Sunday, September 23, 2012

Circumcision: Bullied by Scientists, Betrayed by Donors

One might be shocked at the Victorian prudishness to be heard in discussions about HIV throughout East Africa. I was at a meeting of young peer educators, who should already be in a position to know better, they are in their late teens and twenties. But several of the male educators agreed that HIV is 'women's fault' because they only wear two layers of clothing below the waist, underwear and trousers or skirt. The other layer they are 'traditionally' (amazing what is referred to as tradition) supposed to wear are either 'cycles' (shorts that go to just above the knee), or a petticoat (so perhaps even trousers are deprecated).

Those who agreed with this, when pressed, said that they and others were tempted by women who did not wear the requisite number of layers. Considering we were supposed to be discussing modes of transmission, the phenomena involved in HIV transmission, blaming it on the way women dress seems a bit far removed from helpful details of what to avoid and why such things should be avoided. Eventually people moved on to 'sharp objects', but eliciting what kinds of sharp objects and explanations of precisely why sharp objects should be involved in HIV transmission took a lot of prompting.

Even then, there was a lengthy discussion of whether 'deep kissing' can transmit HIV if one or both parties was bleeding profusely from the mouth, and another about whether HIV really 'dies in seconds' or if it can survive for minutes, or longer. There was no mention of blood borne diseases aside from HIV, or of whether it was vital to avoid having the blood of other people introduced into your own bloodstream via some kind of sharp object, whether it was from a medical injection with a reused syringe, a razor, a tattoo needle or an infant's teeth. In case you are wondering, it is prudent to avoid having contaminated blood in your blood stream. It may sound obvious, but people do seem a lot more worried about things like underwear and kissing.

The conversation moved on to 'idleness', perhaps continuing the Victorian flavor. People should not be 'idle' because 'idle people' have unsafe sex and 'spread' HIV. Far from advocating for economic interventions on the grounds that people are poor, unemployed and unable to provide for themselves, unemployed and underemployed people are in need of something to do to help them resist temptation. The discussion was long and tedious, as they tend to be, and I eventually had to move on before the idleness discussion ended. But I was sorry I didn't have the time to say that HIV prevalence tends to be higher among employed people, often among the best educated and wealthiest employed people.

For example, the latest HIV related statistics I could find are for Uganda, and prevalence is 8% among the employed, but only 5% among those who are not employed. Indeed, the biggest differences seem to relate to what kind of employment a person is engaged in. Other figures find that HIV prevalence is lowest among those in 'domestic employment'; 'housegirls' (often being blamed for 'bringing HIV into the house', echoes of Charles Dickens?), at 6.9%. But it rises to 16.3% among public administration workers. I may be missing something, of course. 'Idleness' may be more prevalent among those in employment, and far more prevalent among those in certain types of employment.

I was asking a lot of people about the current voluntary medical male circumcision (VMMC) program, of which most people seem to be in favor, and the subject of hygiene arose repeatedly. Perhaps this moves us on from the Victorian era to herald in a more 20th century obsession with hygiene, especially popular among many of the big philanthropists, Carnegie, Rockefeller and others. But it's difficult to see what kind of hygiene the VMMC program hopes to promote, even the obvious, genital hygiene. I was taken to slum areas, where the most obvious lack in hygiene include large pools of stagnant water, piles of smouldering rubbish, mud houses, open defecation and the like. It will take a lot more than circumcising men to improve even genital hygiene.

It may seem shocking to those who have been to slum areas, where the vast majority of urban dwellers live, that proponents of VMMC think circumcising men could come anywhere close to being a priority. If seeing the conditions people live in is not enough, they should have a look at the conditions in hospitals and hear about the amount of disease and injury that comes from the very places where sick people are supposed to be attended to. Even street kids, who sleep rough, often in wet, filthy places and struggle to feed and cloth themselves have been targeted by the current program. Is it even ethical to carry out an operation on someone that you know lives in such conditions, where they are susceptible to all kinds of infection, probably for months?

Moral and even religious associations are often close to the surface when talking to people about HIV. It doesn't take much to prompt reactions suggesting that many people have little time for talk about the viral explanation of AIDS. A few mention taboos or 'chira', but others talk of or hint about the 'low morals' of people who are infected with HIV. This may suggest that, although they all say 'safe sex' can protect you from HIV, ultimately they may not really believe that safe sex is enough! Some appear to believe that people's levels (and type) of religious faith determine their likelihood of being infected, protected, perhaps even of being cured of HIV.

I interviewed a Pastor who belongs to an indigenous Kenyan Church that circumcises boys on the eighth day (following Leviticus 12). He seems quite convinced that circumcision reduces HIV transmission, citing all the publicity that everyone else seems to be able to recite like articles of faith. But others have pointed out that HIV prevalence is also high among his church members and among some circumcising tribes. The pastor, seemingly being prompted by his bishop, concluded that people must accept that HIV is being caused by unprotected sex, so they must decease from their bad behaviors and that they should also accept circumcision.

I'm not faulting the pastor on his biblical interpretation. But the relevant chapter has more to say about cleanliness than just circumcision. If cleanliness and hygiene are so important, the highest priority would seem to be the provision of clean water and sanitation for everyone. Circumcising all the men who live on the street, work in the lake, live in slums and face so many preventable health and HIV risks in their daily lives (to say nothing of the risks women face) could do a lot more harm than good. Without clean water and sanitation, lack of hygiene will continue to be behind much of the morbidity and mortality among people, whether they are circumcised or not, even whether they are male or female, adult or child.

The problem with all the talk about sin, idleness, evil, immorality, bad behavior and the rest is that it seems to miss the biggest denials of human rights that most people in Kenya face: the rights to health, education, water and sanitation, infrastructure, employment and many more. Given the conditions people have to live in, the explanatory power of individual sexual behavior in HIV transmission is completely deflated. Perhaps the pastor and others are looking for splinters, rather than beams. Walk through a slum, and I don't think the need for circumcision will be the first thing that strikes you. And if you see street kids, even the ones who don't (yet) sniff glue, you will probably think that circumcision could not possibly be safe for them, given the conditions they have to live in.

Those wielding their scientific data (and scalpels) are happy to bully anyone who threatens to get in their way, and everyone is happy if they are recipients of donor largesse. Even those cajoled into being circumcised by promises of '60% protection' (whatever people think that means), of being 'men' and of making the wise/smart choice (according to the billboards), free healthcare (as long as it's just circumcision), protection from various other sexually transmitted infections, better sex for them and their partners (yes, this claim is also used) and the endorsement of Luo politicians and elders, seem to be happy.

Most of those who have had the operation under the current program so far are not sexually active adults (or would have been circumcised anyway, but are availing of the free option), and therefore are not likely to face high risk of being infected through their sexual behavior. But all circumcision operations are being counted towards the (movable) target, any drop in HIV transmission can be attributed to the program and any increase in transmission can be attributed to the individual behavior of those infected, to the fact that they did not practice 'safe sex', as they were advised to do. Meanwhile, appalling living conditions, hazardous healthcare, poverty and lack of opportunity, low levels of education and multiple other factors ensure that people's lives remain blighted, with HIV being only one of many sources of the blight.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]



Anonymous said...

Justice at last for man who got a false +ve

Simon said...

Thank you for the link. I'm glad he got to the bottom of it, but sad it took so long. The arrogance of the SDA doctor is disgraceful, but tracing infections needs to be a top priority. Otherwise there will always be stigma and we will never know where infections are coming from. We are 30 years into the epidemic and we don't know how most people have been infected, we just assume it was sexual transmission. So, whatever the source, it can continue to give rise to more infections. Justice for one man, but what about justice for all the others who have died thinking they are 'bad' people, abandoned by friends and relatives? What about justice for all Kenyans and Africans? And how are we going to prevent new infections if we are not prepared to investigate where they may be coming from?

Mel said...

There is no doubt that there are many other issues facing Kenyans and East Africans... so many people live in poverty that it results in drug and alcohol abuse, an increase in commercial sex workers, and ultimately, more transmission of HIV. Many people live in completely deplorable conditions, especially in some of the larger slums in Nairobi. I also don't doubt that their method of advertising circumcision may be somewhat lacking; more money could certainly be put into education of HIV as well.

However, something I've found while working in Kenya, is that educating people, even on topics like HIV that effect them so greatly and so personally, is extremely difficult. People are very set in their ways. I have Kenyan friends, who are educated, who research HIV, who see the effects of AIDS in their friends and families- but who still don't use condoms, because they don't like them. If this is what we're up against, it will be a mighty battle indeed.

However, what we've found is that there is very strong evidence that circumcision can help curtail infection with HIV. In such dire circumstances, I often wonder how there can be so much backlash against it- NOT, surprisingly, from Kenyans, who often jump at the chance to protect themselves in this way- but from the western world who shout that it is genital mutilation and we are doing such a terrible thing to these poor Kenyans. But the data doesn't lie- Circumcision is a viable strategy to not only prevent men from contracting HIV but to therefore prevent their wives and girlfriends from contracting it too. I'd suggest you take a look at the literature on this- it's quite astounding.

Simon said...

Hi Mel
Thank you for your comment. The fact that there are many problems aside from HIV does not mean that all, or even any, of those problems increase HIV transmission. That is not my argument, and I'm assuming it's not yours, either. Nor am I arguing that circumcision is genital mutilation.

The data you call strong evidence is not, in reality, strong evidence at all. It suggests that, under the fairly safe conditions of a randomized controlled trial, circumcision appears to give some protection. But the trial explicitly does not show that it protects from heterosexually transmitted HIV because no effort is made to establish how people became infected, even though there is suspicion that some may have been infected because of the operation.

Interesting that you've found people are set in their ways in Kenya, that's what a lot of people say. But 450,000 people are said to have already been circumcised under the program, in the first four years of a 10 year program. So either a lot more than education was used to 'persuade' them, or we are just wrong, that people are not set in their ways, that they will do things to protect themselves. But then it must be asked why people would not take other measures that could easily be more easily employed than circumcision, regardless of their gender, circumcision status, level of poverty, etc. After all, the vast majority of Kenyan men are already circumcised.

I find your contention that 'data doesn't lie' to be extremely naive for someone who is a PhD candidate and I hope you are not studying a scientific subject. Even those promoting the program whom I spoke to did not claim that the evidence is strong; the most that one said is that it's 'getting stronger', which suggests that this is a huge experiment to which people have not given their consent. Others promoting the program only agreed on one thing: there's a lot of money in circumcision. Several even said that they don't believe it will make much difference.

Only one said he fully believed in VMMC and had been circumcised himself. But after giving me all the predictable 'statistics' and arguments, he said, in some frustration, that it is 'your fault, you donors, who tell us what to do with the money'. And we agreed that there are a lot more urgent things to be concerned with in Kenya than circumcision. We agreed that donors should also put some money into safe healthcare, water and sanitation, etc. Hardly a ringing endorsement.

In fact, the only people who seemed wholly convinced were the ordinary people that you find so set in their ways.

Thank you for your suggestion that I take a look at the literature. It was my perusal of the literature that resulted in my spending quite a few years researching HIV in Kenya, and in particular male circumcision. A cursory read may be convincing enough, but even papers by some of the most enthusiastic proponents suggest that the evidence is weak and effectiveness at the community intervention level is completely unknown; it might even be negative, and they do not deny this.

Joseph said...

"...what we've found is that there is very strong evidence that circumcision can help curtail infection with HIV."

It would be nice if you can tell us what this "evidence" is, and by "evidence," I demand a detailed, demonstrable causal link, not just carefully chosen statistics that do not correlate with the rest of the world.

"In such dire circumstances, I often wonder how there can be so much backlash against it- NOT, surprisingly, from Kenyans, who often jump at the chance to protect themselves in this way- but from the western world who shout that it is genital mutilation and we are doing such a terrible thing to these poor Kenyans."

Where there is smoke, there is fire, my friend. Do not fall under the impression that circumcision was something "just" discovered yesterday. Circumcision made the rounds in English-speaking countries, and even though it has but been a fad long-past, it is still quite prevalent in the United States. There is so much "backlash" because we can see that Africa is being bulldozed by people with money and an agenda whose least interest is HIV prevention but the justification and promulgation of a "procedure" which happens to be a cherished tradition.

"But the data doesn't lie-"

The data is only as good as its collectors. What data were they looking for? What data have they ignored? What questions were they asking? Were they looking to prevent HIV? Or promote a procedure they don't want to see die out in their own countries?

Here is some "data" that doesn't lie; at one point, over 90% of all male children in the United States was being circumcised in childhood. That number, according to the CDC, has fallen to 56%. Circumcision is a money maker for the doctors who perform it, not to mention a cherished tradition to Jews and Muslims. (Do you know that many "reseachers" have this conflict of interest?) Circumcision is a procedure that Western doctors and adherents of Judaism want to preserve. Did it ever occur to you that they are trying to use their "research" in Africa, and the fact that many men are being circumcised under the guise of "HIV prevention" to push circumcision as hard as they can in America and other countries? Did it ever occur to you that this is not about HIV prevention at all, but a desperate attempt to vindicate a precious tradition, not to mention a money-maker?

Joseph said...

"Circumcision is a viable strategy to not only prevent men from contracting HIV but to therefore prevent their wives and girlfriends from contracting it too. I'd suggest you take a look at the literature on this- it's quite astounding."

Yes, I suggest you take a look at the literature, and not just what is presented to you. The fact of the matter is that HIV transmission has been found to be more prevalent in circumcised men in 10 out of 18 countries (USAID). Despite the fact that over 80% of all US males are circumcised from birth, our country does poorly in comparison to other industrialized nations where circumcision is rare.

And another thing; even if the "research" is correct, the "protection" is only for the MAN. Where on EARTH do you get off it protects WOMEN? A study by Marie Wawer, one of the same people who wrote the big three "trials" in Africa, showed that women with circumcised partners were contracting HIV at an alarming rate. So much that she had to cancel her "research." (She wanted to prove that circumcision protected women.)

Scrutinize the literature, and make no mistake; attractive numbers abound in select "studies," but there is not a single "study," there is not a single doctor or "researcher" that can demonstrably prove that the foreskin is the prime port of entry for HIV, and that cutting it off "reduces" transmission.

Do you buy the idea that "HIV is transmitted by the Langerhans cells?" Look again; this is pure unproven BELIEF. Research shows that the Langerhans cells are actually quite effective in fending off HIV, because they release langherin, which destroys the virus.

Do you buy the idea that "the keratinized mucosa of the circumcised male keeps out HIV?" Look again; Dinh et al have written THREE studies that fail to visualize this. They show that it makes no difference in whether a man is circumcised or not, and that people have to look for another explanation.

Poorly conducted "research," if it can even be called that, select statistics that do not correlate with the real world, and a failure to present a causal link. These are but a few problems with the "literature" that you say is so "strong."

Despite the fact that 80% of all US men are circumcised, their sexual healths are poorer than various countries in Europe and Asia where most men still have anatomically correct genitalia.

Why is that?

Who does the "60% protection" not manifesting itself outside of the "carefully conducted research" we keep hearing about?

Why is a medical intervention that never worked in America is suddenly going to start working miracles in Africa?

You probably hear more opposition outside of Kenya than inside, because we've "been there."

This is a crock.

The reason people in Africa keep repeating it is because it is their livelihood; African circumcision promoters must repeat the lies their donors tell them. They must repeat whatever they are told because circumcision is their meal ticket.

"It is difficult to get a man to understand something, when his salary depends upon his not understanding it."
~Upton Sinclair

Yes, look at the research. And read it well; the numbers are for specific select regions in Africa, they do not correlate with real world data, not to mention there is no actual demonstrable link between circumcision and a reduced HIV transmission rate, only pure unsubstantiated speculation and belief.

This is belief-based, not "evidence-based" medicine.

Simon said...

Thanks you for your comments Joseph, they hit the nail on the head, as always!

Simon said...

This article may interest Mel, who thinks data can't lie: