Health Related Political Footballs

It seems like a short time since the issue of mass male circumcision (MMC) became a political football and it is not even the latest issue to have that status any more. But articles about it still appear every now and again and there seem to be a handful of genuine projects aiming to roll out MMC in some countries.

The Integrated Regional Information Networks (IRIN) has a recent article on the subject and lists the countries that have made some progress towards rolling out MMC. I notice Kenya is not on the list and not much progress seems to have been made in the eight countries in the list. Most sub Saharan African countries suffer from a lack of capacity and this seems unlikely to change in the near future.

On the one hand, a country could approach HIV as if it was just one disease of many and build up their overall health services. But most donor funding goes towards a handful of diseases, the main one being HIV. Very little funding, if any, goes towards building up health services in general.

Alternatively, countries could extend the capacity of existing health services to accommodate some kind of MMC programme. The latter approach might be like the attempt to test people for HIV (in the form of voluntary counselling and testing clinics) and the attempt to distribute treatment to as many infected people as possible. But after many years and extraordinary amounts of money being spent on these areas, these efforts have had limited success.

It’s important to note also that there are still many questions about the benefits of MMC and precious little discussion about the downsides. This is worrying and gives the impression that MMC is being promoted without taking into account the welfare of the people who will be involved. Of course, that wouldn't make MMC much different from development projects in general.

But the aim of MMC, ostensibly, is to reduce HIV transmission. It is believed that circumcised men are far less likely to become infected with HIV than uncircumcised men. The level of protection offered by circumcision is a matter of debate. I hope the debate is comprehensive and well informed because any measure that could reduce HIV transmission should be welcomed.

That is, any measure that has substantial benefits and few, if any, adverse effects. And circumcision may have quite a number of adverse effects. Rather than rehearsing the possible adverse effects here, I recommend the Male Circumcision and HIV website.

But my objection to MMC is slightly different. Given that I would argue that if Kenya had good health, education and other social services in the first place, HIV would never have spread as it did and would be easier to fight now. Therefore I see little point in piecemeal programmes that address one small factor in HIV transmission at a time.

Men are becoming infected because they don't know enough about safe sex and they don't have a high level of sexual health. Women are becoming infected because they have, in general, even poorer levels of health and education than men. There are employment, infrastructure, legal, lifestyle, tribal and many other reasons why men and women continue to be infected with HIV.

All of the factors in HIV transmission need to be addressed, not just the one or two factors that seem most attractive at a given time. Why MMC seems so appealing is really not that clear but ask yourself this question: would you go to a clinic to be circumcised if you knew that 1 in 5 operations resulted in some kind of adverse effect? Would you allow a clinic to circumcise your children?

Who in their right mind would advocate a programme of MMC in a country where tens of thousands of women die giving birth or shortly after giving birth, where tens of thousands of children die of diarrhoea, acute respiratory conditions, malnutrition or other easily curable or treatable diseases or where a substantial number of people will never have access to a qualified doctor in their whole life?

Kenya needs good health services, education and other social services. I know I keep beating on about it but these other political footballs are just distractions. I guess they are supposed to distract but we shouldn't forget the problems that Kenyan people face: they relate to day to day issues, such as food shortages and high food prices, unaffordable health care, appalling educational facilities and standards, political unrest, corruption and many other things.

Tackle the issues that face people on a daily basis and the problem of reducing HIV transmission will be a whole lot easier, whatever measures are deemed most appropriate in the end.