Thursday, September 27, 2012

Where Circumcision is the Bottom Line, Health is an Externality

It's remarkable how many different areas of daily life people who have heard of the Voluntary Medical Male Circumcision program (VMMC) in Kenya associate with male circumcision, and its claimed effectiveness in reducing transmission of HIV, and even various sexually transmitted infections (STI). Many of the things people talk about when asked about VMMC have little to do with the program and do not correspond to any of the findings of the three randomized controlled trials (RCT) commonly used to justify the plan to circumcise between 20 and 40 million African males.

Some tell you that sex is better, for men and for women, more satisfying, more pleasurable. This seems like a rather subjective argument for carrying out an invasive operation on millions with the aim of reducing HIV transmission, especially as those carrying out the program are also urging people to have fewer sexual partners, to wait until they are married, etc. One man I spoke to said it's easier to put on a condom if you are circumcised. He runs a large clinic that carries out VMMC, among other things. He agreed that the relative ease of putting on a condom is not a scientific finding, though. One can hear similarly subjective appeals to the aesthetic appearance of circumcision.

However someone else I spoke to, who has been involved in 'mobilizing' people to be circumcised, said that for every person who says sex is better after being circumcised, or that putting on condoms is easier, and various other claimed 'advantages' of the operation, there is someone who will say the opposite. More tellingly, he said he felt under pressure to emphasize the 'advantages' and claimed advantages of circumcision and ignore or dismiss any perceived or claimed disadvantages.

Over 80% of Kenyan males are circumcised as an infant or as an adolescent, for cultural or religious reasons. As a result, a lot of people will already tell you that it is better to be circumcised. Those who do it for religious reasons follow the relevant teachings of their faith. And those who do it for tribal reasons follow their tribal customs. Among those who are circumcised for tribal reasons, it is a rite of passage. It is the time when a boy becomes a man. Even adults who are not circumcised, whether they belong to a circumcising or non-circumcising tribe, are considered to be mere boys, unfit to take part in adult affairs, including leadership. Most of the uncircumcised males in Kenya are members of the Luo tribe.

The above mentioned RCTs did not make any such claims about unfitness for government, of course. But they were used to persuade Luo elders and Luo politicians to get behind the campaign, particularly by openly declaring their support for it, by stating in public that they would not, as Luos, object to circumcision on the grounds that it is not part of the Luo tradition, even by getting circumcised themselves if they had not already been circumcised for some other reason. The fact that many senior Luos got behind the campaign is said to be one of the reasons for objections to it being dropped. This didn't result in large numbers of Luo adults agreeing to be circumcised, but it did result in large numbers of Luo parents, apparently, giving their consent for their teenage boys to be circumcised.

Perhaps members of other tribes will no longer be able to say that Luos are not manly or mature, or that they are otherwise unfit for government on the basis of their circumcision status. But it seems unlikely that inter-tribal animosities will be assuaged so easily. The fact that mobs carrying out forcible circumcisions have been heard to claim that they are 'kicking AIDS out of Africa' may suggest that 'traditional' reasons for certain practices can readily be supplemented with non-traditional justifications. Indeed, the association of circumcision status with HIV status may further enforce the already high levels of stigma and discrimination faced by HIV positive people.

But one of the most invidious of all the inappropriate arguments for VMMC is the appeal to hygiene and cleanliness. One of the RCTs did find evidence that HIV transmission may be related in some way to genital hygiene. It was found that men waiting for a while after sex and then cleaning with a dry cloth, rather than soap and water, gave better protection against HIV than circumcision status. In other words, uncircumcised and circumcised men alike could reduce their chances of being infected by employing appropriate hygiene measures. But those measures do not appear to be a part of the current VMMC campaign.

On the contrary, people I asked about hygiene and cleaning practices said they washed straight away, with soap and water. One even said you must wash before and after sex. While these beliefs may not relate directly to the VMMC campaign, nor do they appear to have been addressed by the campaign. There are things people should know about genital hygiene, but washing immediately after sex and using water, soap and even disinfectant may increase HIV transmission, rather than reduce it. The VMMC campaign appears to tap into some existing beliefs about hygiene that could be modified; but this doesn't appear to be one of the aims of the program.

Perhaps one of the reasons why those promoting VMMC are so reluctant to discuss the importance of genital hygiene is that they know that hygiene is a long standing and, so far, intractable problem, that goes way beyond HIV and STIs. The health of everyone is compromised by lack of access to clean water and sanitation. Removing foreskins does not improve hygiene if the very conditions that enable health and cleanliness are missing; it could even increase the risk of those circumcised, especially in the months following the operation. Health facilities themselves often lack access to water, sanitation, soap, disinfectant and other supplies that are vital to ensure adequate levels of infection control.

People's beliefs about hygiene may be influenced by the constant mention of germs in TV advertisements for soap, disinfectant and other hygiene related products. Several people I spoke to talked about germs and dirt, apparently believing that circumcision would help with these problems. But even they agreed that being circumcised is not enough to ensure that a person washes properly. The hygiene related products they mentioned, Smile (brand of soap), Jik (brand of bleach), Dettol (brand of disinfectant) and Omo (brand of soap powder), are useless in the absence of clean water and sanitation.

It is shocking enough to find that the VMMC campaign doesn't appear to address people's knowledge of genital hygiene, nor even to attempt to address lack of access to water and sanitation, which proponents are well aware is vital to all aspects of health, not just sexual health. But it is also disappointing that the people who tell me that circumcision is 'cleaner' do not also complain about problems like lack of running water, open defecation, pools of stagnant water, piles of smouldering rubbish and deplorable housing. Given the state of the slums where the majority of urban-dwelling Kenyans live, do they or those promoting VMMC really think male circumcision is a priority, even a sexual health priority?

Proponents of VMMC can be vague about what kind of people makes up the 450,000 who have already been circumcised under the current program. Even they have admitted that a lot are teenagers, rather than adults. Some are not Luos, they are members of tribes who already practice circumcision. But how many of them are adults, particularly adults who are at high risk of being infected with HIV and who, the story goes, would be protected by 'up to 60%' if they were circumcised? And how many are people who live in such appalling conditions that circumcision, or even HIV, are not among their top priorities, nor even among the highest health risks they face?

Those working on the VMMC program are well aware that most people who are claimed would be protected by the operation have not agreed to be circumcised, and that most people who have agreed are at low risk of being infected with HIV. They just seem completely unconcerned by these matters. The reasoning seems to be that VMMC attracts a lot of funding, whereas genital hygiene does not. Health in Kenya will never improve appreciably until clean water and sanitation are accessible to all; they are even prerequisites to the effectiveness of all other health provision and all other fields of development. But it's VMMC that has attracted the money, therefore circumcisions will be carried out. The consequences in economic terms, the only terms that seem to count (or to be counted) in development, are mere externalities.

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



Unknown said...

Thank you once again for your honest look at the situation. I am saddened by how poorly the U.S. and others behave towards our African brothers and sisters. It seems like those who want to donate to circumcision campaigns care only about making themselves (their genital mutilation) feel normal thorough junk science and lies. They do not seem to want to find a cure, educate, or provide healthy living situations. I am tired of people speaking well of those who lie and harm. If a man has all the info fine let him be circumcised if he wishes, but let us stop the lies.

Simon said...

Thank you for your comment. I've been noticing that there is not much science, even junk science. It seems that people are persuaded by entirely unscientific arguments, ones that have no empirical support; circumcision makes you a man; circumcised men are cleaner; circumcised men get more pleasure in bed; circumcised men give women more pleasure in bed; circumcision makes it easier to put on a condom; etc, the list goes on. Responding with scientific objections is useless when the argument is entirely subjective in the first place. You're right, if a man has all the info...but most of those targeted seem to be boys. The men appear to be saying no.