appeared in Uganda's East African Business Week. Normally newspapers just churn out press releases as if they are articles, with few changes, but this one apologetically rejects the HIV orthodoxy. The author cites the recent Boyle and Hill article where it is pointed out that the impressive sounding 60% relative risk reduction needs to be compared to the 1.3% absolute risk reduction, which is far more relevant.

But the Ugandan article goes further: "the Permanent Secretary in the Ministry of Health, Dr Asuman Lukwago" says "should [circumcision] be proved [ineffective], the country will drop the method for other viable ones". Let's hope the PS is right. The Ugandan article also touches on the fact that in some parts of Kenya, where circumcision is widespread, HIV prevalence is high. This is also true of several other African countries and several tribes in Kenya. But the HIV industry has always managed to select the data that suits them and you rarely hear any complaints from politicians.

Another article finds that a program that aimed to circumcise 70,000 Kenyan men in a 30 day period only managed to achieve a total of 40,000. Apparently, the shortfall is partly due to heavy rains. Their target of about 1.1 million will require that they achieve at least 40,000 every month until the end of 2013, so let's pray for dry weather. The article also refers to a finding that around one third of men who are circumcised engage in sexual activity a few weeks after the operation, which means that they risk transmitting HIV if they are positive and being infected if their partner is positive. It also sounds like some of them think condoms are no longer necessary, even though one of the aims of the program is to reinforce the continued need for condoms after circumcision.

More surprisingly, the Kenyan article expresses doubts about the ability of Kenya's health services to meet demand. "Health workers are burdened and there are other priorities that compete", according to a clinical manager. But are the health facilities currently providing the service able to do so safely? Many people who became infected during clinical trials of mass male circumcision are thought not to have been infected through sexual activity. There are good reasons to suspect that health services in Kenya and other high HIV prevalence countries are risky places.

But are we even arguing about science here? Associations between circumcision and low HIV prevalence are easily balanced, perhaps even outweighed, by associations between circumcision and high prevalence. If evidence, however valid, is carefully sifted and selected for the bits that suit a particular purpose, what difference does it make how 'scientific' it is? There is a more important issue here which is highly pragmatic. How should people in countries being trageted by mass male circumcision programs react? What should they do? These questions are as vital for women as they are for men, for children as much as for adults.

Circumcision, and the HIV industry's broader obsession with sexual transmission of HIV, results in people not necessarily seeing the simple and effective steps they can take to avoid being infected and how they can protect their family and friends. They need to know about the risks that arise from unsafe healthcare and cosmetic procedures, indeed, anything that involves possible bloodborne infection.

Proponents of circumcision want us to believe that HIV is almost always transmitted through heterosexual sex, but only in African countries. Much of the epidemiological data collected does not support that hypothesis; so how could this virus be difficult to transmit through heterosexual sex, in theory and in practice, yet be almost always so transmitted in African countries? Scientists may be employed to collect and analyse the data, but who commissions the data? Who controls the money that pays for it? Who decides what should be published, how it should be presented and what is deserving of the attention of the press?

Whether you're a scientist or not, look at the tone in which some of these articles are written, look at the rhetoric; think of the economics behind circumcision and other public health programs; look at the politics behind the concentration on some diseases to the exclusion of most others; even take a look at the history of involuntary circumcision in Kenya or the far longer history of forced circumcision around the world. Doesn't everyone have the right to health, to healthcare, to choose what kind of healthcare they receive? From a pragmatic point of view, from the point of view of those who are not scientists, politicians, industrialists, careerists or whatever else, it's best not to be distracted by what many people seem to do with their science.

[For more about male circumcision as a strategy for HIV reduction, see the Don't Get Stuck With HIV site.]



Joseph said...

In several videos already, I have heard commentary to the effect of:

"It is against this background that we do our work."

(The background being the cultural attitudes on circumcision, the forced genital cutting, what it means to some tribes to be or not be circumcised, and the work being the promotion of circumcision as HIV prevention.)

One such video can be seen here:

"In it to save lives," it is called. Better named "In it for the fortune and fame."

Incidentally, I've recently managed to come across this:

In my opinion, given the history of circumcision in the West, I think that the "researchers" and organizers went ahead with their plan knowing full well the implications of what this means for some tribes. They did this BECAUSE of the stigma circumcision has in countries in Africa.

Their aim wasn't so much HIV prevention, as much as the preservation of what is a cash-cow in the US and in some parts of Europe, and a very heavily safe-guarded "tradition" for others, namely Jews and Muslims.

They wanted to ensure as much circumcisions, forced or voluntary as possible, and what better way to do this than by pouring gasoline into an already lit fire? What better way to ensure more men undergo circumcision than by stigmatizing having a foreskin? What better way than by equating having a foreskin with someone who is HIV+?

I'm afraid that if this was their plan, they did this out of hubris, and it is going to backfire in a deadly way. They are trying their hardest to market "safe, medical circumcision," but how many men are going to skip that and just get circumcised where they live the good ol' traditional way? How many men are going to be forcibly circumcised as the Kikuyu do the Luo?

But what's worse, what is the inverse of seeing having a foreskin as a risk for HIV? The answer is seeing circumcised men as AIDS-free. Women are going to reject HIV/AIDS conscious intact men who use condoms over the cut men who don't. That's not going to reduce the spread of sexually transmitted HIV.

I'm afraid this circumcision/HIV hoax is going to collapse on its own weight. But I think by then it will be too late, and the WHO etc. will have dug themselves in too deep.

I think Africans on the ground need to be reminded of who started all of this: The "researchers" and their "science."

Do not let them get away.

Do not let the "researchers" Halperin, Wawer, Gray, Moses, Weiss, Auvert, Bailey, Wamay etc. go Scott free.

Remember these names. Hold these people accountable for using "science" to push absolute self-serving quackery on the people of Africa.


Simon said...

It's shocking to hear that, after so many years and so many hundreds of millions of dollars spent, half of all Ugandans think HIV can be spread by mosquitoes, 'because they are illiterate', according to the video below:

Uganda was probably the first African country to receive aid money for HIV programs, for all the good it has done. The 'comprehensive knowledge' people are said to need is about condoms, rejecting 'misconceptions', etc, little or nothing about non-sexually transmitted HIV.

The upshot is that one third of women have the 'knowledge' and only just over 40% of men do.

If one of the HIV industry's insights is that people are illiterate, then perhaps randomised controlled trials of the sort that have been popular in African countries are not particularly appropriate. Are they even ethical? How can someone give informed consent under such circumstances?

If one of the HIV industry's insights is that people are illiterate, why do they not spend money on education and literacy, instead of pushing doctrinaire agenda that are infused with global politics, religion, pseudo-morality and the like?

Hasn't the HIV industry noticed the conditions in health services in countries like Uganda? Haven't they noticed that hospitals are not safe places to receive health services, particularly circumcisions and other operations? Don't they think that illiterate people with abysmal health services need accessible and safe healthcare?

Despite this apparent lack of insight, all the industry can think about is male circumcision, prevention of mother to child transmission and a few other 'tricks'. Never mind education and health. Preventing infections in mothers should be prior to mother to child transmission, which means non-sexually transmitted HIV needs to be investigated.

The problem with spreading a mixture of truths, half-truths and lies is that you don't get to choose which ones you can take back, which ones people will believe, which ones they totally misunderstand, etc. What a mess. But hey, just think of the commercial opportunities!

Given that married people and those in long term relationships contribute most to Uganda's epidemic, the take home message of the video seems to be that Ugandan men are feckless and the women are promiscuous. Data collected about sexual behavior doesn't support those messages so the HIV industry says or implies that they are lying.

That's why HIV industry programs treat Africans like a bunch of animals being rounded up to be receive whatever they are handing out. It's hard not to conclude that those who receive this kind of treatment are not seen as humans and that human rights are not relevant.

Petit Poulet said...

The HIV industry is not above using racial stereotypes to keep their funding rolling it. How pathetic! I agree, once a lie or half-truth is put out there, the water is already polluted.
Good science can be poorly applied or misused, but in the case of the circumcision solution or the multiple concomitant sexual partners theory: bad science is bad science.

Keep up the good work, Simon.

Gregor said...

You make a good point that HIV is spread by means other than sex and that the powers that be are ignoring that fact. Circumcision will not help but it will harm.

Joseph said...

The science is only as good as the scientists.

This is why studies get retracted.

Investigate the "researchers," who funds them, and why.

When the tobacco companies produce "studies" that show their product doesn't cause lung cancer, we have what's called a "conflict of interest."

When whalers produce "research" that shows whales are flourishing, and that they're not hurting the environment, we have what's called a "conflict of interest."

When American medicine is producing "evidence" that there are "medical benefits" to circumcision, which also happens to be a major cash cow in the US (1.3 million boys are circumcised a year, and the procedure ranges from 1 to 8 hundred dollars, do the math) we have a "conflict of interest."

When Operation Abraham comes from Israel and they want to "help" circumcise millions of Africans in the name of HIV prevention, when circumcision also happens to be a point of contention for Jews that goes back about 2000 years, you also have a conflict of interest.

So is this about HIV prevention? Is this about "saving lives?"

Or is this about safe-guarding a procedure that happens to be a money-maker in the US? Which also happens to be a sacred ritual for the Jewish people?

Are we going to just "forget" that "researchers" have been trying to produce the "science" that vindicates circumcision for close to 200 years, and pretend like they've only "just found" that circumcision "saves lives" but yesterday?

Check out the time-line for the circumcision "research" here:

What I find remarkable is how, despite the two-century long quest to try and vindicate circumcision, some "researchers" actually try to say they've "never used surgery to prevent disease." Advocates of circumcision will keep trying to use argumentum ad antiquitam to say how circumcision "has been happening for over 6000 years," but at the same time they want to claim that circumcision is this brand new thing no one's ever heard about. It's "a paradigm shift." Paradigm shift indeed.

"We've never used surgery to prevent an infectious disease. It's a completely new concept, a new paradigm. How can we train all the surgeons to do this procedure and equip them."
--Ronald Gray. JohnsHopkinsSPH, (2009). Impact.

Simon said...

Thank you all for your comments. I'll continue the theme in my next post but I wish circumcision was not being given so much credibility, especially if it will not reduce transmission and may even increase it. There are enough health issues to get on with, it's not as if there is any shortage.