Friday, August 24, 2012

Circumcision - Medical Intervention, Money Spinner or Revenge?

"Kenya: Urine Can't Heal You - Catholic Church", says the headline. Apparently some priests have been claiming that urine cures certain conditions. The bishop has said the responsibility of the church is to "advocate for spiritual fitness" and to leave health advice to medical experts. It's a pity they didn't feel the same way about using condoms to reduce HIV transmission. But no one could accuse them of being progressive.

What is more surprising to me is that the Catholic Church doesn't seem to be so bothered about the preaching from the HIV industry about mass male circumcision reducing HIV transmission from males to females. Ostensibly, the circumcision is voluntary. But many feel the program is being imposed on them and a lot of inaccurate and incomplete information is being given out about it, even by some 'medical experts'. Don't the church feel people should have a right to choose, a right to full and accurate information, a right to protection from those who wish to impose their will?

Many of Kenya's tribes circumcise for cultural reasons. However, there are a few that don't circumcise, also for cultural reasons. Sometimes it seems that the cultural practice of circumcising is being held up as in some way superior to the cultural practice of not circumcising. Persecution of non-circumcising people and the use of forced circumcision as an instrument of torture or a weapon of war predates the development of the HIV industry, and even the HIV pandemic. But the claim that circumcision reduces HIV transmission is creeping into the rhetoric reported from gangs of thugs who circumcise men in public, for whatever reasons.

It's very unclear how many people the industry hopes to circumcise. Sometimes they claim that adult men are being targeted; yet many accounts suggests that boys are turning up in large numbers. Parents of infants are also being encouraged to have the operation carried out, even though there is no evidence that this will have any positive impact on HIV transmission. The lowest figures are over 20 million. But some estimate as high as 38 million. And a throwaway remark by the CEO of a producer of 'bloodless' circumcision clamps suggests that hundreds of millions is the ultimate target.

The HIV industry is famous for spending enormous sums of money on red herrings, so there's nothing very surprising at their enthusiasm to spend as much as possible before the bubble bursts. But it must be wondered how many people will be needlessly infected and how many will die as a result of this deflection of vast sums of money. But the Catholic Church has problems of its own. Perhaps that's why it doesn't want to get involved in something that will not result in any of the billions being directed to the church, nor even add to the numbers of poor people who pay monthly dues so priests and other members of the hierarchy can live a comfortable life

But despite all the hype, there have been two big stumbling blocks. One is the obvious lack of funding, supplies, equipment and trained staff, which have delayed some programs in Kenya and Uganda. The other is the sheer numbers involved. Most sub-Saharan African countries can only provide adequate healthcare for a small proportion of people, the ones who can afford private care. For the rest, it's a free for all; you never know what you'll get until you've got it. The logistics of carrying out so many operations would be daunting in a country with a good health infrastructure, let alone those whose health systems have been running down for 20-30 years.

But in most African countries it's not going to be possible. Tossing about notional figures for costs and targets will have no impact on the harsh realities faced by developing countries. Countries that started several years ago are still a long way from their targets. Kenya may seem to be way ahead, their target is only 2 million (though the figures cited can vary considerably), but people are just not turning up in high enough numbers. Those who got in early and received the benefits offered, however dubious, are not being followed by others in particularly high numbers.

In countries where people are most likely to die of preventable and treatable illnesses, it would seem smart to concentrate as much health capacity as possible on these, rather than frittering away everything on a program that will have very little benefit and may have a lot of adverse effects. Women are far more likely to be infected with HIV than men; circumcision is claimed to reduce HIV transmission from women to men, but it is likely to increase transmission from men to women. Surely this is not the optimum way to reduce HIV transmission, is it? Even drinking urine would be cheaper, which may explain the church's objection to it, and would probably do less damage.

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


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