Could PrEP be in Competition with Mass Male Circumcision Programs?

[Reposted from the Pre-Exposure Prophylaxis (PrEP) Blog]

After years of trying to create a market for pre-exposure prophylaxis (PrEP) pills, such as Truvada, Big Pharma has turned to their favorite mass marketing ploy: dumping their products in African countries that are starved of health funding. Of course, why wouldn't they dump them in Africa, won't they be paid for with donor funding?

An article in Kenya's The Star entitled "Kenya: 'Wonder Pill' for Risky Sex On the Way" takes the unusual step of raising some difficult questions about PrEP, rather than repeating the Big Pharma press release, despite a shaky introduction. The article continues "Kenyans involved in risky sex behaviours will soon get a 'wonder pill' that can prevent HIV infections. Experts say Truvada, which some call the 'new condom', can reduce chances of catching HIV but there are fears the drug may be misused by the youth".

What, exactly, would constitute misuse of the drug? If it can cut the risk of infection by "up to 75 per cent if one faithfully swallows it daily", what could go wrong? Well, as the article eventually reveals, most people don't swallow drugs daily and most people can not expect 'up to 75%' reduction in risk. That figure is not even from a randomized controlled trial, but from a 'sub-group' study, where the best results are used to exaggerate the level of protection people, in (comparatively) strict trial conditions, may expect. Outside of that sub-group, and outside of drug trial conditions, risk reduction is far lower.

It's odd that such reports talk about studies and proofs for something that they then refer to as a 'wonder pill', a 'new condom' and talk of 'up to 75% protection' (although that's a bit weak compared to the term 'invisible condom' used by those marketing mass male circumcision), and the like. These are PR buzzwords, not scientific findings.

It is said that PrEP programs intend identifying those most at risk of being infected, such as sex workers, intravenous drug users and men who have sex with men. This will be a departure from vilifying these already stigmatized and criminalized groups; it remains to be seen how much donor funding will actually be spent on these groups to provide them with PrEP, given that it has been so difficult in the past to provide them with condoms, injecting equipment and even basic sex and sexuality education.

As the article says, Truvada is expensive, and it has made billions of dollars for Gilead. So it's worth their while pushing as much of the stuff as possible in countries with high HIV prevalence while the patent guarantees that their product will face little competition. By the time the patent expires the likes of Bills Clinton and Gates will surely have set up some program whereby the drugs can continue to be purchased at inflated prices.

The article makes the important point that nearly 1 million HIV positive Kenyans currently need antiroviral drugs just to keep them alive. So why would donors want to provide these same drugs to people who are not yet infected with HIV (aside from an obvious desire to enrich big pharma)?

Oddly enough, a cost effectiveness study makes its estimates using existing levels of male circumcision and antiretroviral therapy. This means that the three multi-billion dollar programs will be in direct competition with each other for funding, and each one will be trying to claim that any drop in HIV incidence is a result of their work. The study also seems to assume far higher levels of success than have been achieved so far. But that's big pharma for you.

While Gilead and other pharmaceuticals can gain a lot from any increase in antiretroviral therapy and PrEP programs, they may not stand to gain from mass male circumcision programs. Their assumption that their PrEP programs will be cost effective only in countries where circumcision levels are low suggests that by the time their product may be approved, the circumcision programs will already need to have failed, some time around 2015.

Worries that people may use PrEP as a kind of recreational drug, so they can dispense with the use of condoms when they are engaging in sex with people who may face a high risk of being HIV positive are not very convincingly addressed; nor are worries that overuse and misuse of antiretrovirals, either for HIV positive people or as PrEP, are brushed aside, with remarks about "government policy" and making the drug available "in form of a package that probably includes HIV testing and other prevention methods".

I seem to remember condoms, circumcision, ABC and various other programs being made available in the form of a package, without that leading to extraordinary results. But it will be interesting to see if PrEP will erode some of the funding currently being made available to, or earmarked for, mass male circumcision programs.

Circumcision programs stand to rake in billions for the big providers, but widespread use of PrEP would be worth far more. It's unlikely that a full scale version of both programs could co-exist; they are not mutually exclusive, but their cost effectiveness is predicated on their being the only or the main program in high HIV prevalence countries.

Whether one program displaces another, or whether they all get funded, the losers will be people in high HIV prevalence African countries, which will continue to suffer from under-funded health and education sectors. They will continue to be a mere 'territory' for sales reps, who will continue to carve things up in ways that should be very familiar to us by now.

What do Media Censorship and Manipulation, Gates, the BBC and Circumcision Have in Common?

Internews describes itself as an "international non-profit organization whose mission is to empower local media worldwide to give people the news and information they need, the ability to connect and the means to make their voices heard". But one of their much trumpeted programs claims to train journalists about the 'science' behind mass male circumcision programs in Kenya and creating demand for the procedure. There's quite a difference between training journalists on the 'science' of circumcision and creating demand, and the latter generally has little to do with empowerment.

The fact that the BBC's Media Action portal, Creating Demand for Voluntary Male Medical Circumcision, which is backed by the Bill and Melinda Gates Foundation, has named the work of Internews as an example of best practice also says a lot more about the three institutions' shared biases than about empowerment. Even the URL bluntly states the bias.

A press release gushes: "Internews’ training approach illustrates the benefits of training journalists to report accurately and impartially on culturally sensitive topics, such as VMMC. The training resulted in some 100 news stories focused on this high impact HIV prevention procedure that were published or broadcast. What was notable was that the media did not carry any negative news stories about the topic during the period that Kenya was rolling out the medical procedure in Nyanza Province." Oddly, another version of this press release uses the term "falsely negative news stories"; I wonder which is correct? Or is any negative news story 'falsely negative'?

So where is the impartiality in creating demand for mass male circumcision? If people have reservations about circumcision perhaps they have good reasons to. But if the procedure is as wonderful as proponents claim it is, why should such aggressive demand creation be necessary? It is claimed that Internews training "does not prescribe to journalists what to cover" but that their main concern is accuracy. Yet their country director Ida Jooste, perhaps inadvertently, flatly contradicts this claim.

She says that a "critical article was published in Uganda about VMMC quoting a poor-quality study which attacked the credibility" of the often cited Randomised Controlled Trials that took place in Kenya, Uganda and South Africa. Without citing that 'poor-quality' study, she goes on: "Rather than wait for the Kenyan media to pick up and run the story, Internews proactively convened a round-table with journalists and VMMC experts from the National AIDS and STI Control Program, and other organizations to analyze the story and examine its scientific arguments. As a result, not a single media outlet in Kenya chose to pick up or run the sensational story."

I don't think I'd use the word 'impartial' there. Ensuring that only positive coverage is aired and that negative coverage is quashed is media censorship and control, pure and simple. This is all paid for by the US taxpayer, though it seems the UK may now have something to do with it too.

Internews also 'worked with' (should that be 'worked on'?) civil society and health agencies working in the field of mass male circumcision. When they ran a conference focusing on women's 'involvement' in mass male circumcision, "to their delight" this resulted in 25 news and feature stories. This is pure manipulation, but those involved seem to express no shame, apology or even justification for it. Joost is even cited as saying "We believe that the impact of positive media coverage, or at the very least, the absence of negative coverage, complements and reinforces traditional public campaigns aimed at creating demand and behaviour change".

The above illustrates a concerted effort by a donor (Gates), an international media outlet (the BBC, via its corporate social responsibility wing) and a well-funded US non-profit, to control the Kenyan media. These parties then openly report their successful manipulation and censorship of the media, which has resulted in completely biased coverage of a public health program that is opposed by many of those who have taken the time to inform themselves about it.

What kind of foreign donor funded public health program, only carried out on certain African populations, is so important that it is necessary to manipulate the press so that they only report positive stories and that they don't report negative stories about it? If Kenyan people had any objections to this kind of neo-imperialism, would their press even report it? If the US wanted to impose a mass male circumcision program in the UK, would the BBC also collude with Gates, PEPFAR, CDC, UNAIDS and other parties to make sure objections were not heard? This must be what is meant by 'informed consent'.

The Media in Africa: Beware of Natives

BuzzFeed has photos of 10 signs photographed in South Africa during the apartheid era and it is truly shocking to think that, as the article points out, these signs only became illegal in 1994. But that's why it should be even more shocking that instances of extreme racism and apartheid style thinking should still be so common in the international media today. I have listed a number of examples below, with links to some of the most offensive articles I've read in the past few years.

These are just the tip of the iceberg and a full study would take years. But, in no particular order, let's start with the stories about condom 'recycling' in Kenya and condom 'rental' in Tanzania. Whether the journalists who wrote these stories were bored or desperate is just one question; but what about the media outlet that published them and the public who read them?

One that goes back a few years is the 'story' about starving HIV positive people on antiretroviral drugs eating cow dung in Swaziland. Numerous media outlets echoed that one and it cropped up several times. There was even a story about a woman in Namibia who  claimed to have eaten cow dung but then admitted that she had made it up. She didn't attract anywhere near as much publicity, though.

The ever-popular notion of 'African' sexuality is a trusty tool in the journalist's store of prejudices. Although it has been debunked many times, the media picture of Africans has remained faithful to their apartheid agenda. Africans are truly 'other', that's why there are such massive HIV epidemics in some African countries, isn't it?

The UNAIDS Modes of Transmission analysis, which produces the 'science' behind the media's HIV related racism has also been criticized, but why attack the source of so many stories that everyone seems to enjoy and find so completely inoffensive? UNAIDS even recognizes the true HIV danger in African countries, unsafe healthcare. But they keep that to themselves, publishing advice about avoiding non-UN approved health facilities in a booklet for UN employees, courtesy of the sweetly named 'UN Cares' (about its own employees).

Occasionally a journalist may allude to the use of African participants as research fodder, but people are too used to hearing about the oversexed and feckless African to care very much about such abuse, especially when it can always be dressed up as 'helping'.

It's coming up to about six years since the international media 'discovered' the Tanzanian albino attacks and killings, even though they had been reported in local media for some time. The sloppy and offensive coverage that followed this great 'scoop' for the BBC continues, as do the attacks on persons with albinism. Why revise a story that has won praise and awards? Of what importance are accuracy and insight when opportunities for self-adulation are at stake?

The disgusting US Christian right story of the use of adult pampers as a result of anal sex among men who have sex with men has even done the rounds in some of the local media. We see articles about African countries claiming that homosexuality is 'brought in' by foreigners. But where did the homophobia come from?

There are sometimes instances of the kind of media friendly racism that is 'roundly' condemned, trivial matters that keep readers entertained, much easier to write about than anything that matters. But what the media writes is clearly not yet a source of offence to most people. Perhaps in years to come sites will be able to list some of the shockingly abusive things the mainstream media published about African people, who knows?

Open Letter to the United Nations Office of the High Commission for Human Rights

[Crossposted from Blogtivist; the link provided to the UN report was to a different report and the correct link has now been provided, apologies for any confusion this may have caused]

Dear High Commissioner Navanethem Pillay

This open letter to you is about one of your recent reports, entitled 'Persons with albinism' (A/HRC/24/57), dated 12 September 2013. Your summary gets to the point: "In some communities, erroneous beliefs and myths influenced by superstition put the security and life of persons with albinism at risk." You also refer to 'ritual' killings and attacks to which many persons with albinism have been subjected over the last six or seven years, particularly in Tanzania. You remark that "[t]he information on the various cases collected by OHCHR came from multiple sources, but the level of verification varies in each case.

It is this level of verification that especially interests me. Earlier in the report you stated that "[t]he collection and verification of cases of ritual attacks is a challenge due to the secret nature of witchcraft rituals, the inability and/or fear of victims’ relatives to report such incidents...[etc]." I would suggest that, from the earliest killing reported in the international media, widely believed to emanate from the BBC, all witchdoctors and other people reputed to be engaged in witchcraft, or related activities (very different sorts of activity among which the BBC makes no useful distinction), have been thus implicated in the attacks.

I hardly need to remind you what that means. Many people, in Tanzania and other countries, have been persecuted by mobs, even lynched, because of the belief that they were engaged in witchcraft or something similar. Indeed, what may have been the first 'ritual' killing of a person with albinism, reported in the Legal and Human Rights Center in their 2006 report, is a brief mention of two men who were lynched by a mob; the brief mention is, essentially, about the killers themselves, not their victim. Your report does not mention the Tanzanian Witchcraft Ordinance of 1928, which proscribes public accusations of witchcraft without providing evidence that the accused actually practiced witchcraft or claimed to possess witchcraft powers, etc, but I’m sure you are acutely aware of the risks that those merely suspected of witchcraft, and even those investigating attacks on persons with albinism, face.

I needn't labor the point; witchdoctors have very good reason to be secretive, especially when everyone points the finger at them following the (rether frequent) occasions on which the media sees fit to implicate them. I'm sure you haven't forgotten earlier stories about the 'skin trade' in Tanzania, 'devil worship' in Kenya and various other phenomena more notable for the vast number of column inches dedicated to them that to the substantive content of the various reports that came to be written about them.

Your report notes that victims, their relatives and fellow community members are afraid to report killings. But it's only natural to fear those who are thought to have magical powers, and worse, to be so ruthless that they would attack people with machetes to maim and/or kill them, or even to instigate such a killing. However, could people actually be more afraid of the absolute demons they read about in the press than anything they have ever experienced? Could they be afraid of something they have never seen, but which they are assured by everyone who has read these reports, exists among them and wields a terrible power over them?

As you say, levels of verification are important. The vast quantity of media coverage may one day yield up something that constitutes evidence of such devotion to superstitions that it leads to maimings and killings; the small handful of sources of information on which the media depends, and on which your preliminary report now depends, may have some checkable, some verifiable source of information that lies, however hidden, behind it. Perhaps this could be used to carry out an investigation into some of the killings, at least the ones for which there is even a minimum level of documentation.

But I would suggest that the media itself has often been secretive, a bit ritualistic, even a bit fetishistic, at times. They constantly refer to things as if they have evidence, words like 'official' are used (although few journalists, if any, seem to view the police, or any other commonly used informants in such cases, as a possible source of anything except further unsubstantiated information, ridicule, stories about corruption, predictable stuff), they write as if the very dogs on the streets know that all these attacks were carried out by witchdoctors who paid 'middlemen' to 'obtain' body parts of people with albinism, for which 'rich and powerful' people pay large amounts of money to ensure that they become more rich and powerful.

It's a very credible story, in a sense, given the many other incredible stories we are told about Africans or, in this case, Tanzanians; a story of superstition, poverty, bullying by rich people, incompetence by 'officials'. But it's a story for which the media provide little or no evidence. Tanzanian people may well have been convinced that witchdoctors are rich and powerful, and that they themselves could become rich and powerful by working for them, or for their rich and powerful clients. But, aside from the plentiful supply of gossip, where is the evidence? Or should I ask what constitutes evidence in these cases? If the sheer number of media reports constituted evidence, all Tanzanian witchdoctors (and those thought to be witchdoctors) would be locked up, perhaps even condemned to death. But none, as far as I know, have been executed (unless some have been killed by mobs). Few have even been through the courts.

I truly hope any evidence that exists that sheds light on these attacks on people with albinism is going to be handed over to you by those who have generated so many media reports based on what seems to them to be so certain. Your preliminary report suggests that little new evidence, with a reasonable level of verification, has yet been made available to you. It is to be hoped that all will be revealed in the final report, after a thorough investigation, one that looks critically at the assumptions we have been making for around seven years without putting a stop to the attacks, apprehending the attackers, or protecting the victims and those around them.

As things stand right now, perhaps there is something wrong with our assumptions? The practice of 'witchcraft' was banned without that preventing further attacks. Over 170 people were allegedly arrested, and let go (at least, I hope they were let go). Apparently over 70 of them said they had been told by witchdoctors to bring them albino body parts. Could this be an important lead? Or could it suggest that everyone reads what has been written in all the papers for months, or talks to someone who does? None of these people were convicted. That could be because there was no evidence, aside from the fact that they were witchdoctors, suspected of being witchdoctors, associated with witchdoctors, etc.

Or maybe they were not involved, or not even completely aware of what was going on, aside from what they read in newspapers or heard from people who read them, or claimed to? The media calculated and recalculated the figures for victims and deaths: there were 4 in December 2007 but 20 by January 2008, without any media report that I could find accounting for any of these new attacks by providing basic details; who were all these victims? Generally we don’t even know their names, sometimes not even their gender. Was their body discovered somewhere, or was there even a body? You may think these are silly questions, because the media eventually agreed by some time around 2012 that there were over 70 deaths. But how starkly all this contrasts with reporting on murders in Western countries, where some of them become household names; at least we get the basic details.

At first, it was claimed there were 71 deaths if you included 17 from Burundi, seven from Kenya and three from Swaziland, but it is asserted that there were 71 deaths in Tanzania by the end of 2012, without that qualification, and by 2013 the BBC raised that to 72 deaths in Tanzania. I suggest that the running tally of deaths has become a bit confused and that various reports are mixing up important details. Perhaps all I am lacking is access to ‘official’ sources, to which some refer, but if there are official sources I believe they should be named, or at least described. Otherwise we don’t know if this is an instance of secrecy, sloppiness or exaggeration.

According to the media accounts that I have looked at there were well over 30 deaths that attracted enough media interest for something about the incident to be recorded, the age, location or some circumstance, such as 'skinning' of the victim. There were well over 70 documented attacks. Not over 70 killings, as the media eventually agreed, but as I said, they could be keeping their cards close to their chest. But attacks continue. Media coverage has waned considerably since 2008 and 2009, but I have tried to account for documented victims in the linked table and I would welcome additions to it.

You will, no doubt, have read a lot already, possibly coming across odd recurrences and even more odd contradictions, even convenient, but unsubstantiated juxtapositions. You will probably even notice that predictions, such as the fear that lots of persons with albinism would be maimed and killed before the 2010 Tanzanian elections turned out to be unfounded? It doesn't say that in the mainstream media, as far as I know, but nor could I find any articles about a noticeable uptick in attacks. Documented victims peaked in 2008, but again in 2011. There was a big dip in 2009 (without a corresponding dip in media coverage), with a further dip in 2010, by which time media coverage began an exponential decline that has continued for several years. I quite accept, of course, that my data is limited to what is available, free of charge, online; the media may have access to other information to which I am not privy, but to which, I hope, you are privy.

To conclude: you mention 'erroneous beliefs and myths, heavily influenced by superstition' in your analysis of attacks on persons with albinism. I would add to that a set of erroneous beliefs and myths that are heavily influenced, even promoted, by the media. If people believe in the great power of witchdoctors, and believe that they can get paid a lot of money to carry out a maiming or a murder, they are quite wrong, and it behooves the media to make that completely clear, now. But why would ordinary Tanzanians even believe such a thing? Perhaps they deserve to be condemned for being stupid enough to commit a terrible crime on the stuff of rumor and gossip. But ordinary Tanzanians themselves are not the source of all rumor and gossip, nor are they the sole spreaders of rumor and gossip.

If it is the case that not all witchdoctors are so powerful and so ruthless, that not all 'middlemen' (and what ordinary Tanzanian could not, going by media descriptions, fill that role?) are so greedy or so gullible, even that most ordinary Tanzanians living in rural communities (and we are frequently told about levels of superstition in rural areas) are not so cowardly or so despicable as to turn a blind eye, or to conspire with other parties, as to maim and kill members of their own community or their own family 'because of their superstition', or worse, because of lust for money, then the entire investigation of the attacks needs to begin again.

Why? Because the received view of these attacks needs to be called into question. We simply don’t know much for sure about witchcraft, a ‘trade’ in body parts, or a ‘rich elite’ that is willing to pay large sums of money for goods and services provided by witchdoctors; we don't know who we are looking for, what they are like, how many they are, aside from the suggestions provided by the media.

I believe  it is vital for us to understand the root causes of attacks and discrimination, and your report refers  to these among your recommendations. However, the distinction between the causes of the attacks and the causes of the discrimination is just as vital. The attacks are a relatively new phenomenon, even various media cited sources agree on that. But the discrimination goes back decades, perhaps centuries, and affects the millions of disabled people living just in Tanzania alone (an estimated 2% of the population), to this day, not just the tens of thousands of persons with albinism (or hundreds of thousands, depending on which article you read).

Media reports, and other reports depending on media reports, do not constitute a solid foundation on which to base further investigations. I am sure you are aware of that, but what I have read so far, in the media and in other reports, is highly questionable. Yet I see virtually the same material in your preliminary report. It is not my intention to advise you, only to urge you that the current body of data on attacks on people with albinism may not yet be very reliable.

I look forward to a report that results in the protection of persons with albinism, brings perpetrators of violence to justice and ensures that these attacks never happen again. Following the publication of the report, persons with albinism, those associated with them, those associated with attacks on them, and all other innocent people, will enjoy those human rights that have, up to now, been denied them.

In addition to compiling a web page of documented attacks, to which I have provided a link, I have various other data that I have collected. If I can be of any assistance to you or your officers, please do not hesitate to get in touch with me.

Respectfully

Simon Collery

Guardians of the Orthodoxy: Writing about Rights and Rites

[Cross posted from the Blogtivist site]

Following a facile article in favor of mass male circumcision on the Poz.com site (which I discuss on another blog), where the author went to some lengths to pretend he was not in favor of it, there is an article defending circumcision as a religious rite for Jewish people, with even a single mention of Muslims (at a time when even vaguely pro-Muslim, or non-anti-Muslim, sentiment in the media is particularly unfashionable) in the English Guardian. The title of the Guardian article reads: "A ban on male circumcision would be antisemitic. How could it not be?" The article purports to be a response to the Council of Europe's 'comparisons' of male genital mutilation with female genital mutilation, with the author claiming there is no acronym for the former, suggesting that she has familiarized herself with neither the literature nor the operation.

But enthusiasm for circumcision is not confined to the operation as a religious rite. The big money is behind it as a 'preventive' against HIV and several sexually transmitted infections. Starting with adults and teenagers as targets for mass male circumcision campaigns, proponents have long been setting their sights on infants. Never mind the fact that most infants don't engage in any kind of sexual behavior, least of all a kind that would be claimed to increase the risk of HIV transmission in those who have not been circumcised, not even by the most rabid proponent of the operation. Proponents of circumcision *want* to circumcise everyone, at all costs. What could be easier than starting with Africans, about whom few in the media care very much.

What has the Poz.com argument got to do with the Guardian article? After all, Poz.com is promoting circumcision for its claimed protection against HIV and the Guardian is promoting it as a religious rite. Well, both articles argue for the mainstream, financially sound view, the view that doesn't fly in the face of current political sentiment and, more importantly, doesn't fly in the face of important funders and supporters. Poz.com depends on big pharma for its funding, along with some other wealthy institutions. The Guardian does not (entirely), but the Guardian's Development section is funded by the Gates Foundation. That is higly significant when it comes to circumcision: the Gates Foundation is not just pro-circumcision, it funds one of the three main websites that promote circumcision, the Clearinghouse on Male Circumcision for HIV Prevention (the other two are the WHO and USAID).

In fact, the Foundation has also funded research carried out on African participants, research that is highly questionable, ethically as well as empirically. The Guardian's article doesn't appear on their Development section, but the connection with as huge a figure in the realm of circumcision promotion as Bill Gates is of a significance that should not be dismissed lightly. In addition, the Guardian article defends circumcision as a religious rite, but the Poz.com article, by implication, opposes non-circumcision as a cultural right. Ethically and empirically dubious arguments are being shoved down the throats of Africans who do not currently circumcise, by people who do not consider for one moment that others have the right to choose not to circumcise, for cultural reasons. In Kenya, for example, it is for cultural reasons that members of the Luo tribe do not circumcise, and the same goes for many other Africans. It is not because they, like the Europeans, do not believe that the reasons given for mass male circumcision are completely unconvincing (arguments that have changed many times over the decades, except in the fervor with which they are expressed).

Back to Tanya Gold's arguments in the Guardian. The Council of Europe, astutely enough, used the phrase violation of the physical integrity of the body' to describe male circumcision. Even defenders of the operation could hardly deny that it violates the physical integrity of the body, could they? After all, that's the point of it, as a rite and as a putative protection against HIV. Gold doesn't tell us if she would object if the Council had attempted to suggest that parents be allowed to wait until their boys were old enough to decide whether to be circumcised or not. After all, compromises have been made before. Religious and cultural rites have been modified, even abandoned altogether. Tattooing and body piercing are not banned, but people are not permitted to tattoo and pierce parts of their babies, or even their children. These also violate the physical integrity of the body, although many people believe that they are worth having, for cosmetic or other reasons.

Even Gold is 'repulsed' by certain conditions that may surround circumcision, as if these conditions are not common. But most circumcisions are carried out in non-sterile, non-clinical conditions. In fact, like the violation of the physical integrity of the body, this is what makes them a matter of religious or cultural rite, rather than an operation that people can have carried out in a hospital, preferably when they are old enough to decide if they want to have their foreskin removed. Gold is not arguing for these conditions, but she is arguing for the religious right to perform circumcisions, and (perhaps) for the cultural right (or maybe she only considers Jewish circumcision to be worth defending? She is not clear on this.) Would Gold consider allowing parents to wait until their son could decide for himself? We expect those who perform rites and rituals we (in the West) consider repulsive, harmful, etc, to compromise or even abandon those rites and rituals. Why not discuss such a compromise with those who practice circumcision?

Gold objects to calling ritual circumcision a 'violation of children's rights'. But if there are exceptions to a law against violation of children's rights, and violation of the physical integrity of the body in particular, how does this affect other children's rights, even human rights in general? Can you argue that certain rights should be denied to those infants where parents believe that that would constitute a denial of their own religious rights to circumcise their child? Are human rights not interrelated, interdependent and indivisible: Gold seems to believe that circumcision does not involve violation of the physical integrity of the body, which is ridiculous, though she may prefer a different way of expressing the same thing. But she also seems to believe that circumcising infants is not a violation of their rights, and that banning infant circumcision denies parents their rights. She doesn't make the distinction between infant circumcision and adult circumcision, but she seems to believe that the Jewish rite necessarily requires that it be carried out on infants.

Sadly, Gold has confined her arguments to the rights of Jewish people and chosen to write about antisemitism, rather than dealing with the broader issues of circumcision, human rights, the right to choose (particularly the right to choose not to circumcise), children's rights and the like. True, she stuck her neck out by using the word 'Muslim' once and had the temerity not to include any other words beloved by journalists and home office officials as an accompaniment to the word 'Muslim', but she is clearly not in the business of standing up for what she believes in. It's almost as if it's not her job to believe in things. She invokes the typical 'slippery slope' argument: if circumcision is a "human rights violation against children... This is a trend – and so of course the next stage is prohibition." We wouldn't want to use emotive arguments, would we? There is a "dark marriage between human-rights agitators and racists", according to Gold.

Which means that in objecting to infant circumcision, either as a religious rite or as a means of 'preventing' HIV, I am not just an antisemite, but I am also in bed with racists. I am supporting the "removal of Jews from Europe". There was me thinking that I was arguing for human rights and against abuses of human rights, especially ones that journalists typically ignore, such as the rights of people who are not wealthy, or powerful, or perhaps people who are not even Guardian readers (who?), although I read the Guardian myself. Gold ends her piece with a sentiment that I would agree with if it were about journalists: "some Jews are always packed in their minds". But I can't reassert my credentials as a defender of human rights by accusing a journalist of having views that are formed independently of thought, evidence, logic or humanity; that's shooting fish in a barrel.

What Happens when an 'Activist' Site is Bought off by the Multinationals?

The website 'poz.com', which is about HIV, but from a US point of view, has a recent article on circumcision by Ben Ryan, who is apparently a journalist. The strapline reads "Major studies support circumcision as prevention in Africa but a small yet vocal group argues the science is flawed. Can circumcision lower U.S. HIV rates?" The question is odd, because the article is not primarily about whether the operation can or can not lower transmission in the US (Ryan seems to suggest the answer is 'yes', but in a country where HIV transmission is predominantly among men who have sex with men and intravenous drug users, 'no' seems much more likely to be correct). The article is not really about the science either, but rather how that 'science' is used. (Even the title, 'Cut to Fit', sounds like an ironic reference to the author's journalistic style.)

Ryan gives a selective review of the 'science' as he sees it, listing the major players in circumcision promotion, major in terms of the funding they receive, anyway. But all this is contrasted to an 'ideological war', by what Ryan brands as a small group of 'dissidents'. The fact that many of those who oppose the imposition of mass male circumcision on tens of millions of African men who are not already circumcised, and male infants born to people who would not normally choose circumcision in infancy, are also scientists doesn't seem relevant. The facts that skepticism is not inherently unscientific and that not all those who oppose mass male circumcision can correctly be referred to as 'dissidents' also seem unimportant to Ryan.

Although Ryan enjoys the term 'intactivist' to refer to people who oppose mass male circumcision on the grounds that the 'science' is highly flawed, this is not a widely used term by opponents. Some, like myself, oppose mass male circumcision on human rights grounds, and on the grounds that insisting on every man conforming to what is an American preference is an outrageous instance of cultural imperialism; but I certainly wouldn't call myself an intactivist. According to Ryan, those who oppose mass male circumcision are mainly Americans and Europeans, without pointing out that those who promote it are almost all American, and all their funding is from America.

Part of the pretence of 'giving both sides of the story' involves interviews with people whom Ryan subtly belittles. One of those interviewed is John Potterat, who has carefully outlined the reasons for skepticism about the 'scientific' literature, which is freely available on the Social Science Research Network. According to Ryan and his favored informants, 'dissidents' are 'hampering progress', 'spreading misinformation' and 'creating skeptics among those who stand to benefit', the last referring to African people, whose future is being put in jeopardy because of a handful of unscientific people who are not epidemiologists or health scientists, and therefore should not hold an opinion on human rights or cultural imperialism, or so Ryan wants us to believe.

Ryan also interviews Rachel Baggaley, who has an MD, who reassures us that the three million figure the WHO claims have been circumcised under the program sounds very low beside the 20 million originally hoped to 'benefit' from the operation because 20 million was 'aspirational'; that the WHO had "underestimated the complexities and social sensitivities required to successfully promote the program in certain populations". Could some of these 'social sensitivities' be similar to the views of the people Ryan considers to be a mere fringe of 'dissent? What Baggaley is delicately referring to is a dearth of safe health facilities, experienced health personnel and supplies needed to provide mass male circumcision that doesn't result in a lot of botched operations and a huge increase in hospital transmitted HIV; also, that infuriating barrier to US cultural imperialism: foreigners, non-Americans.

Another 'dissident' cited is David Gisselquist, who has spent years publishing articles showing that unsafe healthcare and cosmetic practices may be making a significant contribution to the most serious HIV epidemics in the world, which are all in sub-Saharan Africa. The evidence for various types of non-sexually transmitted HIV is spread over hundreds of papers, written by people from various backgrounds, including public health, medicine, epidemiology and others. Indeed, one of the most important factors in transmitting HIV in African countries is circumcision itself, not just medical circumcisions carried out in unsafe health facilities, but also circumcisions that are carried out for cultural reasons, generally carried out in unhygienic conditions.

While presenting arguments against mass male circumcision in a context that makes them futile, Ryan lists the arguments for the program as if they were some kind of holy grail of truth, true for all time, in all places, as true for non-Americans as for Americans. Those pushing for the program keep going on about how similar the results of all the randomized controlled trials were, without this being held up to any kind of questioning; were these crusaders really so lucky, that all three trials came up with almost the same results? Why were the trials carried out in those areas, among those people, with those specific (poorly described) methodologies? Were any other trials carried out that may show the opposite effect? And why are the mass male circumcision programs going ahead in areas where HIV prevalence is already higher among circumcised men than uncircumcised men? What about current programs that are currently suggesting that mass male circumcision programs seem to be increasing HIV transmission, in Botswana and Kenya?

Oddly enough, Ryan gives the last word to Baggaley, who now refers to those who oppose the US funded mass circumcision of African men as 'denialists'. She says they are generally not from high HIV prevalence countries, as if those promoting the program are. Seeing herself as having the perspective of a 'young man in South Africa', she finds objections to the operation to be 'paternalistic'. Evidently she doesn't see the paternalism in spending billions of US dollars on persuading people to be circumcised by telling them that there are numerous advantages to be enjoyed. How is that different from the various (also US funded) efforts to persuade poor people to be sterilized? How is that different from various syphilis 'experiments' carried out on African Americans, or similar ones carried out in Guatemala?

In stark contrast to Ryan's stance of appearing to be 'giving both sides of the argument' while achieving no such thing, Brian D Earp has written a very cogent rebuttal of all the bits and bobs that Ryan thinks of as science. Earp does put his cards on the table: he is not undecided about whether mass male circumcision is a good or bad thing. But neither is Ryan, he just pretends to be. If you are interested in reading solid rebuttals of the arguments of those claiming to be 'scientists', and others, it's worth reading Earp's article in full. I can not do it any justice by paraphrasing it.

To conclude, branding people as 'denialists' or as being 'unscientific', even when the point is not a scientific one, or not entirely a matter of science, has a long history. Journalists pretending to be (or thinking that they are?) even handed is also an old trick. So people have to think for themselves: would you do it to someone you love, or would you wait till they were old enough to decide for themselves? And even if your answer is 'yes', and you would circumcise your son when he's still an infant, does that mean tens of millions of African men should be persuaded by the US (and by US funded 'Kofi Annan' type figures) to do the same, using a hotch-potch of scare stories, half baked theories and outright lies, all dressed up as some kind of scientific canon, and that tens of millions of African infants should also be circumcised, their parents having been primed using the same body of 'evidence'?

Risk of Blood-borne Viruses from Skin-piercing Beauty Treatments

[Crossposted from the Don't Get Stuck With HIV site]

In the light of several recent news reports, the Don't Get Stuck With HIV site has created a new page on possible risks associated with use of skin-piercing products such as Botox and Malanotan. Injection of anabolic steroids and other performance enhancing drugs can carry similar risks, especially if they are administered in an unsterile environment, and/or administered by untrained or inexperienced providers. The UK Government has issued a warning, saying that steroid users are at higher risk of HIV and viral hepatitis. The Don't Get Stuck With HIV page offers easy to follow advice to people considering such treatments.

Similar information and advice on injections in general is available throughout the Don't Get Stuck With HIV site; healthcare risks aside from injections are discussed here. There is also information on risks from other cosmetic treatments, such as tattooing, ear and body piercing, manicures and pedicures and hair styling and shaving. However, beauty treatments that pierce the skin may be more risky than some of these other cosmetic treatments because instruments such as needles go deeper below the skin than tattoo needles, for example.

A recent article on the BBC website draws attention to the concerns of a health watchdog about the safety of Botox injections in the UK. They are also questioning the safety of anabolic steroids, tanning agents and dermal fillers. These treatments can be obtained in salons, or they can be self administered. The article warns that sharing equipment can carry a risk of infection with HIV, hepatitis or other blood borne diseases. The UK's National Institute for Health and Care Excellence (NICE) is currently preparing guidelines on these issues.

Botox is a prescription only drug. However, an Australian news network ran an article late last year about a 'backyard botox' clinic, a specific clinic in Western Australia where infection control practices were found to be lacking, highlighting some of the health risks involved. It is said that the risk of infection with blood-borne diseases is small, but nevertheless real. Some practitioners may offer such treatments in the home, where conditions are likely to be unsuitable.

In 2008, the BBC reported that a growing number of people in the UK are injecting themselves with an unlicensed hormonal tanning drug called Melanotan. It is possible that this drug is being sold illegally online, in salons, in gyms and in health and fitness centers.

The Ever-Widening Rift Between the Media and Reality in Africa

[Cross-posted from Blogtivist]

There has been little agreement about how many albino people in Tanzania have been killed, apparently for their body parts, between 2006 and 2013. But since the middle of 2010, around 70 deaths has been a common estimate, and one which did not increase much over the following three years. The number of articles identified about these events comes to 71 in total, reaching a peak of 23 in 2009. The number of documented victims, of both deadly and non-deadly attacks, is also about 71 (some may not be albinos, some may not be Tanzanian and some may or may not have been injured or killed), peaking at 17 in 2008 and again at 15 in 2011. But only 24 of these documented incidents are reported deaths; of these deaths, only 10 are named by any of the various online sources I have examined.

[Click on image for larger version]

A list of all the sources used for collecting various data is available, which includes a timeline of events, at least as they were reported by the media. It’s not an exact timeline, with some dates referring to publication rather than the occurrence of the events, which may not even be made clear; the list of sources and other sets of data are, of course, a work-in-progress (which may never be completed).

The timeline starts about 9 years before the first report of an albino killing, in1997, when the New York Times runs an article about albinos in Zimbabwe and their struggle for equality; there are even mentions of witchcraft and superstition. Other articles during this period report similar issues, in various African countries, but there is no mention of killings or maimings. Even a peer-reviewed article in August 2006 in BioMed Central makes no mention of such events, though it notes that “People with albinism also face social discrimination as a result of their difference in appearance”.

In April 2007, the Tanzanian Human Rights Report (for 2006) lists public executions that they have recorded for 2006. One particular incident, which occurred in April, stands out: “Two brothers, Benedict and William David (29) were believed to have murdered and taken the organs of Alex Aaron, an albino. When the brothers were arrested, the villagers began hurtling stones at them until they died.” No further comment has been found about this incident, even in subsequent reports. However, a later Human Rights Report (for 2007) says that there were 20 albino people killed in 2007.

In December 2007 there were two reports of attacks on albinos, and a later report by Under the Same Sun (UTSS) names three people who were attacked, but not killed. The first mention by the BBC found relating to attacks on Tanzanian albino people was another early source of information. From this time onward, all articles mention witchcraft (or something similar) and the bestowal of wealth or some other such objective. Vicky Ntetema of the BBC (later to join UTSS) says that this is the “first time that albinos have been targeted in ritual killings” although this turns out to be incorrect according to sources that were not available at the time (such as the 2007 Human Rights Report, noted above).

Only a few months after the issue of attacks on albinos first attracts the attention of the media, the President of Tanzania orders a “crackdown on witchdoctors who use body parts from albinos in magic potions to bring people good luck or fortune”. The certainty with which witchdoctors (also miners and fishermen) are targeted, and equal certainty about magic potions which bring good luck or fortune, suggests that there may be a lot of information about these attacks that is not so easily available online; unless press reports themselves are considered to be reliable. But this is only a preliminary study. There are likely to be many parts of the puzzle that are either unavailable online or difficult to locate. (In early 2009, the government launched another initiative: “citizens will be invited to write down on slips of paper the names of those they suspect of involvement”, dubbed ‘witch naming‘ by the BBC and a ‘secret vote‘ by Reuters.)

By this time, early 2008, it is common currency (in the media) that demand for magic potions comes from people engaged in mining and fishing (for example, in the article citing the president, linked to in the previous paragraph). The number of albino people murdered is now put at 19 or more in the last year. Reference is made to a ‘growing trade in body parts’ in several articles and hints have been made about large sums of money; exact sums of money have not yet been mentioned. The BBC names a victim for the first time in late July 2008 and in the same month refers to an undercover investigation by one of their own journalists which reveals that and albino body part costs about $2,000. This figure and similar amounts crop up frequently in future articles, but it is often unclear whether it is what the ‘client’ pays, what the ‘witchdoctor’ pays those procuring the body part, etc.

Several commentators note that these vicious attacks on albinos started fairly recently (contrary to the claims of UTSS and others that they have been going on “since time beyond memory“). An article in September 2008 says the phenomenon arose some time in the last 10 years. There are several reports ofsimilar attacks in Burundi but it is claimed that the bodies/body parts are destined for Tanzania. Peter Ash, founder of UTSS, told the Vancouver Sun newspaper in a recent interview that the practice of killing albinos had only begun in the last decade, and “the killing of albinos and trafficking in body parts appears to be centered … in and around the city of Mwanza.” This statement is made in an article about the killing of two albino children in Swaziland, and claims that the attacks are ‘spreading’.

There are two reports of people trying to ‘sell’ an albino. One man is said to have tried to sell his wife for $3,000 to ‘businessmen’ from DRC. Another attemptedto ‘sell’ his friend for $250,000, but it turned out to be a sting operation by the police and he was arrested and imprisoned for human trafficking. Over the years there have also been mentions of shoes made of the skin of albino people, thedrinking of the blood of albino people (referred to as ‘cannibalism’) and the belief that having sexual intercourse with an albino woman will cure AIDS.

The exact phrase ‘luck in love, life and business’ crops up at least nine times in the literature; it is just one of many instances of the use of copy and paste journalism. One might wonder with some of the stories if we are looking at copycat incidents, copycat journalism, or a combination?

Several commentators make the prediction that numbers of attacks on albino people will increase in the run up to the elections (in 2010) because superstitious politicians will be consulting witchdoctors for potions to improve their chances of winning a seat. This prediction appears to have been incorrect, unless those making it were too modest to note their prescience after the elections.

Perhaps there were already signs that the media was tiring of attacks on albino people in Tanzania as early as mid-2010, when their rough (very rough) count of deaths had reached 71 and never really went any higher, despite there being 8 documented victims in that year and 11 the year before. The number of articles halved in 2010 and would halve again in 2011 (and again in 2012), even though the number of documented victims rose to 11 in 2011. Two out of the three articles in 2012 were about albino models and there have only been four in 2013.

There have been 9 documented attacks on albino people in Tanzania this year, including at least 2 killings (although one of those killed may not have been an albino person). So maybe the media will renew its (obsessive, bordering on pathological) interest in these attacks? Or maybe they will not; after all, the mere fact that someone has been killed under bizarre circumstances is not always enough for the media to take an interest; just as, perhaps, the appearance of a bizarre incident in the media may not be an indication that the incident ever occurred, or that its description bears any resemblance to anything that ever occurred, anywhere?

Misinformation from UNAIDS' flawed Modes of Transmission model

[By Dr David Gissselquist - Cross-posted from the 'Don't Get Stuck With HIV' website and blog]

To defeat HIV/AIDS in Africa, UNAIDS recommends: “Know your epidemic.” The best way to do so is to investigate to trace the source of infections – especially in children with HIV-negative mothers, virgins, and married people with HIV-negative spouses and no outside partners.

But that’s not what UNAIDS urges African governments to do. Instead, UNAIDS urges governments to use its Modes of Transmission (MOT) model to estimate numbers of infections from various risks.

But the MOT model contains a glaring error. Because of this error, whoever uses the model ends up estimating far too many infections coming from spouse-to-spouse transmission.

In Uganda, for example, the MOT model estimates that 60,948 married adults got HIV from their spouses during 2008. This is two-thirds of the model’s estimated total new infections from all risks in Uganda in 2008.

The MOT model got this number by supposing that 5.9% of married adults (421,000 adults) were HIV-negative with HIV-positive spouses, and that 14.5% of these spouses at risk got HIV from husbands or wives in 2008 (60,948 = 14.5% x 421,000).

But the number of spouses at risk is far, far less. Uganda’s 2004/5 HIV/AIDS Sero-behavioral Survey reports that 6.2% of husbands and 5.2% of wives were HIV-positive.  But – and this is the important fact the MOT model ignored – most HIV-positive husbands and wives were married to each other. Only 2.8% of wives and 1.8% of husbands were HIV-negative with HIV-positive spouses.

Overall only about 2.3% of married adults (averaging 2.8% of wives and 1.8% of husbands) were HIV-negative with HIV-positive spouses – only 222,000 vs. the 421,000 estimated in the MOT model. If 14.5% of these 222,000 adults got HIV from their spouses in a year, that would account for 32,100 new infections (14.5% x 222,000), far less than the 60,948 estimated in the MOT model.

Why is this important? Because if fewer infections are coming from spouses, how did so many Ugandans get HIV in 2008? In other words, the MOT not only over-estimates HIV from spouses, but also underestimates infections from other risks.

What risks are underestimated? Hold on now! Don’t run away with sexual fantasies about young people and some married adults having too much fun with non-spousal partners. Indulging in racist and stigmatizing sexual fantasies is something too many official AIDS experts like to do. But the evidence does not support such fantasies. The best information on sexual behavior does not come close to explaining Uganda’s epidemic.

Setting aside sexual fantasies, the underestimated risks are more likely to be those that UNAIDS’ staff and other health professionals want to ignore – skin-piercing procedures with unsterile instruments, such as injections, dental care, manicures, etc. This is true not only in Uganda but also in more than 15 other African countries that have used the MOT model to get ridiculous figures on numbers of HIV infections from spouses.

Remember how we began: The best way to “know your epidemic” is to trace infections. Let’s challenge HIV/AIDS researchers -- finally -- to do their job. Although it’s decades too late, tracing is still needed to find all the important risks and to stop Africa’s generalized HIV/AIDS epidemics.

[Note: This blog summarizes evidence and arguments in: Gisselquist D. UNAIDS' Modes of Transmission model misinforms HIV prevention efforts in Africa’s generalized epidemics, available at:  http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2315554.]