Thursday, April 2, 2009

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

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

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

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

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

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

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

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

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

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

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

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

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



Mark Lyndon said...

The studies which allegedly show a reduction in HIV among circumcised men are highly questionable. Not one of them was finished, despite the protective effect appearing to decline well below the oft-reported 65%, and several of the subjects disappearing. The fact that one study described circumcision as "comparable to a vaccine of high efficacy" seems to show clear bias. They appear to have been seeking a certain result. One has to wonder how many of the people promoting circumcision in Africa are themselves circumcised. Daniel Halperin is the grandson of a mohel, and seems to think that "maybe in some small way (he's) destined to help pass along (circumcision)" so his objectivity is questionable.

Other epidemiological studies have shown no correlation between HIV and circumcision, but rather with the numbers of sex workers, or the prevalence of "dry sex".

The two continents with the highest rates of AIDS are the same two continents with the highest rates of male circumcision. Rwanda has almost double the rate of HIV in circed men than intact men, yet they've just started a nationwide circumcision campaign. Other countries where circumcised men are *more* likely to be HIV+ are Cameroon, Ghana, Lesotho, Malawi, Swaziland, and Tanzania. That's seven countries where men are more likely to be HIV+ if they've been circumcised.

Cameroon: table 16.9, p17 (4.1% v 1.1%)
Ghana: table 13.9 (1.6% v 1.4%)
Lesotho: table 12.9 (22.8% v 15.2%)
Malawi: table 12.6, p257 (13.2% v 9.5%)
Rwanda: , table 15.11 (3.5% v 2.1%)
Swaziland table 14.10 (21.8% v 19.5%)

Something is very wrong here. These people aren't interested in fighting HIV, but in promoting circumcision (or sometimes anything-but-condoms), and their actions will cost lives not save them.

If you read those reports btw, the level of knowledge about HIV is quite frightening. In Malawi for instance, only 57% know that condoms protect against HIV/AIDS, and only 68% know that limiting sexual partners protects against HIV/AIDS. There are people who haven't even heard of condoms. It just seems really misguided to be hailing male circumcision as the way forward. It would help if some of the aid donors didn't refuse to fund condom education, or work that involves talking to prostitutes. There are African prostitutes that sleep with 20-50 men a day, and some of them say that hardly any of the men use a condom. If anyone really cares about men, women, and children dying in Africa, surely they'd be focussing on education about safe sex rather than surgery that offers limited protection at best, and runs a high risk of risk compensatory behaviour.

Circumcised male virgins are more likely to be HIV+ than intact male virgins, as the operation sometimes infects men. The latest news is that circumcised HIV+ men appear more likely to transmit the virus to women than intact HIV+ men (even after the healing period is over). Eight additional women appear to have been infected during that study, solely because their husbands were circumcised. This is not the first time that HIV in women has been linked to partner circumcision.

ABC works against HIV. Circumcision appears not to. Remember that circumcision won't make any difference unless someone is having unsafe sex with an HIV+ partner.

Female circumcision seems to protect against HIV too btw, but we wouldn't investigate cutting off women's labia, and then start promoting that.

For a good summary of the case against promoting circumcision in Africa, see this link:

Simon said...

Hi Mark, thank you for your fulsome reply. I agree that things are not straightforward with circumcision but the point I was trying to make is the futility of targeting HIV without building up health services. The absence of facilities for pregnant women and the subsequent absence of facilities for obstetric fistula suggest that Kenya is not up to a relatively small scale programme, therefore the idea that they could run a successful large scale MMC programme is laughable. Targeting HIV to the exclusion of most other diseases and refusing to improve health, education and other social services has so far led to failure and will continue to do so.

As for ABC working, as you claim, I think if you were as diligent in researching ABC as you are in researching the disadvantages of circumcision, you would think otherwise. But that's another day's work.

Joel said...

I think the key you are making that I would agree with is that we need to INCREASE both education and resources. People ALL need to understand what HIV is, what causes, what DOES NOT cause it, and they also need access to condoms, and access to STI testing facilities.

THESE are IMPERITIVE to dealing with the HIV crisis, nothing else will do.

And circumcision only gets in the way, it clogs up resources, it is not effective (despite claims), and it creates MORE myths, and MORE problems.

The fact is the first two things are needed before circumcision should ever even come into anyones head.. and then if you think about it, if the first two things are in place, circumcision would no longer be necessary.

MMC tries to treat a large population the way a military commander throws troops into battle, thinking about numbers, not about people.

EDUCATION - give people the knowledge to save themselves. That is all we'll ever be able to do, and that's all we OUGHT to do. That is all that is ethical to do.

knowledge is power, it really is.

Simon said...

Hi Joel, thank you for your comment. I agree with you to a large extent but I wouldn't dismiss circumcision altogether, it's premature to do so. But the ethical problems do need to be addressed, as you say.

As for knowledge being power, I don't agree with that. Education is important, vital, even, but people need a lot more empowerment than just education. There is little incentive for people to spend a long time at school or college if they face a life of subsistence afterwards.

I think power is power and knowledge can often help, other things being equal. But all too often, knowledge on its own does little. Young girls marrying older men in Western Kenya can know all about the dangers but have little choice about whether to marry them. And there are many other instances of where knowledge is not power when it comes to sexual behaviour and HIV, I'm afraid.

Mark Lyndon said...

I disagree with you about ABC Simon, but I definitely agree with your main point.

Rwanda has only one doctor for every 50,000 people and one nurse for every 3,900 people, so why are they rolling out mass circumcision? Intact Rwandan men are less likely to be HIV+ than circumcised Rwandan men anyway.

Something is very wrong here. It appears that some people aren't interested in fighting HIV, but in promoting circumcision (or sometimes anything-but-condoms), and their actions will cost lives not save them.

Simon said...

Hi Mark, thank you. Well, my argument against ABC is similar to my argument against MMC. The country (Kenya, but most African countries, I think) does not have the capacity to roll out large scale programmes and people. In addition, people are either not in a position to abstain, be faithful or use a condom or they are unwilling to. ABC campaigns, like MMC and universal testing and treatment, require a good health and education infrastructure and this is absent.

Your points about Rwanda are well taken, I agree that such proposed programmes seem to be based on little or no evidence. I would also say that evidence of something in one country does not always apply to other countries. In Kenya, I think there is some correlation between circumcision and low rates of HIV (and Islam and low HIV) but the reverse is the case in other countries.

Many HIV programmes were based on the somewhat mythical accounts of HIV reduction in Uganda. Even if these accounts of HIV reduction were true, the situation in Kenya and other countries are different from what may have obtained in Uganda. But it's far easier to roll out the same old programmes everywhere. Hence, with MMC.

I think there may be further evidence for your case against MMC soon. The North Eastern province, where there is one doctor for every 100,000 people, HIV has been low. It was said that this is because they are Ethnic Somalis and their lifestyles don't put them at risk of HIV. Also, male circumcision is 100%. Factors that suggested that HIV could one day increase there have been ignored, such as the high rate of intergenerational marriages, high rates of female circumcision and extremely low health, education and other indicators.

I think the isolation of many North Eastern Kenyans may have protected them and their relative invisibility makes it seem as if HIV is lower there. But this may not remain the case and there is now worry that nomadic people and people who haven't yet been much affected by HIV are becoming infected in higher numbers. Of course, I may be wrong about this, but it's an interesting trend to watch.