Thursday, March 22, 2012
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.]