Religion, Former Colonial Powers; Fighting Prejudice with Prejudice?

In a paper entitled 'Religious and Cultural Traits in HIV/AIDS Epidemics in Sub-Saharan Africa', the authors conclude that the Islamic faith is protective against HIV. Their conclusions about the role of colonial powers is not quite so clear, except to the extent that former British colonies (FBC) tend to be predominantly Protestant (or non-Catholic) and most of the countries that are predominantly Catholic are former non-British colonies (FNBC).

Making associations between HIV and religion, high prevalence and Christianity, low prevalence and Islam, high prevalence and FBCs, lower prevalence and FNBCs, etc, are very tempting. All the predominantly Muslim countries in Africa have low HIV prevalence, with Guinea-Bissau (3.9%) being the only one with a figure higher than 2% (and it is only 45% Muslim). Prevalence in countries with 90% or more Muslims only reaches a high of 1.1% in Sudan.

All the countries with prevalence above 4% are predominantly Christian; out of these, only four are FNBCs. There are nine countries with over 1 million people living with HIV. Only one is an FNBC (Mozambique) and only one is roughly evenly split into Christians and Muslims (Nigeria). All the highest prevalence figures are in the Christian dominated Southern region, and the four with prevalence below .4% are in the predominantly Muslim North.

But things come apart a bit when you look at countries that are Christian, but not predominantly Protestant. There are six predominantly Catholic countries, all FNBCs, where the highest prevalence figure is 2.9%; all these countries are in Central Africa. Yet, a number of countries made up of between 20% and almost 50% Catholic populations have some of the highest prevalence figures, too.

While Muslims and Catholics (ostensibly) oppose extra-marital sex, homosexuality and various other phenomena, so do Protestants and other non-Catholic Christian churches. Suggesting that such opposition is stronger or more active in countries with lower HIV prevalence risks arguing in a circle.

Some useful generalizations can be made, such as very high prevalence in Southern Africa, very low prevalence in North Africa, mainly low prevalence in West and Central Africa and high prevalence in East Africa. It is also broadly true that most predominantly Christian FBCs are Protestant dominated, rather than Catholic dominated. With the exception of Mozambique, prevalence in all FNBCs is never higher than 5%; but these countries can be predominantly Muslim, Christian, mixed, or Catholic.

There are two major objections to the analysis given or implied in this paper. The first is is that patterns and generalizations that can be made at the regional level, or even at the country level, do not always hold within countries; the second objection is to the assumption that HIV is almost always sexually transmitted.

The authors find some broad correlations but they do not discuss causality. They claim that the populations of countries such as Egypt, Tunisia and Algeria, for example, were protected from HIV because of their Muslim faith and the practices that go with that. But those countries, and others in the North, might have been 'protected' by one of the largest desert areas in the world, the Sahara.

In addition, HIV in those countries is mainly subtype B, which is generally associated with male to male sex (and to a lesser extent injected drug use). Subtype B is rare in other parts of Africa, with the exception of South Africa (where it mainly seems to infect men who have sex with men). HIV epidemics appear to form different patterns across regions and countries. But it also forms different patterns within countries.

High HIV prevalence in the Southern region may be facilitated, to some extent at least, by the well developed infrastructure there, infrastructure that would have been built by the British Colonial power. The same colonial power built far fewer roads or other infrastructure in East Africa, and none at all in Central Africa, where they had very little control.

However, they had control of a number of West African countries, where there is generally a strong infrastructure. Why did HIV not spread around West Africa to the extent it did in Southern Africa? Well developed infrastructure may partly explain variation in HIV prevalence between some countries and some regions, but it doesn't explain enough. There are clearly factors operating within each country that account for some variation in HIV prevalence.

Regarding the second objection, the authors link the Muslim faith with certain moral precepts which they feel protect people from HIV. However, the majority of people in non-Muslim countries were not infected because they engaged in 'immoral' behavior. Even 'official' figures show that the bulk of people infected in many high prevalence countries have only one sexual partner, and most of those partners are HIV negative.

The 'promiscuous African' stereotype can not be used to explain HIV transmission because it is a prejudice, not an empirical fact about people with HIV, or about people from countries with high HIV prevalence. But similarly, the 'non-promiscuous Muslim' is also a stereotype, however positive. If you can not discern a person's sexual behavior from their HIV status, nor discern a person's HIV status from their sexual behavior, the conclusion that being a Muslim is protective against HIV is unwarranted.

Religion and former colonial power may be two important influences in HIV epidemics, but the authors fail to show convincingly how they operate on HIV transmission. Arguing that those and all other relevant factors relate exclusively to indivicual sexual behavior fails to explain the spread of HIV within countries. Heterogeneity between and within African countries suggests that HIV prevalence is not all about sex, and that not all factors operate at the individual level.

South African National HIV Survey Betrays Those Facing Non-Sexual Risks

The latest South African National HIV Prevalence, Incidence and Behaviour Survey, 2012 was released recently. Much of the media coverage concentrated on things like the worrying increase in HIV prevalence compared to the last survey, which was carried out in 2008, said to be the combined result of new infections and a big increase in the number of people living longer with HIV as a result of being on antiretroviral therapy.

The report is a useful document, as far as it goes. But there isn't even a hint that several non-sexual modes of HIV transmission could be contributing to the worst HIV epidemic in the world (in terms of number of people living with HIV, 6.4 million). This is a lot more worrying than the increase in prevalence, because failing to address non-sexual modes of transmission will result in people continuing to be infected through unsafe healthcare, unsafe cosmetic practices and unsafe traditional practices.

Underlining the clear assumption that almost all HIV transmission is a result of unsafe sexual behavior, there is a lot of attention paid to mass male circumcision programs. These are not going so well in South Africa because the majority of circumcised people chose this as a tribal rite, not because they had been hoodwinked into believing that it would save them from various diseases, HIV just being one of them. But the report fails to stress that this means most circumcised males in South Africa faced a far higher risk of being infected with a number of diseases by being circumcised in unsterile conditions.

The report also agonizes over the usual 'behavioral determinants of HIV', such as early sexual debut (a minority of males and females become sexually active at a young age, the vast majority don't), 'intergenerational' sex (a minority, about a fifth of females do, most males don't and this issue has been questioned recently), multiple sexual partners (also a minority do this, more males than females, although HIV prevalence is far higher among females) and condom use (increasing, but probably too low to have much impact on transmission).

However, simply ignoring the possible significance of how people respond to questions is the most arrogant, and probably the most dangerous aspect of the report. There is a list of reasons people gave for believing they would not contract HIV and a few from this list were cited in the media, triumphantly, because some people who thought they would not contract the virus were already infected. Here's the list, with the number of people giving the response and the percentage:

Reasons for belief one would not contract HIV - number and % of cases

I have never had sex before 21,150, 11.0
I abstain from sex 21,147, 21.3
I am faithful to my partner 21,144, 32.0
I trust my partner 21,149, 22.5
I use condoms 21,146, 19.2
I know my HIV status 21,136, 9.8
I know the status of my partner 21,134, 4.4
I do not have sex with sex workers/prostitutes 21,112, 1.7
My ancestors protect me 21,070, 1.1
God protects me 21,142, 2.5
I am not at risk for HIV 21,151, 8.9
Other 21,142, 10.4

Do those carrying out the survey never, for one moment, suspect that some people might be telling the truth? Some people who have never had sex before are being told for the first time that they are HIV positive, and that it's almost certain they were infected through some kind of unsafe sex. What efforts are made to find out how they were infected? What about those who are faithful to their partner? Is their partner tested?

The authors of the report seem to relish the term 'evidence-based' when referring to various different 'interventions' that are expected to reduce HIV transmission; when these interventions appear to fail, those who become infected, or who give inconvenient answers to survey questions, are blamed for their 'sexual behavior'. If the researchers don't even check how people become infected, in what way are the interventions evidence-based? If people are not believed when the answers don't suit the researchers, why should we accept other parts of the report where the answers are in line with what the researchers expect to hear?

Assuming that HIV is almost always transmitted through 'unsafe' sexual behavior, regardless of all the indications that it is also transmitted through unsafe healthcare, cosmetic or traditional practices, is a betrayal of HIV positive people; it is also a betrayal of those who still risk becoming infected through such routes. These non-sexual routes urgently need to be addressed by investigating and cleaning up health centers, salons and other potential locations, and by warning patients about the dangers of being exposed to the blood and bodily fluids of other people.

HIV Strategy: Blaming the Victim and their Individual Behavior

[Cross posted from the Don't Get Stuck With HIV website.]

Since the early days of HIV/AIDS, finger pointing has been the main publicity angle. In Western countries the collective finger was pointed at men who have sex with men. Their reaction was to object to the finger being pointed at them and to insist that everyone is equally at risk. Though some still believe that everyone is equally at risk, it is not true. In Western countries the majority of HIV transmissions have always been among men who have sex with men, with a smaller proportion of transmissions through intravenous drug use.

But things are quite different in developing countries, particularly high HIV prevalence African countries. In high HIV prevalence countries men who have sex with men, intravenous drug users and even sex workers contribute a relatively small proportion of HIV transmissions. In fact, the largest contribution still appears to come from those with little or no risk; mainly monogamous heterosexuals. So the process of finger pointing often turns into one of victim blaming. After all, you can't point the finger at everyone around you, nor at someone who is HIV negative; so the clearest 'evidence' of unsafe sexual behavior becomes HIV positive status.

This gives rise to the task of explaining how a virus that is difficult to transmit through heterosexual sex outside of Africa is so frequently transmitted through that route in Africa. The HIV industry needed to show that 'Africans' must be promiscuous, ignorant and unhygienic. This wasn't too difficult because population control advocates (the word 'eugenics' is no longer fashionable), a significant proportion of wealthy NGOs operating in Africa, had had been playing the over-sexed, under-educated slum-dweller cards for decades.

The processes of pointing the finger at a particular group whose behavior was disapproved of, blaming those infected with HIV for their status, and concluding that HIV is all a matter of individual behavior, threw off course any efforts to reduce HIV transmission in developing countries. Although 'prevention' activities only receive a small proportion of HIV funding, that is still a massive amount of money. But prevention activities have rarely gone beyond exhortations to 'behave' in a particular way. The finger-wagging programs perfected by population control NGOs decades before HIV was identified became, and often remain, the state of the art of HIV prevention.

There has been plenty of research showing that these finger-wagging programs are of little or no benefit (except to the NGOs). An example of such research shows that "peer education programs in developing countries are moderately effective at improving behavioral outcomes, but show no significant impact on biological outcomes". There is a voluminous body of literature showing that you can't simply wag your finger at people and expect them to change their behavior, whether the aim is to address substance abuse, dangerous driving, over-eating or anything else.

Sometimes the association of HIV transmission with individual behavior is further connected with conditions that are beyond the control of the victim, for example, poverty. But this has also given rise to confusion: there is plenty of evidence that HIV in African countries is transmitted among wealthier people. This challenges the idea that HIV epidemics are driven by sexual behavior because, even if wealthy people 'can afford to have a lot of sex and a lot of partners', as the HIV industry would have it, there would need to be some poor people involved in this theory. Rich people don't pay other rich people for sex.

Instead of looking beyond sex, or sex and poverty, it seems some researchers are convinced they will eventually find out how sex and economic inequalities 'drive' HIV epidemics. One paper concludes that "Further work is needed to understand the mechanisms explaining the concentration of HIV/AIDS among wealthier individuals and urban residents in [sub-Saharan Africa]". But they don't seem to consider the possibility that their protohypothesis about sex is simply wrong. They don't seem to think that non-sexual transmission may be a very significant factor in the spread of HIV among wealthier people.

HIV can be transmitted through unsafe healthcare and other skin-piercing processes, such as various cosmetic processes. Wealthy people tend to have better access to healthcare. In fact, urban dwellers also tend to have better access to healthcare. Perhaps this is why the above paper found that HIV is "generally concentrated among wealthier men and women". This may also explain why HIV "was concentrated among the poor in urban areas but among wealthier adults in rural areas" in a number of countries.

Instead of trying so hard (and failing, over and over again) to find out what it is about the sexual behavior of wealthy people and urban dwellers, perhaps researchers should look at non-sexual risks, as well as sexual risks. Could the risks that people face be determined by their wealth and environment, precisely because they are not sexual risks, but healthcare and other risks? These risks are clearly not *individual* risks. They relate to health-seeking behavior, but it is not the behavior of wealthy and/or urban-dwelling people that gives rise to infection with HIV in a hospital or salon; the risk of infection depends on whether the facility is safe or not (which might vary considerably over time).

Some historians of HIV, such as Jacques Pepin (The Origins of Aids), admit that HIV was mainly transmitted through unsafe healthcare for many decades, and hardly ever through sexual behavior. But they don't explain how healthcare transmission magically disappeared in the 1980s even though conditions in many African countries remain very unsafe (although how unsafe they are is still a dangerously under-researched field).

Coupled with the magical disappearance of the risk of HIV transmission in under-equipped, under-staffed and badly run health facilities is the magical re-appearance of the promiscuous, ignorant and dirty African, though for many, this had never really gone away. Pepin vaguely mentions things like 'urbanization' as the main explanation for levels of promiscuity for which there has never been any evidence and which do not explain very high rates of heterosexual transmission of HIV anyway.

Ugandans have recently responded to having the finger pointed at them by allowing an 'anti-homosexuality' bill to be passed, effectively saying 'it's not us, it's them'. Various human rights groups, and even some donors, may belatedly object to such disgusting measures, which are being copied by other African countries. But the objection needs to be directed at the approach to HIV that began a long time ago, and began in Western countries, not in African countries. Men who have sex with men are by no means the only group who have been blamed for HIV epidemics. Other groups include long distance drivers, sex workers, house girls, fishermen, miners, and many others. It's this finger-pointing approach that gives rise to the stigma that those pointing the finger claim to abhor.

Thirty years into the HIV epidemic (I'm adopting the view that HIV is not a pandemic because most people don't face any risk of being infected and prevalence is, and will remain, low in most countries) research institutions, NGOs, international bodies and, perhaps most importantly, donors are still obsessing about sexual behavior and pretending that HIV status is up to the individual when it is clear that a large, but as yet unestimated, proportion of infections is a result of unsafe healthcare and other skin-piercing processes.

UNAIDS' Dubious Claims about HIV/AIDS 2013

[Cross-posted from the Don't Get Stuck With HIV site.]

UNAIDS risk missing their target of reducing "sexual transmission of HIV by 50% by 2015". But there is a way of meeting that target, and they could meet it by tomorrow. If they belatedly admit that HIV is far more easily transmitted through unsafe healthcare, they could begin to estimate the contribution of things like reuse of needles, syringes and other equipment that comes into contact with blood and other bodily fluids.

This would also greatly assist their progress towards their 'ZeroDiscrimination' target too, because even though they can't reverse the damage they have done by insisting that Africans are irremediably promiscuous, the status of this claim as institutionalized racism will eventually become clear, at least to those who are prepared to think the issue through a little (a surprisingly small number of people so far).

After all, reducing 'sexual transmission' is one of their stated goals, whereas UNAIDS has barely breathed a word about transmission through unsafe healthcare in their 20 year, multibillion dollar, celebrity studded reign. They could just quietly (imperceptibly, even) reveal some changes in the way figures are collected and next December 1, a re-estimation of non-sexual transmission of HIV could be the subject most deserving of their customary (spontaneous) standing ovation module.

UNAIDS are uncharacteristically frank about mass male circumcision, which is something of an embarrassing fiasco: "As of December 2012, 3.2 million African men had been circumcised [...]. The cumulative number of men circumcised almost doubled in 2012, rising from 1.5 million as of December 2011. Still, it is clear that reaching the estimated target number of 20 million in 2015 will require a dramatic acceleration." (They don't say how many of the 3.2 million circumcised over quite a few years would have been circumcised anyway but took advantage of the free (anesthetized) operation.) Might this spell an unobtrusive retreat from this dangerous imperialist program?

But one of the heftiest pieces of bullshit in the 'report' (and there is stiff competition) is about "the goal of providing antiretroviral therapy to 15 million people by 2015". They say that "As of December 2012, an estimated 9.7 million people in low- and middle-income countries were receiving antiretroviral therapy, an increase of 1.6 million over 2011. That brings the world nearly two-thirds of the way towards the 2015 target of 15 million people accessing antiretroviral treatment."

The difference between UNAIDS' claim and the truth is expressed in a few words, such as 'were receiving' therapy. If they said that 9.7 million people had been recruited on to a therapy program, that might have been true (or somewhat closer to the truth). But 9.7 million is, at best, the number of people who have at one time been put on a program. Neither UNAIDS, WHO, PEPFAR, CDC nor anyone else knows how many of those 9.7 million ever took the drugs, or for how long, how many dropped out of the program, how many were recruited on to two or more programs or simply died, etc.

No one knows, and no one really cares because 9.7 million is an impressive figure, and it sounds like a good attempt at the 15 million target. There is not much incentive to estimate how many people are alive and on antiretroviral treatment, indeed, such an estimate could prove fatal to several substantial institutions (not just UNAIDS, which seems to thrive on failure to achieve anything at all, aside from spending money and institutionalizing bigotry). Is the true figure 8 million people, 7 million, or some far lower number? Billions of dollars say that no one is going to ask this impertinent question (unless they are not in receipt of any of those billions, and never will be).

Unsafe healthcare does exist in extremely poor, high HIV prevalence countries, surprising as that may seem to those who are used to the mainstream view that HIV is hardly ever transmitted through heterosexual sex in every country in the world, but almost always transmitted through heterosexual sex in a handful of African countries. What contribution does unsafe healthcare make to the worst HIV epidemics in the world, all in sub-Saharan Africa? Would it be the one or two percent UNAIDS grudgingly suggests, or something far higher? We don't know yet. No billions have been offered for the answer to this question.

Using cumulative figures is great, because you get that great 'step' effect when you produce bar graphs, and there is nothing like comforting, progressive steps to convince people that everything is good in UNAIDSland, and in the HIV industry in general. A very achievable 2015 target would be the abolition of UNAIDS and the promotion of safe healthcare. Because unsafe healthcare risks the spread of HIV, something UNAIDS has never got around to accepting. But I suspect that instead, there will be a continuation of the finger-pointing and victim-blaming that has characterized the mainstream approach to HIV in high prevalence countries so far.

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.

Maternal Health Care a Significant HIV Risk in Ethiopia

[Cross-posted from the Don't Get Stuck With HIV site.]

A young doctor who had been working for 26-28 hours was taking blood from a baby born to a HIV positive mother and accidentally pricked himself with the needle. He reported the incident and got some kind of treatment in the same hospital, but he had to drive himself to another hospital 45 minutes away to get the drugs he needed after being awake for 29 hours. There are several issues here but I'd like to concentrate on the fact that a hospital that had a HIV positive female patient did not have the drugs required to administer post-exposure prophylaxis. Thankfully the doctor in question was OK, but he had to wait six months to have that confirmed.

An accident like this could occur in any country in the world. In this instance it happened in Ireland, where HIV prevalence is very low, around 0.2%. The mother was known to be HIV positive, whereas the HIV status of a significant proportion of people in many countries, perhaps the majority of people in high prevalence countries, would not be known. Needlestick injuries are more common in places where there are fewer staff, less well trained staff and where access to supplies and equipment are poor. But even in countries where conditions for infection control are probably good there can be slips, such as the one described above.

Of course, the fact that conditions for infection control are not good in developing countries does not mean HIV is frequently transmitted through unsafe medical procedures. UNAIDS, WHO and the rest may be right in their claim that only 2-2.5% of HIV transmission is accounted for by unsafe injections, contaminated blood transfusions and other health care risks. But it would be comforting to hear that unexplained HIV outbreaks are investigated. It's not as if there are no such unexplained outbreaks; many infants are found to be HIV positive even though their mother is negative; many adults are infected even though they have no identifiable sexual risk, etc.

One of the oldest high prevalence HIV epidemics in Africa, that in Uganda, should have taught us a lot. It is now obvious that at least some of the rapid drop in prevalence after its peak in the late 80s must have been a result of high death rates. Some of the drop in incidence, the rate of new infections, must have been a result of improvements in infection control practices in health facilities. Very little of the drop in infections can clearly be associated with various 'initiatives' aiming to address sexual behavior, which (much) later became known as ABC (Abstain, Be faithful and use Condoms). So why is there now so much emphasis on sexual behavior when we know that many of those approaches have had very little impact, in Uganda or anywhere else?

According to an article from IRIN news, Uganda is targeting 'cheaters'. This is an extremely inept piece of campaigning (and reporting). Knowing that someone is HIV positive is not the same as knowing how they became infected. The data itself even suggests that most of the people considered to be 'cheaters' could not have been infected through sexual behavior because their behavior is classified as low risk. Some of them may have been infected sexually, but it is unlikely that they all were. Yet this group, people who are in long-term relationships, often married, makes up the biggest group of HIV positive people, 43% of all new infections. To establish how they became infected it is first necessary to do some investigating.

Another group of unexplained infections can be found among women of child-bearing age. Some may well be infected sexually, but some may not. It's certainly not a foregone conclusion that all of them must have been infected sexually just because they have had sex. The group that is especially in need of investigation is those who have given birth with the assistance of a health care professional. The 2005 Demographic and Health Survey for Ethiopia shows that HIV prevalence is eight times higher for this group (prevalence is 9.9% for those who received assistance from a health professional and 1.2% for those who gave birth without assistance from a health professional). In addition, HIV prevalence is a lot lower among men. HIV in Ethiopia is very low in rural areas and appears to be higher among employed, better educated, wealthier people who live in urban areas. A more recent Demographic and Health Survey for Ethiopia was published in 2011, but there is no figure cited for this group.

There are so many ways HIV can be transmitted, especially in countries where HIV prevalence is high and most people don't know they are infected. It must also be remembered that most people don't realize that there are significant non-sexual risks; if they don't know about the risks they will not know anything about protecting themselves and their families. There are health care risks, such as operations, vaccinations and dental care, traditional practices, such as circumcision, scarification and traditional medicine and cosmetic risks, such as manicures, pedicures, tattoos and piercing.

Rather than continuing to waste money on sexual behavior interventions, many of which have been largely unsuccessful and all of which fuel the stigma that attaches to HIV infection in African countries, it is time to investigate non-sexual transmission in all its forms. If there is any shortage of evidence that non-sexual HIV transmission makes a significant and underestimated contribution to serious HIV epidemics, that can only be because of a lack of research and a lack of investigation where levels of HIV transmission are unexplained by sexual behavior alone.

Donor countries, including Ireland, are keen to get women in developing countries to use ante-natal care clinics and other health facilities. Far more important than providing people with health care is providing people with safe health care; otherwise we could be increasing risk of transmission of HIV and other infectious diseases rather than reducing risk. Needlestick incidents are probably the least of people's worries in countries like Ethiopia, but only because many people don't attend health facilities most of the time. If our aim is to increase access to health care we had better ensure that health facilities are also safe.

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

PrePex at Loggerheads with Main Recipients of Circumcision Funding?

Only a few weeks ago, the owners of the company that makes PrePex 'bloodless' circumcision devices (effectively, a plastic ring and a rubber band) were happily plugging their ware, a difficult process of persuading journalists to regurgitate an entire press release without any research or criticism. This time, the press release was set in Uganda and a researcher, presumably one not versed in the skills of PR, claimed that "We have so far tested it on about 50 clients but we need 250 more to confirm its acceptability but so far it has worked properly with those who used it". No need for any Ugandans to worry, then.

But alas, some of the main proponents of circumcision, who are also some of the main recipients of the copious millions of dollars available for the mass male circumcision programs in Africa, have announced that "The PrePex Device Is Unlikely to Achieve Cost-Savings Compared to the Forceps-Guided Method in Male Circumcision Programs in Sub-Saharan Africa". They were even generous enough to make the findings available in a free peer-reviewed source. This is all the more remarkable when you consider how most research relating to mass male circumcision is made available: selectively, at the convenience of those who collected the data, rather than that of anyone who may wish to scrutinize it.

Of course, this may be just a bit of a spat between those who prefer to know that scalpels are used (who currently receive the lion's share of funding) and those who don't give a toss how the operation is carried out as long as they make lots of money out of it. The paper by Walter Obiero, Marisa Young and Robert Bailey claims that at $45-50, the PrePex method is "unlikely to result in significant cost-savings". The authors declare no competing interest, unless the fact that at least one of them is a founder of the Nyanza Reproductive Health Society, which provided some of the funding for the research, represents some kind of competing interest.

The $45-50 figure is interesting. According to an article from the UK's National Secular Society, hospitals in Sheffield are going to start charging for non-medical circumcision. They carry out fewer than 200 per year, which is surprising enough, but they expect to save nearly $1,600 per operation. Could it really cost 32 times more to carry out a circumcision in an English hospital? I can imagine costs are lower in African countries, for lots of reasons, but I wonder what, exactly, will be excluded from the mass circumcision campaigns to keep the costs so low. I wonder also if Sheffield could be induced to reconsider their decision if they could offer the operation so cheaply, and how many people would then take them up on it.

One person commenting on Sheffield's decision feels that this may give rise to 'backstreet operations'. But in African countries where circumcision is already carried out for tribal reasons, almost all circumcisions are 'backstreet operations', carried out by someone with no medical training, often without sterile instruments. The several billion dollars on offer for mass male circumcision programs in African countries are mainly available in areas where circumcision is not routinely carried out already.

A spokesperson for the National Health Service said: "Non-therapeutic circumcisions are not clinical interventions and as a group, we would not want anybody to undergo a medical procedure if there was no specific clinical need." A spokesperson for the National Secular Society said "We believe that non-therapeutic circumcision should not be permitted until the boy is old enough to give informed consent." These guys have evidently never heard about the US government's plans for African males.

Most articles promoting mass male circumcision for high HIV prevalence African countries claim that "results from three trials in sub-Saharan Africa, including one from Rakai, Uganda, showed that circumcision could reduce HIV transmission from positive women to negative male partners by up to 60 percent". This is not what the trials showed. HIV transmission was lower in the group that was circumcised than in the group that was not. But the trial did not show that all transmission was a result of sexual contact. Some may have been through unsterile healthcare, reused medical equipment, etc. Perhaps more importantly, at least one of the trials suggests that HIV transmission increased in the control group, rather than decreasing in the intervention group.

It seems hard to believe that current interest in promoting mass male circumcision to reduce HIV transmission from females to males could be based entirely on the evidence for the effectiveness of such a strategy, because the evidence is extremely mixed so far. It seems equally hard to believe that the whole thing is just a money earner for those competing for funding. But there is a lot of money involved. You might expect the Nyanza Reproductive Health Society to be unworried about whether PrePex is used, or some other method. But the difference in cost could be about 10%, some $100,000,000. So how much does something have to be worth to be a 'competing interest'?

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

Mass Male Circumcision: it's Not Done in Europe, So Why do we Tolerate it in Africa?

The current plan to circumcise 20 million African adults and countless millions of African infants arose purely from the prevailing view that HIV is almost always transmitted sexually in African countries. If we had tested that view years ago and modified it appropriately in the light of available evidence, the issue of aggressively promoting circumcision and spending billions of dollars of 'aid' money on it would never have arisen. It would have been clear that HIV is not exclusively transmitted through sexual contact, that it is also transmitted through unsafe healthcare, cosmetic and traditional practices.

If circumcision reduces HIV transmission, it could only reduce sexual transmission, not transmission through other modes. It is also only claimed to reduce sexual transmission from females to males; it may increase transmission from males to females and, given that prevalence is higher, often much higher among females in African countries, this may result in circumcision programs increasing HIV transmission overall. In addition, African countries' crumbling health systems would not be able to provide tens of millions of safe male circumcisions; the most basic health services are denied to most people and available services are known to be very unsafe.

We have privileged HIV above all other diseases and we have privileged sexual transmission above all other modes of transmission. By doing this, we have stigmatized every African as sexually promiscuous and every HIV positive African as paying the price for their own behavior; yet we fail to acknowledge that HIV is not always transmitted sexually. So why are circumcisions now carried out so readily in countries where most other kinds of operation and medical procedure are unavailable? Even where other procedures may save people's lives, disproportionate amounts of money are spent on sexually transmitted HIV, including in areas where HIV is certainly not the highest priority, sometimes not even a low priority.

Therefore, in the interest of safe healthcare for all, it is necessary to oppose mass male circumcision programs. They will not reduce HIV transmission much, if at all; they will not be carried out in contexts where safe healthcare is generally available; and they will be carried out in countries where the most common causes of illness and death are generally ignored, despite being far higher priorities than HIV or sexual health. For example, there is an urgent need to address reproductive health more broadly, the overall health of women, infants and children and the health of men who are not HIV positive, nor at risk of being infected through their sexual behavior. Diseases that relate to living conditions, such as TB, that infect far more people than in countries where living conditions are better, also need to be addressed. There are also water-borne diseases that infect, debilitate and kill millions because of lack of access to clean water and sanitation.

HIV needs to be put in perspective; it is a virus, one of many, sometimes sexually transmitted, sometimes non-sexually transmitted. We don't even have any idea of the extent of non-sexual transmission, so we can neither tell how much transmission mass male circumcision could avert, if any, nor can we tell how many people are likely to be infected and/or to infect others as a result of the circumcision programs. Mass male circumcision is part of a much bigger picture, and it's because the bigger picture of HIV is distorted by Western obsession with 'African' sexual behavior that we've ended up with something as stupid as mass male circumcision. People are being denied their right to health care, to safe healthcare, to bodily integrity and to many other things. Circumcision is just one problem and the mass male circumcision problem grew out of our failure to address non-sexually transmitted HIV, safe healthcare and all the more important development areas in developing countries.

I am not an 'intactivist' and I don't advocate for 'intactivism', not because genital integrity is too small or too unimportant an issue; it's because it is just a part of a much bigger picture. Most human rights are being denied in some developing countries, not just a handful of rights. Genital integrity is just a part of something that is too big to ignore: bodily integrity and the other human rights that are being denied to those who are denied their right to bodily integrity. Circumcision itself may do harm, it may do good, it may do nothing. But it is the aggressive promotion of mass male circumcision programs in places where most forms of healthcare are unavailable and most available healthcare is not safe that is most objectionable.

If anyone tells you that healthcare services fail people in high HIV prevalence countries because of stigma, health seeking behaviors, culture, education, tradition, or anything else, remember that healthcare services are far more likely to fail because they are not available to most people; where they are available, they are likely to be unsafe. This is not to say that stigma is not an issue, but it is one that arises from the view, mentioned above, that HIV is almost always transmitted through heterosexual sex in African countries. Education also fails people, and not just in relation to health. Health seeking behaviors, culture, tradition and other issues may well be important issues. But they are of less importance where access to healthcare is poor and where that healthcare is not safe.

Despite lengthy (and lucrative) campaigns telling us that everyone is at equal risk of being infected with HIV, that HIV is an 'equal opportunities' virus, that it's all about sexual behavior, etc, it has long been clear that risk is most definitely not 'equal'. Both men and women who are receptive sexual partners face a very high sexual risk. Men who only engage in insertive sex (i.e. most heterosexual men) and who have no other risks are very unlikely to become infected, so women face higher sexual risks than men. Intravenous drug use is the second biggest risk in most rich countries. But the extent of non-sexual infection through unsafe healthcare, cosmetic and traditional practices in high HIV prevalence countries is not well known and is often not even acknowledged.

In wealthy countries circumcision stands out as an anomaly, where female genital mutilation (FGM) is viewed as a denial of the right to bodily integrity. We don't need to argue against FGM on the grounds that it causes physical (and psychological) damage, or that it may present problems later on in life. The fact that there is a right to bodily integrity is enough, but the anomaly stems from the fact that male circumcision is not seen as a denial of the right to bodily integrity. Some argue for male circumcision as a religious or cultural right, and that is not a problem, as long as it is the adult individual who makes the decision, not the parent.

But in developing countries, there is nothing anomalous about programs funded by Western governments telling people what is good for their health, regardless of broken down and unsafe health facilities, cultural and religious practices, or even human rights. FGM is opposed on grounds that should also be used to argue against male circumcision, yet male circumcision is promoted with the claim that it reduces sexual transmission of a virus, in the full knowledge that the virus is not always transmitted sexually and that it may be transmitted through circumcision itself. Western countries were once opposed to breastfeeding. Indeed, it may have been Western churches that once opposed circumcision in parts of Africa, or at least deemed it unnecessary for people who had been converted to Western religions. Claimed health benefits do not justify mass male circumcision programs.

In developing countries, circumcision is just one issue out of many, the tip of the iceberg. If we were to forget circumcision and concentrate all our attention on some other issue tomorrow no one would be any worse off. Singling out HIV, circumcision or any other issue, divorced from the context that gives rise to the issue, is part of the problem. If we didn't believe the lie that HIV is almost always transmitted sexually in African countries, we wouldn't even be questioning the wisdom of mass male circumcision, and those promoting it would not have received billions of dollars to ride roughshod over African people.

If it was decided that some other kind of intervention reduced HIV transmission, such as giving HIV positive people ARVs long before there is a clinical benefit (it's called Treatment as Prevention) or giving HIV negative people ARVs because they have or may have a HIV positive partner (it's called PrEP, pre-exposure prophylaxis) or give lifelong ARV treatment to pregnant women, rather than a short course of ARVs (it's called B+), those may become as aggressively promoted as circumcision. Sadly, all three of these are already being aggressively promoted even though the net benefit may be low and there may be very serious consequences in terms of transmission rates and health more broadly.

We don't have to do research to know that people need safe healthcare, education, infrastructure and the like, but we seem to avoid getting involved in these basic human rights and instead allude to things like corruption and culture and whatever else journalists and academics tell us is pertinent. Mass male circumcision programs are not wrong because they won't work or because circumcision reduces sensitivity or has anything else to do with sex or the penis. They are wrong because people have a right to bodily integrity, to safe healthcare and to many other things that are currently denied to them.

This is not merely a logical or academic argument against circumcision; we know that we couldn't carry out such programs on our own fellow country people, regardless of any claimed benefits, public health or otherwise; so why are we even discussing doing so in African countries? Aggressive promotion of mass male circumcision programs in African countries, mainly funded and carried out using US money, has got to stop.

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

TB and Gold Mining: Sending Them Home To Die

A message from the director of the film 'They Go to Die' (YouTube video).


Jonathan P Smith, an American epidemiologist, is making a film about the kind of scenario mentioned in yesterday's blog post: South African miners and their families being infected with TB as a result of living and working in appalling conditions, and the failure of crumbling health services to offer the level of treatment that would cure people of the disease, prevent it from spreading and avoid drug resistant strains developing.

Smith follows four former gold miners who have contracted resistant TB while working at a gold mine. The gold mine's hospital has failed to treat the men and they are now being sent home. It is likely they will die from TB, but also that they will infect a number of other people first. As they have a resistant strain, they can also transmit this resistance. Treatment will therefore be difficult, very expensive and unlikely to be available. Their immediate family will probably be most at risk.

Mine owners are under no obligation to treat miners infected with TB. But government programs to eradicate the disease are unable to influence the working and living conditions that result in TB spreading rapidly and resistant strains of TB from developing and spreading. Eradication programs are often separate from other health services, because health services are unable to cope even with far less threatening diseases, and funding levels mean that TB eradication often amounts to little more than free drugs.

Squalid living and working conditions ensure that a disease like TB will remain endemic, and that people will remain highly susceptible. Circular migration from home to work and back ensure that TB will be spread widely. Intermittent health services ensure that resistant strains will develop and be spread, to infect and reinfect people of all ages. Add to this a high disease burden and an underfunded health sector, and you have a production line of sick people, packaged up to receive whatever pharmaceutical companies have to offer.

The figures Smith cites are staggering: TB rates among South African gold miners are 1,400 times rates in western countries. Western countries may be willing to send money and drugs for TB eradication programs, but we also enjoy cheap consumer goods, which depend on costs for raw materials being kept as low as possible. As a result, conditions in mines remain hazardous and miners and their families suffer the consequences. Even HIV, which attracts more funding than any other disease, is rampant in mining areas.

Smith notes that those infected with HIV are very vulnerable to TB but he doesn't mention if those with TB are more likely to be infected with HIV. TB has always infected poorer people in higher numbers whereas HIV has often been more closely associated with wealthier, better educated people. But HIV prevalence also tends to be higher among employed people, especially those in formal employment, such as mining. The received view of HIV transmission, that it is mainly a result of unsafe heterosexual sex, would suggest that employed people take more sexual risks. But perhaps employment related health facility conditions may play a role here?

People working in mines do have access to health services, but those services tend to be basic. It is unlikely that safe healthcare is a high priority. Miners suffering from diseases that are common in terrible living and working conditions, such as TB, respiratory infections, intestinal parasites, nutritional deficiencies, water-borne diseases and sexually transmitted infections (STI), may face additional risks in health facilities. Do those facilities have enough basic supplies, such as gloves, injecting equipment, sterilizing fluid, gauze, etc? Are there enough well-trained personnel? Can safety be guaranteed? Or are mining hospitals as unsafe as most hospitals in high HIV prevalence countries?

Some of the highest TB figures are found in countries that have significant mining interests, and in countries that supply the migrant labor. But some of the highest HIV figures are also found in these countries. Much has been written about the role of sexual behavior in an effort to explain these epidemics. But a lot less has been written about the possible role of unsafe healthcare. There is a great fondness for writing about and reading about sexual behavior, but this could mask the elevated levels of non-sexual risk that miners and others must face.

TB spreads easily among people who live together, especially in overcrowded slums. It also spreads easily among people who work in badly ventilated mines. But HIV does not spread so readily through unsafe sex alone. Perhaps transmission through unsafe healthcare could help to account for some of the worst epidemics in the world? Perhaps unsafe healthcare could explain why many infants are infected when their mother is not and why so many people with a HIV negative partner become infected where there is no obvious sexual risk?

Smith writes: “What is the point of public health research if there is no public health benefit? We, as researchers, have an ethical obligation to not simply perform epidemiological research, but advocate a positive change in our research population... [T]o conduct research without the intention of betterment within that population makes a mockery of our public health researches.” This could equally be applied to all research, such as human rights, development, anthropology, even industry related research.

[For more about non-sexual HIV transmission through unsafe healthcare, see the Don't Get Stuck With HIV site.]

TB: the Emergency is that We Have Failed, Time for a Different Approach

The English Daily Mail is not a source I would usually turn to for articles about global health issues, but the English MP Peter Hain does have some interesting remarks to make about TB. Following the government's decision to postpone mass culling of badgers to cut transmission of bovine TB to cattle, Hain reminds us that human TB kills about 1.4 million people every year.

Hain also mentions the issue that excites the pharmaceutical industry the most: drug-resistant strains of TB, which are developing and spreading rapidly. If ever there were a demonstration of the foolishness of believing that health was just a matter of fighting disease and that fighting disease is just a matter of throwing drugs at a handful of headline-grabbing diseases, TB is one.

There have been TB eradication programs around for decades and it is the failure of these programs to do any more than throw drugs at people that allows resistance to develop so readily. TB could have been contained a long time ago. But health is not just a matter of fighting disease and TB eradication (or HIV eradication, or any other disease) is not just a matter of drugs.

For a start, people live in appalling conditions. TB spreads rapidly in appalling living conditions, just as water-borne diseases spread rapidly among people who have little or no access to clean water and good sanitation. As long as people live in such conditions, they will continue to suffer from and die from diseases, many of which are preventable and/or treatable. Leaving people in their current conditions means that throwing drugs at them will be of little benefit; for every vaccine they receive, there are hundreds, perhaps thousands of other diseases they can suffer and die from.

Then there are people's working conditions. Hain notes that some of the worst TB epidemics are in South Africa's gold, diamond and coal mining areas, which are said to be responsible for 760,000 new cases of TB every year and the highest death rates for TB in the world. The conditions in which miners work are ideal for the spread of TB. As migrant laborers, most of them return to their families frequently, and they risk spreading TB to anyone with whom they come into contact.

According to Hain, a "migrant worker with TB will typically spread the infection to 10 to 15 other people each year that he’s sick". (Compare this to the 1.2-1.4 people to whom a HIV positive person will typically transmit the virus.) Worse still, "When he returns to his home community, he may not have access to health services capable of putting patients through the necessary six months of TB treatment". Though TB sometimes attracts enough funding for 'treatment' to be free to many people, drugs alone are generally not enough.

The living and working conditions people experience are not conducive to lengthy and expensive drug regimes. Treatment interruptions and treatment failures can quickly give rise to resistant strains of TB developing, which can also be transmitted to others. As resistant TB can be up to 100 times more expensive to treat than non-resistant strains, many will die of the disease. And because it is so readily transmitted, others will be infected with this resistant strain, also.

That's the bit that makes pharmaceutical companies so happy. There's no doubt that they will make a lot more money out of resistant TB. But one of the reasons throwing drugs at the problem does not work is because living and working conditions are not generally addressed by TB eradication programs. Most people don't have access to the sort of health services that will ensure they receive everything they need to clear them of TB. But most also live in conditions where they are highly susceptible to transmitting TB and to being infected, or reinfected, with TB and resistant TB.

Mine owners are not called upon to make conditions healthier. Western buyers of South African raw materials are not keen to increase their costs. The 'economy' of South Africa may depend on mining revenue, but unless that is translated into better living and working conditions for miners, TB and other diseases are not just going to disappear. Good for Big Pharma, not so bad for wealthy South Africans, but not so good for ordinary South Africans.

Hain is incorrect if he assumes that a thriving mining sector results in a stronger economy and that this results in better healthcare systems. The TB epidemic is costing the country a lot of money. So it may seem like a good investment to throw drugs at those with TB. But it's not just healthcare systems that are lacking, it's also education, water and sanitation, habitation and working conditions that are making and keeping people sick.

Hain's suggested approach sounds good, but it is inaccurate to say that an emergency response is needed. Poor living and working conditions mean that emergencies frequently arise, do a lot of damage and can not easily be remedied. But lack of health structures, health personnel, infrastructure and other things mean that TB and other diseases can not be eradicated.

Even ridiculous programs that consist of little more than showering people with drugs could do a lot of good, but not if other conditions are not improved first. There's little to be gained from eradicating one disease only for people to suffer from and die from other diseases, particularly resistant versions of more easily eradicated diseases.

TB, like HIV, is not an emergency in the way that a hurricane or tsunami is. These epidemics result from the conditions in which people live. Massive epidemics are a consequence of most people living in terrible conditions. These are long term trends, many people have never experienced anything but poverty and struggle. Perhaps an emergency can be declared in response to endemic diseases, one by one, as seems to be the favored approach by international institutions. But why not address the conditions in which people live and work, the rights they are denied, the determinants of health and the rest?

The emergency is that we have tried and failed to eradicate some of the most serious diseases by addressing them one by one and merely throwing drugs at them. The emergency is that realizing there is a problem and setting up institutions in wealthy countries is not enough. Countries like South Africa need health systems, education, infrastructure and decent living and working conditions. Addressing TB on its own will continue to fail unless other development areas are also addressed. If there is an emergency, it is that we have known all this for decades and have systematically failed to act on that information.

Peter Hain is not wrong, but we don't need to address basic health and social services and various other problems in order to eradicate TB, we need to do all these to eradicate any disease. We also need to address these issues to ensure that people enjoy good health, which is not merely the absence of disease. Of course, these are also conditions under which diseases can be controlled, and that includes TB. Throwing drugs at people and sending them back to the conditions in which diseases thrive, what we are doing right now, is clearly not the right approach.


[For more about non-sexual HIV transmission through unsafe healthcare, see the Don't Get Stuck With HIV site.]

Circumcision: a Case of Retributive Healthcare?

There are many objections to mass male circumcision, but only a few of them should be required to convince someone that the vast majority of operations should never have been carried out, and that infant circumcision should not be routine anywhere. I would attach most weight to the argument that infant circumcision is a denial of the right to bodily integrity and follow that up with the consideration that it is done without consent, and can easily be postponed until the infant grows up. Where consent can truly be claimed to be informed, adult circumcision should not be so problematic. Current mass male circumcision programs in African countries are demonstrating clearly that most adult men do not choose to be circumcised; whether those who have consented are appropriately informed is open to question.

But the most important objection against mass male circumcision as a HIV transmission reduction intervention is, in my view, that not all HIV transmission is a result of sexual intercourse. Circumcision does not reduce non-sexual HIV transmission, for example, that which is a result of unsafe healthcare, cosmetic or traditional practices. The majority of circumcisions in Africa are carried out in traditional, non-sterile conditions. But even conditions in hospitals and clinics are well known to be unsafe. The UN are very clear on this point, issuing its employees with their own injecting equipment when they are in developing countries because "there is no guarantee of the proper sterilization of such materials." UN employees are also reassured that "We in the UN system are unlikely to become infected this way since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment."

The US Centers for Disease Control (CDC) states that "Injection safety is part of the minimum expectation for safe care anywhere healthcare is delivered; yet, CDC has had to investigate outbreak after outbreak of life-threatening infections caused by injection errors.  How can this completely preventable problem continue to go unchecked?  Lack of initial and continued infection control training, denial of the problem, reimbursement pressures, drug shortages, and lack of appreciation for the consequences have all been used as excuses; but in 2012 there is no acceptable excuse for an unsafe injection in the United States."

But what about safe healthcare in developing countries? The Safepoint Trust finds that each and every year due to unsafe injections there are:

• 230,000 HIV Infections
• 1,000,000 Hepatitis C Infections
• 21,000,000 Hepatitis B Infections
• The above resulting in 1,300,000 deaths each year (WHO figures)
• Syringe re-use kills more people than Malaria a year which the WHO estimate kills 1,000,000 a year (WHO)
• At least 50% of injections given were unsafe (WHO)

Safepoint only reports on injections. What about other healthcare procedures that may spread diseases, especially deadly ones? Many health facilities lack basic infection control capabilities and supplies, such as clean water, soap, gloves, disinfectant and much else. There are also the risks people face as a result of cosmetic procedures, such as pedicures and tattoos, and traditional procedures, such as scarification, male and female genital mutilation and traditional medicine.

Why are we even talking about something as invasive as circumcision, involving tens of millions of men and possibly hundreds of millions of infants? So many medical procedures are already carried out in unsterile conditions and can expose patients to risks of infection with HIV, hepatitis and perhaps other diseases. The circumcision operation itself is a risk for HIV and unless the risk of hospital transmitted HIV infection is acknowledged, it is not acceptable to carry out these mass male circumcision programs. It is not possible to claim that people can give their informed consent where they are unaware of the risk of infection through non-sexual routes.

A third important objection to mass male circumcision is that people in developing countries, particularly the high HIV prevalence African countries where all these mass male circumcision programs are taking place, are denied many of the most basic types of treatment. How can we propose universal infant circumcision where half of all infant deaths and a massive percentage of serious infant sickness is a result of systematic denial of basic human rights, such as access to clean water and sanitation, adequate levels of nutrition, decent living conditions, basic health services, an acceptable level of literacy and education, employment, infrastructure and a lot more?

To force 'healthcare' in the form of mass male circumcision programs on people who are lacking so many more important things is extremely patronizing, at best. But to force unsafe healthcare on people who have little access to the kind of information they need to be sure that they are protecting themselves against infection with HIV and other diseases, and against all the threats of unsafe healthcare, would be criminal behavior in western countries. Why are western countries silent about this treatment of people in developing countries? Are we punishing Africans for their poverty and lack of development, or just for their perceived sexual behavior? Mass male circumcision programs do seem very much like a form of 'retributive healthcare'.


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

A Vagina is Not a Penis, But Mutilation is Always Mutilation

Those opposing female genital mutilation (FGM) often claim that male circumcision is a completely different thing, and many have no objection to it. To the extent that a vagina is not a penis, FGM and male circumcision are quite different. But they both involve mutilation. It is not the seriousness of the mutilation of a vagina that is objected to. If it was, some forms of FGM would certainly be more objectionable than male circumcision; but some forms would be a lot less objectionable.

FGM is opposed, and rightly so, because it is mutilation, and is generally carried out without consent. It also tends to be carried out in non-sterile conditions and can lead to very serious consequences in later life. But even if it were a mild operation (for example, the American Pediatric Society's 'nick') with no long term consequences whatsoever, carried out in clinical conditions by a trained surgeon, and with parental consent, most people would still object to it.

There have been calls in the UK to make 'home circumcision' (for males) illegal, following several infant deaths as a result of the operation being carried out by unqualified people in unsterile conditions. But why should serious injury or death be required before the legitimacy of male circumcision is questioned? By what reasoning is male circumcision an elective operation that parents can legally choose on behalf of their children, but female genital mutilation an outrage?

The American Academy of Pediatrics is often cited on the subject of infant male circumcision, but they do not suggest that parents should choose circumcision for their children. They say that "the health benefits of newborn male circumcision outweigh the risks, but the benefits are not great enough to recommend universal newborn circumcision" and that "the final decision should still be left to parents to make in the context of their religious, ethical and cultural beliefs". The academy was a bit hesitant about FGM for a while but they later expressed their opposition to all forms of mutilation, even forms that do no permanent damage.

I'm not sure what kind of ethical belief could lead one to choose circumcision for an infant. But why should religious and cultural beliefs be a reason for parents being allowed to choose an unnecessary operation for their children, one that leaves permanent damage? Surely your membership of that religion doesn't depend on your being circumcised as an infant, does it? Does it depend on the operation being carried out against ones will, or can one choose it later in life?

FGM sometimes involves removal of flesh, though it need not do so to be considered mutilation. Male circumcision always involves removal of flesh. Is it really possible that the former is mutilation and the latter is an elective operation just because of the differing gender? And what about the claim that infant male circumcision is 'easier', 'causes less pain', or is in any way preferable to adult circumcision? Is there any basis for the claim, or is it only made to justify the lack of consent involved in infant male circumcision? Would anyone make the same claim about FGM (which is not generally practiced on infants)?

My view of the right to bodily integrity is that it applies equally to males and females, infants and adults, and to people of all religions and cultural groups. FGM constitutes a denial of the right to bodily integrity and ignores the principle of informed consent, but so does male circumcision (excepting cases where there is a medical need). A tolerant society would allow people their religious beliefs, but it would at the same time protect all people from injury. Nobody is being denied their "right to freedom of thought, conscience and religion" as a result of the right of all, male and female, to be protected from bodily harm.

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

Safe Healthcare and Bodily Integrity For All

Opposition to male circumcision need not be based on the claim that the operation is harmful, nor on the claim that it is more or less harmful than female genital mutilation (FGM), or various other processes. The facts that it is harmful, and can be more harmful than certain instances of FGM and other processes are important, but not as important as the fact that infant circumcision, like infant FGM, is a denial of the right to bodily integrity. Therefore it is no good claiming that it is cleaner, looks better, protects from diseases, etc. Those considerations, even if true, can not be used to deny the right to bodily integrity.

Many things are good for people's health and far fewer are campaigning for them, such as safe healthcare in developing countries. This is also a human right; hopefully safe healthcare rather than just any old healthcare. There is a lot of evidence that it is unsafe healthcare that causes much of the mortality and morbidity in countries with a high disease burden. We don't even need to carry out expensive research to show that safe healthcare improves health. So why the billions for circumcision, and the heavy handed campaigning, when there are more obvious and more urgent things that need to be addressed?

When it comes to the claim that circumcision reduces HIV transmission, there are several serious problems. For a start, it reinforces the view that most HIV transmission is sexual transmission, even though none of the randomized controlled trials excluded the possibility that some of the people who were infected were not infected through sex. If most HIV transmission is sexual it is unlikely circumcision will have much net benefit, especially when you consider that it is thought to increase transmission from men to women. But if most HIV transmission is not sexual, circumcision will very likely increase the risks that men face, given the conditions in healthcare facilities in high HIV prevalence countries.

Where FGM is banned, it is not permitted just as long as the conditions under which it is carried out are hygienic; it is not allowed if it is a cultural practice; the possibility that it might have some health benefits is not generally even discussed, except to deny that it has any health benefits. But mass male circumcision is aggressively promoted where many women can not even give birth in safe conditions, where people donating blood risk infection with HIV and hepatitis, where the majority of HIV infections occur in long term, monogamous relationships for which no serious sexual risks can be identified.

According to the arguments of the circumcision enthusiasts, every man in the world should be practicing male circumcision. But it's not much practiced in Ireland, or anywhere else in Europe. So why is it acceptable for rich countries to use foreign aid money to carry out mass male circumcision programs in African countries? Is it because we believe that, while HIV is mostly transmitted through male to male sex and intravenous drug use in rich countries, that it is mostly transmitted through unsafe heterosexual sex in African countries? Why do we believe that?

But if we even do a little superficial research, or read UN information leaflets, we must also know that conditions in health facilities in developing countries are unsafe, that blood and skin piercing instruments can be contaminated with HIV and other diseases; isn't it fairly telling that UN employees are issued with their own injecting equipment when going to developing countries? So how can we not believe than some HIV transmission occurs in African hospitals? And how can we believe that only about 2.5% of all HIV transmission in African countries is a result of unsafe healthcare, when the UN warns its own employees about these risks?

Even if the figure is as low as 2.5%, if health facilities are dangerous then half a million Africans could be infected from mass male circumcision programs alone. And it would be difficult to estimate how many infants and boys might be infected with HIV and other diseases through non-medical circumcision, which is what the majority receive. Are we so obsessed with 'African' sexuality that we think there are no other important HIV risks but sexual? The best way to reduce HIV transmission would be to prevent all risks, not just sexual risks. The UN has made a start in reducing the risk of infection among UN employees working in developing countries, but Africans would be wise to note the advice that is given out to non-Africans.

The problem is, of course, that health facilities have been all but ignored since the World Bank and IMF's 'structural adjustment policies' of the 1980s insisted that African countries needed fewer facilities, fewer health professionals, less money spent on training and lower salaries. There is vague talk about 'health systems strengthening' and other nice-sounding programs. But big donors still seem to favor vertical health programs, where separate, parallel health structures need to be set up for each initiative, whether it's polio, cholera, TB, lymphatic filariasis, onchocerciasis, HIV or whatever. Mass male circumcision is just another vertical program, each one destined to cost perhaps as much as real health systems, that people urgently need. And as for safe healthcare? No, that would be too much like development.

The UN is in an odd position because they claim that health facilities are safe enough for Africans as only 2.5% or less of all HIV transmission is a result of unsafe healthcare, but these facilities are not safe enough for their own employees. Even tourists going to African countries can purchase supplies of needles and syringes and they will find warnings about using health facilities in many countries in their guidebooks. It's no secret, just as long as you are from a wealthy country. Can we conclude that, not only are Africans almost uniquely susceptible to sexually transmitted HIV, even where conditions in health facilities are appalling, but also, foreigners from rich countries are uniquely susceptible to healthcare transmitted HIV? If so, then HIV is indeed anomalous.

My guess would be that the UN is telling the truth to its own employees about the dangers of health facilities in developing countries. Therefore, they must be lying when they claim that 80% of HIV transmission is a result of unsafe sex and about 18% is a result of mother to child transmission. So mass male circumcision programs will not reduce HIV transmission via sexual intercourse. On the contrary, they will probably result in increased HIV transmission through unsafe healthcare.

This is not entirely bad news. Since infant circumcision is a denial of the right to bodily integrity, will probably not result in a net reduction in HIV transmission and will cost a lot of money that could better spent on other diseases, mass male circumcision programs will clearly have to be stopped immediately. And that should free up scarce resources for more urgent issues, which should not be very difficult to identify.

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