Wednesday, January 7, 2009

Development by Omission

In a previous posting on male circumcision, I suggested two possible ways of looking at this HIV prevention intervention. Of course, there are many other ways of looking at it! But first, it could be seen as a desperate attempt to throw huge amounts of money at an intervention that will only have limited benefits for a relatively small part of the population.

Or second, it could be seen as a good opportunity to strengthen the whole of Kenya's health sector in order to ensure maximum benefits and sustainability. If several million people are to be circumcised in clinical settings, over a lengthy period, a large number of health personnel will need to be trained, new clinics will have to be built, existing ones will have to be improved, the whole programme will need careful monitoring and evaluation.

Health capacity in Kenya is not very high at present. There are very few facilities per person and very few trained personnel. The figures are better for some provinces, such as Nairobi and Central, but still not encouraging. There have been small improvements in capacity but they don't usually keep pace with the growing population or increasing need.

A reflection of how poor health capacity is at the moment comes from Bungoma in Western province. There, circumcision is very widespread. Some of the operations take place in traditional settings, some in clinical settings. However, the rate of complications resulting from circumcision is very high in both settings, about 25%, overall. Unsurprisingly, the rate is higher in traditional settings, standing at 35%. But it is also worryingly high in clinical settings, standing at 18%.

The pro circumcision argument is generally, either tacitly or explicitly, for circumcision in clinical settings. A recent paper suggests that mass circumcision would involve high costs in the first five years but the savings and benefits would eventually outweigh the costs.

These findings apply to Nyanza province only, where male circumcision is the lowest in Kenya and HIV prevalence is highest. The model the authors use assumes circumcision rates are 10%, which is lower than other estimates I have seen. They also estimate HIV prevalence to be 24%, which is much higher than other estimates, especially for males, male rates being far lower than female rates in Kenya at present. But their results should still hold.

So if total health capacity in Kenya is going to be increased, this can only be a good thing. Of course, the improved capacity only directly applies to a minority of men in the country, though it should benefit health capacity as a whole as well, albeit indirectly. But in short, I find it hard to believe that the intention of those advocating mass circumcision includes strengthening health capacity. I think it is an intervention with very narrow aims (much like universal testing and mass rollout of antiretroviral therapy).

I believe circumcision is an important prevention intervention but it is not the only one and it is not going to have much effect on its own. It is expected to reduce the risk of HIV infection by 60%. That is not enough. Kenyans also need better sexual and reproductive health, better education about sex, health and other things, better social services, employment opportunities, etc. Even if you believe sexual behaviour is the only relevant factor in the transmission of HIV, circumcision on its own will not cut transmission very much.

If programmes to roll out mass circumcision, universal testing and antiretroviral therapy for all those who are found to be HIV positive were to include development of all health, education and social services in Kenya, that would be great. Because at present, public expenditure on health is very low (most expenditure comes from individuals or from donors). For example, immunisation rates are low and infant and child mortality rates are high, especially in the poorer quintiles. Many Kenyans don't live for long enough to become sexually active.

HIV is just one disease, just one of many sexually transmitted diseases. There are many other, more pressing health problems, such as poor nutrition and lack of access to clean water and sanitation. These affect people on a daily basis, causing more illness and death than HIV. HIV takes a long time to kill people, water borne diseases are very quick. On the other hand, nutritional deficiencies are treatable and most water borne diseases are curable!

Incidentally, there are many reasons why health capacity in Kenya is so low. Several decades of structural adjustment policies emanating from the International Monetary Fund (IMF) and the World Bank (WB) have reduced capacity, especially personnel, severely.

But brain drain has also had an enormous influence. Brain drain is not just the process of trained personnel looking for work in other countries because they can't find work in their own country. They often can't find work in their own country because of aforementioned IMF and WB policies. (A cynic may suggest that, however unintended, these policies often seem to benefit wealthy countries.) And they often end up going to other countries because those countries come looking for them.

The costs of educating professional personnel plus other losses that Kenya must bear are huge. The benefits to the wealthy countries who poach them are also huge. Hence the practice of aggressively poaching personnel whenever there is a shortage in these wealthy countries. Countries that have been heavily involved in poaching doctors in large numbers include the US and the UK. Countries that have poached significant numbers of nurses include Canada, Denmark, Finland, Ireland, Portugal, UK and USA.

The UK recently published a nauseatingly sanctimonious document detailing how they did not poach personnel from developing countries. They didn't say that this was only because they discovered they had an oversupply of doctors and nurses and they no longer needed to poach so aggressively, for the moment, anyway. It could be compared to their similarly sanctimonious claim to have reduced carbon emissions when all they had done is externalised them by exporting them to developing countries. But their change of policy is too late to be of much help to Kenyan health services, regardless of their motives.

Development is not, therefore, just about figuring out 'what we can do to help developing countries'. We also need to look at policies and practices that impoverish and exploit developing countries, such as structural adjustment policies, exporting carbon emissions and aggressive poaching of skilled personnel. But these are what the title of this blog refers to, a theme I shall return to frequently.



Anonymous said...

please go check out these two websites and reconsider the use of circumcision as a "health measure"
there is a significant amount of information calling into question the value of circumcision for HIV prevention, and a lot more
also go to

Simon said...

Thank you. Yes, I'm aware there is a lot of doubt cast on the use of circumcision. But I'd prefer to leave that debate for the moment. I think the more important debate is about serious underdevelopment in Kenya. HIV is just one disease and circumcision is just one possible intervention, yet HIV and circumcision seem to get a disproportionate amount of attention.

Anonymous said...

Thank you for writing about this. This blog might be of interest to you

I agree- the most pressing problems facing African countries are lack of clean water to drink and starvation. If these issues were made a priority, it would be much easier to stop the spread of HIV.

Simon said...

Thank you Caroline, yes, I agree circumcision is not yet straightforward. However, the same applies to other solutions to HIV transmission that have been suggested. Even if they would work in principle, medical interventions are unlikely to work very well in a context where health services have been run down over many years.

Also, I think circumcision would be more acceptable if informed consent were involved, but only if absolute freedom could be assured. If someone is faced with censure from his family or community because he decides not to be circumcised, that would be in tension with the possibility of informed consent.

It is difficult to imagine how consent could be informed given the present controversy, mythmaking, propaganda and hysteria surrounding circumcision. Especially in a country where many people still don't receive a complete education and have very little access to reliable information.