Saturday, March 17, 2012
If people don't have access to clean water, adequate sanitation and even hygiene and sanitation related education, it is not time to call in Big Pharma, well funded academic institutions or even massive NGOs. The thought of billions in aid money being made available for expensive technical solutions may be distracting, but water and sanitation related disease epidemics do not just disappear once a vaccine or two have been produced. Western countries have never eradicated endemic diseases through vaccines alone, nor do they keep epidemics at bay simply by developing more and more medicines. So why should vaccines be the first (and last) port of call for so many public health interventions?
This is not to say that vaccines do not have a part to play in reducing and even eradicating some diseases. It's just that vaccines on their own won't be enough if people lack access to clean water and sanitation. The idea that diseases can be picked off one by one for eradication by the mere production of a range of pharmaceutical products is naive; worse than that, the idea is uninformed by all that has been learned by public health experts over several decades. People who consume their own waste (and that of others) will continue to suffer from and die from easily avoided and treated conditions. Using and drinking contaminated water will ensure that people continue to contract all sorts of diseases, vaccines notwithstanding.
This type of technocentric view seems also to be applied to HIV, and perhaps other sexually transmitted diseases. Despite the stunning advances that have been made in antiretroviral drugs, many people still seem to cling to the view that drugs alone will eradicate them all, or at least the most fashionable and profitable ones.
Similarly, it has also been assumed that male circumcision will substantially reduce HIV transmission because it is 'more hygienic' (in addition to a multitude of other claims made to argue for the operation as a means of reducing infection with HIV and various sexually transmitted infections). But is circumcision really preferable to penile hygiene? If people are unable or unwilling to maintain basic levels of hygiene, to what lengths should public health programs go to ensure that lack of hygiene is not responsible for the transmission of diseases? What about people who don't wash their fingernails or who bathe in water contaminated with sewage?
Disturbingly, some of the arguments put forward for male circumcision have, at times, been advanced for female genital mutilation by those who are in favor of it, in particular hygiene, aesthetic appearance, the claims that the opposite sex prefers it and that it prevents masturbation and licentiousness. There may even be a case for claiming that female genital mutilation reduces HIV transmission, a poor case, but no worse than that for male circumcision.
For example, while proponents of mass male circumcision cite the fact that HIV is highest in the Luo tribe in Kenya's Nyanza province, among whom only about 16% are circumcised, HIV is lowest in Kenya's Somali tribe, among whom 100% of males are circumcised. But it is estimated that 100% of female Kenyan Somalis have undergone genital mutilation, compared to no female Luos. Those who hazard a guess at some causal mechanism to explain any reduction in HIV transmission as a result of male circumcision suggest that Langerhans's cells, which are common beneath the foreskin, may play some kind of role. But Langerhans's cells are also plentiful in female genitalia.
These are very unconvincing arguments for female genital mutilation. but it's hard to see why they constitute convincing arguments for mass male circumcision. There are also other tribes in Kenya where male circumcision is widely practiced, such as the Maasai and the Meru, among whom HIV prevalence is not exceptionally low. It has been suggested that improved penile hygiene may be as effective in reducing HIV transmission as circumcision is claimed to be. This has not attracted anywhere near the same level of funding. Yet improved hygiene and access to clean water and sanitation would be of overwhelmingly greater value than circumcising as many as possible of the 15% or so of Kenyans not already circumcised.
[For more about male circumcision as a strategy for HIV reduction, see the Don't Get Stuck With HIV site.]