Cultural Baggage Stymies AIDS Prevention in Africa

Photo credit: Chris Gander, stock.xchng

When two African trials last year showed that circumcised men were 60 percent less likely to become infected with HIV than those with foreskins, the World Health Organization and otherfunders began recommending the procedure as a routine preventive measure. This was front-page news, but part of the story wasn’t told.

For a decade, a handful of HIV prevention professionals had been shouting about the evidence that circumcision could help stop AIDS, but few listened. Their saga offers a painful example of how cultural baggage in the public health world can lead to bad policy—and sometimes, to unnecessary deaths.

Whether it’s abstinence-only education or the refusal, by some African leaders, to acknowledge that HIV causes AIDS, wishful thinking often obscures and hampers public health. In the case of circumcision, 20 years of data have shown that the African countries with high circumcision rates have far lower rates of HIV. Basic research has helped explain this phenomenon by demonstrating that the foreskin contains cells rich with HIV receptors, and that other foreskin infections can provide a bridge for the virus to enter the body. But many of the world’s AIDS authorities put their fingers in their ears when confronted with this evidence.

“The tragedy of the endorsement of male circumcision is that we could have done it five or ten years ago,” said Malcolm Potts (an embryologist and professor of public health at the University of California). “You can’t push the light switch and do a million circumcisions immediately. It takes time. And people are dying as a result.”

To get a feel for the surreal world of AIDS bureaucracies, consider this tale from a friend of mine, an officer of the U.S. HIV prevention program in Southern African when Randall Tobias, director of the President’s Emergency Plan for AIDS Relief or Pepfar, visited his base in Swaziland a few years ago.

In the weeks before Tobias’ visit, my friend’s bosses issued repeated warnings. “Whatever you do,” they said, “do not even mention the subject of male circumcision.”Pepfar has provided lifesaving drugs for about 2 million people with HIV, but also pushed a partisan line of abstinence-based education, sometimes refusing to fund services like those that teach prostitutes to use condoms. Male circumcision was not on its agenda. Tobias, a formerATT and Eli Lilly chief executive, toed the line, urging the “abstain, be faithful, or use a condom” approach. Then he quit the government when he was linked to a D.C. prostitution ring.

As it happens, my friend in Swaziland, Daniel Halperin, a medical anthropologist, was among a small group of researchers who had been frustrated for years by the unwillingness of big AIDS organizations to recognize the more low-tech methods for fighting HIV.

Hundreds of millions of dollars had been sunk into HIV vaccines as well as microbicides designed to protect women from the disease. Hundreds of millions more were paying for condoms. Yet AIDS kept growing. Now, 25 million Africans have the disease, and nearly 2 million died of it last year.

All this time, Halperin was virtually laughed out of HIV prevention conferences for insisting that male circumcision could effectively serve as a first-generation vaccine against AIDS. It was not a perfect prevention, to be sure, but then, none of the scientists working on AIDS vaccines expected to be able to provide a perfect vaccine, either—if they ever succeeded in producing any vaccine, that is.

At a luncheon for Tobias, several Swazi clergyman told him that the biggest cause of HIV’s spread was something no one wanted to talk about: the long-term affairs that married men and women had on the side (see Helen Epstein’s brilliant book for a convincing explanation of how this works). At this point, Tobias happily whipped out a copy of his business memoir, “Put the Moose on the Table,” which preaches the gospel that large organizations fail by ignoring their biggest problems—the elephant in the room, the moose on the table, you get the idea. As a loyal political appointee, Tobias was only too happy to hear these African men fess up to the immoral origins of their tragedy.

My friend is not easily dissuaded, and all the talk of moose made it hard to keep his tongue stapled, especially when so much was at stake. “Ambassador,” he said in a private moment after lunch, “there’s another moose on the table.” Circumcision, he said, could save millions of lives, but no one wanted to talk about it. A week later,Pepfar issued its first news release saying that it was “studying” the issue.

Unfortunately, studying wasn’t enough. It wasn’t until last March, when the National Institutes of Health stopped the African circumcision trials—it was no longer ethical to continue them, because circumcision was clearly beneficial—that the World Health Organization and other agencies did an about-face.

Even then, the cautious consensus statement issued by UNAIDS reflected how leery many specialists remain about the practice.

It has been argued, with some justice, that it would have been irresponsible for AIDS groups to promote male circumcision until the randomized controlled trials, the gold standard of good science, had been conducted.

Among us Semites—Jews and Muslims—circumcision is a tradition with practical origins: it prevents the irritation of sand under the foreskin, and some African tribes ritually circumcise adolescents in coming-of-age rituals. Initially, some scientists speculated that lower HIV rates in Muslim African countries were due to different sexual practices. But this wasn’t the case. In Kenya for example, Muslims have lower HIV infection rates despite cultural practices no different from Christians.

Halperin and other proponents of circumcision have long argued that it would have been prudent, given the horrible advance of AIDS and the potent, if incomplete, evidence for circumcision, to at least discuss it, especially because few other alternatives were available to people trying to survive the epidemic.

It will take precious time to “roll out” a male circumcision policy in Africa, to make sure it is culturally sensitive and that the procedure is done in properly hygienic settings. Sex before the circumcision has healed might cause, rather than prevent HIV infection. It’s time that many Africans don’t have.

“We could have learned what the complication rates are,” said Potts, “who should perform the circumcisions, how many can be done in a day. We could have had that data from the year 2000 or before.”

Potts is a convert to the circumcision cause. As the head of Family Health International, a leading family planning organization, from 1978-1990, he promoted HIV testing and counseling and blanketing the continent with condoms. Later he became an enthusiast of microbicides, medicines that women would insert in the vagina before sex to kill HIV. Neither approach has worked. Potts, unlike many of the leaders of HIV prevention, has the guts to admit he was wrong.

“I spent 10 years working on HIV prevention in Africa,” he said. “I have to say we didn’t make any difference in slowing the epidemic.”

Groups like the UN World Health Organization have been reluctant to deal with circumcision until recently. There are a number of explanations for this. Taken together, they constitute a shocking display of how cultural blinders can cause death.

The first explanation may be that male Europeans, who are powerful in the WHO and other agencies working on AIDS, are, for the most part, not circumcised. From the sexually liberated perspective of European baby boomers, they tend to see circumcision as “unnatural”—an interference with sexual pleasure and a form of sexual repressiveness that the West should not be foisting on Africans.

One academic I spoke with described meeting a World Bank official in Malawi last summer. When she asked her what the bank was doing about circumcision, the woman replied, “We will never do anything about circumcision. Can you imagine the reaction when they hear we want to cut the penises of black men?” The World Bank has gotten a lot of grief for its programs over the decades, she added, and “we don’t want Africans saying, ‘You robbed us of our land and culture, and now you want our foreskins?’ ”

But in fact, surveys of Africans detect little anxiety about circumcision. When Halperin and his HIV prevention colleagues helped introduce the idea in the largely Christian Swaziland a few years ago, it caught on so quickly that men rioted Mbabane, the capital, because of the long waiting lines.

But scientists and charitable organizations have difficulty giving up on cherished notions. When money started flowing into AIDS, the people with infrastructure and staff were family planning groups, which knew how to move condoms and set up counseling, but shied from procedures that seemed culturally sticky.Microbicides were hot because they seemed to “empower” African women.

Male circumcision, neither politically correct nor technologically advanced, had no commercial, scientific or political champions. “It had no advocates except DanielHalperin,” said Ann Swidler , a Berkeley sociologist who is studying the response to the AIDS epidemic in Africa. “Gradually these groups are trying to form, but they still have trouble getting funding. Donors don’t find it sexy.”

In addition, a small but bitterly vocal minority of academics and activists feel that male circumcision, like the female variety, is genital mutilation, and that is causes lifelong psychological trauma and robs men of pleasure (the data doesn’t back them up).

Finally, though, some resources are being generated to promote circumcision. Visit a bris some time if you want to see how innocuous a procedure it can be.

And it may be the kindest cut of all.