Circumcision: Money, Religion, Political Power and Misinformation

The second grouping of data collected in Kenya is about negative perceptions of circumcision, which are currently less numerous than positive perceptions (the subject of yesterday’s post). But one of the most powerful arguments against the voluntary medical male circumcision campaign (VMMC) is that HIV prevalence is also high among circumcising peoples, even among Luo populations. The figures cited by those promoting VMMC are for all Luos, among whom HIV prevalence is high, compared to all non-Luos, among whom HIV prevalence is generally a lot lower. Many Luos are uncircumcised and many non-Luo Kenyans are circumcised. So this is said to be evidence that circumcising hundreds of thousands of Luos, perhaps even millions, will reduce HIV transmission.

The flaw in this argument is that about 20% of Luos are circumcised, for various reasons, including religious, medical and perhaps others. But HIV prevalence is roughly the same among circumcised and uncircumcised Luos. So, even if circumcision protects non-Luos, it doesn't appear to protect Luos. The surprising and disappointing thing is that Luos themselves don't seem aware of this. Some were aware that HIV prevalence can be high among circumcising peoples, but only one seemed to know that HIV prevalence among circumcised Luos is about the same as among uncircumcised Luos. This suggests clearly that the difference in prevalence between Luos and non-Luos probably has little or nothing to do with circumcision status.

I spoke to several people who worked in public health and they knew about the above flaw in the VMMC campaign's arguments, but they should have known also that the evidence currently shows that the operation does not protect Luos. One community leader points out that, though it is US money that is pushing this campaign, many circumcised Americans die of AIDS. It was a traditional Luo leader, a 'Luo elder', who knew that Luos don't seem to be protected by circumcision. But he and other traditional and political leaders agreed to promote the campaign for the good of public health. He and some other elders are now calling for further discussions to clarify these issues.

There is a Christian sect called the Nomiya Church that practices circumcision on 8 day old infants, and any other church member who wishes to be circumcised. One of their pastors told me that only about 40% of members are circumcised. But the church is almost exclusively a Luo church and despite many members being circumcised, HIV prevalence is very high in areas where the Nomiya Church is strongest. The pastor and his bishop agree with this, but they appear to feel that circumcision is more of a spiritual intercession than a public health intervention.

Others I spoke to felt that VMMC would not reduce HIV or would not reduce it much. One community leader advocates against circumcision and he wonders why the US feels it is acceptable to insist that Kenyans and Africans 'need' this intervention, for which they are willing to shell out several billion dollars. He said there were people circumcised under the program who subsequently became infected with HIV. Several public health researchers I spoke to, some who worked for the VMMC campaign, did not even pretend that they thought VMMC would reduce HIV much, if at all. But several of them also pointed out that there was money in VMMC, which means that it will take priority over anything else.

A few people expressed opposition to forcible circumcision, which has been happening on and off for many years. While this is not directly related to VMMC, witnesses to a recent forcible circumcision said the mob involved claimed they were 'kicking AIDS out of Africa'. Some just shrug their shoulders when asked about forcible circumcision, much as they do when asked about other mob activities, such as lynchings for alleged robbery and other offences or assumed offences. Several expressed complete opposition to infant circumcision, but not many. They don't seem to be aware that there are currently trials of infant circumcision in the area. There is no evidence that infant circumcision has any public health benefit relating to HIV, but evidence can always be manufactured.

Only one person spoke of the irreversibility of circumcision in relation to infants; only one spoke of human rights and informed consent; very few mentioned pain. None at all mentioned adverse events, such as infection, scarring, permanent injury, dysfunction, excessive bleeding and the like (although the most alarming evidence of these was collected by the people who are now running the VMMC campaign). Many mentioned 'hygiene', as if uncircumcised men can't clean their penis and as if all circumcised men do clean theirs. But no one mentioned the conditions they lived in: slums, mud houses, piles of smoldering rubbish, stagnant puddles, rotting waste and open defecation, which results in a contaminated water supply which is used for drinking, cooking and cleaning.

Even a 'street kid' who was circumcised under the program, and was still in great pain when I talked to him, didn't ask how he was supposed to keep the wound clean while living on the street, let alone how having a circumcised penis would protect him from the many diseases stemming from inadequate water and sanitation that account for a huge proportion of morbidity and mortality, even among those who are not forced to live on the streets. How someone could persuade him to have an unnecessary and invasive operation, collect him from the street, give him some written instructions and deliver him back on the street again is beyond belief.

Issues of irreversibility, informed choice and human rights are raised in Western countries, such as the US, and rightly so. But circumcision is associated with a very different set of issues in a country like Kenya, where the vast majority of people live in poverty and appalling housing, only have access to unsafe healthcare facilities and receive an atrocious education that often ends far too early in life. It's not that circumcision is killing so many people but that so many preventable illnesses and social problems are killing people and the US has decided that circumcision is what they need. The above conditions are experienced by most Kenyans, circumcised or not, so what will be done once everyone is circumcised? Perhaps Bill Gates (he funds some of the research) will pay someone to invent an antidote to post-circumcision sepsis.

Several of those involved in pushing VMMC have no illusions: it's about money. Some of them admit that they don't believe it is a useful public health intervention. One didn't admit that, but he did say they are still collecting the data and it's looking better and better as time goes by. Meanwhile, all uncircumcised Luo men (and boys and infants) and their sexual partners have become so many million guinea pigs in this big experiment. Religious leaders have come to see HIV as a way of attracting followers, so they are not complaining. Long held cultural prejudices about circumcision making a boy into a man have greatly assisted the program. So the time-honored combination of money, religion and political power is being used to misinform people whom they claim to be supporting, leading and informing.

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