Friday, October 5, 2012

HIV and Circumcision Still Diverting Funding from More Vital Development Issues

A fairly typical headline on Zimbabwe: Investment in Maternal Health Critical. You could put any sub-Saharan African country in the title at any time and you would have a ready-made story. Around the world, one woman dies from complications relating to pregnancy and childbirth every 90 seconds. For Zimbabwe, the figure is about 10 women and girls a day. The "prevailing maternal mortality rate stands at 960 deaths per 100,000 live births, up from 725 deaths per 100,000 in 2009/2010, while child mortality rate is at 86 per 1,000 live [births]."

Zimbabwean Deputy Prime Minister Thokazania Khupe wants to address these issues by scrapping maternity fees at hosptials and clinics and she has sourced $40 million to subsidise the cost. But this is said to be far too little to have much impact on mortality and the scheme has already been suspended.

It may seem daunting to raise sums like $40 million in a hurry, or even higher sums. But it seems Zimbabwe does have a lot of money at its disposal, money which would be far better spent on maternal and child health. Another story says that a USAID funded program aims to circumcise two million Zimbabwean men by 2015. As only 55,000 have so far undergone the program, there must be a lot of money left over. Whether you take the ridiculously low price claimed by circumcistion enthusiasts of about $60 a head, or the more realistic $120 a head, that's still a lot of money, between $117 and $233 million.

Why do I think this would be better spent on maternal and child health? Firstly, because HIV prevalence is roughly the same among circumcised and uncircumcised Zimbabweans. In other words, circumcision hasn't made any difference so far, why should it do so in the future, aside from the fact that proponents of mass male circumcision programs really really want it to work? Secondly, circumcision is only claimed to reduce transmission from women to men, not from men to women. The operation may result in increases in transmission from men to women and infections are already far higher among women.

The country has between three and six times the amount of money they need to substantially reduce maternal (and infant) deaths; spending it on a mass male circumcision program will not reduce HIV, and may even increase it. So why the hesitation? Even if UNAIDS insist that they can only spend this money on circumcision, Zimbabwe would be better off saying no to it. They have nothing to lose by asking.

Most of the deaths are easily preventable and the amount of money available is substantial. The amount saved by not increasing HIV transmission may also prove worthwhile. The article continues: "Africa faces a health-worker crisis: on average, there are only 13.8 nursing and midwifery personnel for every 10,000 people. In the poorest countries, this ratio is less than 1 per 100,000 people". Mass male circumcision programs require huge numbers of health personnel to be retrained, and then their time and attention are diverted from all other health issues. Instead of being trained to carry out circumcisions, additional personnel could be trained in maternal and child health, so that everyone, whether rich or poor, urban or rural dwelling, can have access to decent healthcare. Apparently "80 percent of midwifery posts in the public sector are vacant".

This model could be repeated throughout Southern Africa because it is intended to circumcise 20-40 million men, representing between $1,200,000,000 and $2,400,000,000 if the cost is about $60 per head and up to $4,800,000,000 if the cost is a more credible $120 per head. In addition, the net contribution of circumcision to HIV reduction across 15 high and medium prevalence countries is zero. Many infections from males to females may even be averted, releasing even more funds for maternal and child health.

While circumcising between 20 and 40 million men may seem like non-starter, development programs often seem to take a rather oblique approach. In an article about Kenya, 'Boosting contraceptive use to cut unsafe abortions', you might think providing safe abortions would have a more direct impact. Uptake might be higher too, given that there are many reasons for not using contraceptives. Even in countries where abortions are illegal, ensuring that healthcare is safe and accessible could be a far better way of meeting some women's reproductive health needs.

One of the people interviewed in the article says how confused she was about contraception and suggests that those around her were also confused. But some of the biggest and best funded NGOs have been pushing contraception aggressively for decades in African countries. It doesn't yet seem to be apparent to these NGOs that people who have been denied basic education and health for generations are a lot more difficult to provide for.

Vertical health programs, such as the ubiquitous 'family planning' programs, may be well meaning and often well funded, but understanding of complex issues requires at least some basic education. Simplifying the issues may result in people being able to trot out what they have been force fed on cue, which is great for publicity, marketing, monitoring and evaluation purposes, but it doesn't lead to understanding.

One of the most aggressively marketed contraceptive methods is injectible hormonal contraceptives such as Depo Provera. These are not only expensive, but they have been linked to increased HIV infections among women and increased transmission of HIV from women to men. Appropriate and safe reproductive health may cost a lot less than heavily marketed and overpriced commodities. But instead of finding ways of replacing Depo Provera and similar methods with safer methods, which may also mean lower costs, some contraception obsessed NGOs, backed up by the commercially aware WHO, have issued confusing advice, and continue to push something that could be increasing HIV transmission, with the justification that it is very effective at reducing conception.

Several people working on the mass male circumcision program in Kenya told me that they concentrated on circumcision because there was funding for it. If there was funding for other programs, they would apply to implement them too. There was opposition to circumcision when it was first mooted, but those who really really wanted the program to go ahead took steps to reduce that opposition. If it can be done with circumcision, why not abortion? What kind of cultural and religious objections can people have to abortion that they wouldn't also have to underage sex, extra-marital sex, procrastinated rape, rape and other phenomena that may result in attempted  and unsafe abortions?

Development priorities may well be, as some say, all about money; but there seems to be a lot of money around. However it needs to be spent on programs that improve people's lives, not ones that provide some benefit that may be more than offset in some other way. If Luo politicians, Luo people and the populations of many other African countries got behind mass male circumcision, why not invite them to choose development programs that are genuine priorities rather than donor obsessions? The same NGOs will have their snouts poised over the trough, it's all money to them. But there are beneficial ways of spending it and most Africans probably know what they are. Western donors clearly don't.



Anonymous said...

A doctor friend of mine at a top Nairobi hospital confessed to me the other day that they have no way of screening blood for HIV during the window period. He advised me never to accept blood from people other than trusted family.

Simon said...

Hi, thank you for your comment, I believe that is a potential in many countries. Also a problem is that people receiving transfusions will often get the blood directly from a donor, perhaps a family member, without going through a blood bank, which can often be short of blood. This phenomenon is especially common when there is an emergency, such as a bad road accident, a fire, a terrorist attack or similar. I imagine the problem is a lot worse when there is a doctors' strike or any other kind of disruption. Even accepting blood from 'trusted family' is only good advice if the equipment used is safe, as many blood donors in some countries are likely to have been infected through an unsafe donation procedure. There is some additional information and advice here:

Anonymous said...

Man in US sues blood center after allegedly receiving HIV-infected blood.