Is a Woman with Obstetric Fistula Worth Less than an Uncircumcised Man?

The debate about mass male circumcision (MMC) as a solution to the HIV epidemic rages on. The evidence that, in ideal conditions, male circumcision is protective against HIV, is convincing. On the surface, it seems crazy not to implement MMC in Kenya immediately. Many new infections could be prevented and even rates of transmission of other sexually transmitted infections (STI), such as herpes simplex virus, could be cut.

But Kenyans do not live in ideal conditions. If they did, the HIV epidemic there would not be as serious as it is now. The health infrastructure that would be required for MMC does not exist. After independence in the 60s, Kenya's health infrastructure improved. But from the early 80s, global and domestic crises halted this progress.

Then the World Bank and IMF (International Monetary Fund) introduced structural adjustment policies. Countries that got loans from these institutions had to reduce their social services, reduce their public sector employment, privatise as much as possible, remove 'barriers to trade', etc. This process of impoverishment, despite overwhelming evidence of the damage it causes, continues today.

Men in Kenya would be well advised to think twice about being circumcised. The level of adverse affects is 35% for traditional circumcisions, though these have long been known to be hazardous. But the level of adverse affects for clinically performed circumcisions is 18%. I wouldn't even have a tooth extracted in a health service like this. Kenyan health infrastructure is not up to an MMC campaign. It has been systematically run down for thirty years. It will take a long time to build up. Then an MMC campaign may be more feasible.

But there are still problems. Men (all over the world) don't like using condoms. I have met men who will use any excuse to avoid using them and they jump at any 'evidence' that they don't work, such as the maunderings of some Catholic with odd taste in headgear. There is even a myth that condoms don't work for circumcised men. So, if circumcised men use condoms, circumcision may have some effect on HIV and other STI transmission rates.

There is also a phenomenon referred to as 'disinhibition'. People who have been circumcised have been found to behave as if they are protected from HIV and can do without condoms. The same process is thought to occur among people who are on antiretroviral treatment (ART). There is a danger that people who feel disinhibited are likely to have unprotected sex and thus to undermine the effects of all this expensive prevention and treatment.

It is sometimes argued that circumcision is a small and routine operation. Well, in Western countries, maybe it is. But compare it to another small and routine operation, the operation to correct obstetric fistula (OF). Women who have difficulties in labour sometimes suffer from damage to their bladder or rectum. The result is that the baby usually dies and the mother suffers from chronic incontinence.

Lifelong, chronic incontinence is bad enough in itself, but in some societies, where there is no way to reduce the effects of this condition, the person suffering OF is shunned and stigmatised. They can spend their whole life with a preventable condition that could be reversed by a simple, routine operation. OF often occurs in younger girls and it occurs where births are not attended by trained midwives or otherwise qualified people. Lack of education, as well as poor healthcare, is an important factor in maternal health.

An estimated 3000 women suffer OF every year and most don't get treatment. There is currently a backlog of hundreds of thousands. OF is preventable but Kenyan reproductive and maternal healthcare is inadequate, it is unable to prevent this and other maternal health problems. The infant deaths just add to the huge infant mortality rate, which has been growing since the 1980s. Kenyan healthcare is also unable to provide the operation to reverse the damage and allow women to live a normal life.

If the health infrastructure is not up to preventing OF, it is not up to MMC and the follow up care that would be required. And if this simple, routine operation cannot be carried out for those who continue to suffer from OF, what are the chances that the hundreds of thousands of male children born every year can be safely circumcised and cared for? If there is money available for MMC, there must be money available for OF.

But the problem with MMC is that a simple, routine operation for millions of people requires complex health infrastructure. The basic infrastructure needs to be built first. Then, MMC has a chance of working. If the basic infrastructure is there, OF will not even occur or will be as rare as it is in developed countries.

The persistence of OF bears witness to the lack of health infrastructure in Kenya and clearly indicates that MMC or any other grand programme has little chance of success.