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Circumcision: a Case of Retributive Healthcare?

[Cross-posted from the HIV in Kenya site.]

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’.

13 responses to “Circumcision: a Case of Retributive Healthcare?

  1. jimgthornton January 5, 2013 at 10:05 am

    Lets’s get this straight. The UN and WHO run mass male circumcision campaigns in the hope of reducing HIV transmission. But they do so in the same health facilities where they recommend their own workers to carry clean needle and syringe packs to avoid needle-stick viral infections if they need treatment themselves! Please tell me I’ve got this wrong.

  2. Simon Collery January 5, 2013 at 10:22 am

    Thanks for your comment Jim. It was realized that adverse event rates were very high in clinical settings so designated clinics are used for carrying out many circumcisions; only a minority are carried out in general health facilities. In other words, it was clear that circumcision posed a very high risk. So the risks from unsafe healthcare are well known, particularly to those pushing circumcision. Mass male circumcision is just another vertical program with its own separate facilities and lines of reporting. But infant circumcision is not the norm in a country like Kenya, where people are either not circumcised or they are circumcised when they are in their early teens.

    The proposal to make infant circumcision routine in African hospitals is silent on the issue of whether the operations will be carried out using existing facilities, which do not have a particularly good record when it comes to keeping women and infants alive and healthy. Adults and teenagers are currently being offered an alternative to the crumbling health services everyone else has to put up with, but I doubt if infants will be.

  3. jimgthornton January 5, 2013 at 10:39 am

    Is any Western donor or agency proposing or encouraging infant circumcision?

  4. Simon Collery January 5, 2013 at 11:10 am

    It’s all Western donor funded, though I don’t think there is any non-US funding. There is CDC and PEPFAR money in circumcision research in Kenya and that includes research into infant circumcision, but the current program is targeted at teenagers and adults.

  5. Simon Collery January 8, 2013 at 8:06 pm

    Thank you ‘J’ for the link to the Gates Foundation, run by a man who is not afraid to make it clear that he is completely unaware that HIV prevalence is higher among circumcised men in a lot of the countries being targeted by current mass male circumcision campaigns. Take a look at the link below.

  6. Simon Collery January 8, 2013 at 8:57 pm

    Hi Jim, the programs at present are all aimed at adults, though most of those being circumcised are teenagers. However, there are several papers on PubMed discussing infant circumcision. Here’s one on safety:

    It was funded by various US institutions, including the Gates Foundation. Here’s one about uptake by an overlapping group of authors (I don’t have access to the full paper):

    Here’s another by several of the same authors about the best age for carrying out circumcision, concluding that “Infant circumcision is safe, simple, convenient and cost-effective. The available evidence strongly supports infancy as the optimal time for circumcision.”

    The lead author of the last paper is Brian Morris, a well known Australian proponent of infant circumcision. The American Robert Bailey is an author in all the above papers and has spent many years campaigning for mass male circumcision campaigns, including infant circumcision. He has also been a recipient of substantial funding for circumcision programs.

    I hope that answers your questions.

  7. Anonymous February 8, 2013 at 12:13 pm

    Simon you are making a strong point with regard to this matter. I beleive there are other related cuasing circumstances that can not be isolated or singled out as causative factors for failure on not being able to eliminate the infection. I believe some combined approaches need to be addressed so as to eradicate the problem

  8. jimgthornton February 8, 2013 at 6:08 pm

    see this. US seems to be funding neonatal and child circumcision. Shocking if true. Jim

    • Simon Collery February 9, 2013 at 9:47 am

      Thanks Jim, yes, Robert Bailey, who has been behind much of the rather selective data released for years in East Africa has also been pushing for infant circumcision. I spoke to him one time, he seems to be totally unaware of any of the research that suggests mass male circumcision may be a waste of time and may even be counterproductive. His Nyanza Reproductive Health Society, about which I can find little reliable information, seems to have been set up to push circumcision at all costs and they have received huge amounts of money for it. In fact, much of it appears to have been spent on lavish cars, per diems and the like, but they also claim to have circumcised many hundreds of thousands of men. I haven’t even heard how much money will be made available for infant circumcision.

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