It is now an accepted fact that the Malawi government, the national health authorities and the HIV/AIDS community shamelessly embraced and hastily implemented the ‘mass male circumcision programme’ (MMCP) as a population health measure without any serious assessment of the proffered ‘supposed’ supporting facts of this highly controversial medical intervention: the cons and pros, its applicability to our pandemic, the anticipated real-world effectiveness versus the study intent-to-treat efficacy, the dangers, benefits and opportunity costs of careless and wholesale implementation of such a radical public health intervention.
Owing to the undoubted controversial nature of the adopted HIV-preventive intervention measure—an irreversible surgical intervention—on otherwise healthy bodies (brazenly contravening the medical principle of ‘do no harm’), an informed evaluation report of the short- and longer-term social and cultural impact of ‘male mass circumcision’ as a population health intervention measure should have been proffered by its proponents before its adoption.
The real purpose of circumcision during the early biblical (and medieval) times was to ‘reduce sexual gratification’ (to decrease sexual intercourse by the ‘weakening of the responsible organ’ so that this activity is diminished and the ‘organ in question remains in as quiet a state as possible’) and therefore ‘perfect what is defective morally’ (the violent ‘concupiscence and murderous lust’ that goes beyond what is needed). In Victorian times, circumcision was introduced as a ‘preventive therapy’ to curb excessive masturbation by boys and its perceived ‘ills’ through the ‘amputation of the erotogenic’ foreskin since circumcised boys would not use their (have no) foreskin for masturbation. Circumcision was subsequently accepted as a panacea for many health conditions, including epilepsy, mental illness, paralysis, malnutrition, many ‘derangements’ of the digestive organs, chorea, convulsions, hysteria, schistosomiasis (bilharzia) and other nervous disorders. In the ensuing decades, ‘as each claimed benefit of circumcision was disputed, another would come to take its place’—the present claimed benefits should be seen in exactly the same light.
What does the frequently cited ‘60% relative reduction’ in HIV infections actually mean? In all 3 trials that formed the mainstay of WHO/UNAIDS’s decision to recommend ‘mass male circumcision programme’ as a ‘supposedly’ HIV-preventive measure, 1.18% of men subjected to circumcision became HIV positive while 2.45% of the controls (intact men) became HIV positive, so the ‘absolute decrease’ in HIV infection was only 1.31% which is statistically insignificantly. The decision by WHO/UNAIDS to recommend the circumcision of up to 38 million African men (in the next five-years)—which the Malawi government is religiously implementing with the free-circumcision promotion campaigns—is clearly not underpinned by credible scientific evidence (medical or experimental). Actually, examination of the epidemiological data from several sub-Saharan African countries shows that male circumcision does not provide protection against HIV sexual transmission—the countries include Cameroon, Ghana, Lesotho, Tanzania, Rwanda, Swaziland and Malawi—all of which have a higher prevalence of HIV infection among circumcised men (one epidemiological study of 58,598 men found no relationship between male circumcision and HIV transmission). The claimed efficacy of male circumcision reducing HIV sexual transmission has been further contradicted by no less than 17 observational studies.
For the umpteenth time we are confronted with the classic situation where authorities tasked with the responsibility of making sound decisions on weighty issues like these continue to be strong-armed by extreme greed into making decisions that least help the people they serve. Authorities making decisions on behalf of the country should always be mindful of throwing caution and reason to the wind in their over-excitement with ‘free-lunch offers’ whatever form they take. The more things seem ‘free’ the more exhaustive the cost/benefit analysis of the ‘free’ offer otherwise the only goal we will be serving is serving the not-so-benevolent self-interests of the ‘benefactors’.
The tragedy, however, is that many unsuspecting Malawians will respond positively to the free-circumcision promotion messages which will see many (conservatively, 3 in 10) ‘acquiesce’ to removing the ‘offending’ foreskin at supposedly ‘no’ cost to themselves, never mind premised on false information and deceitful assumptions.
There has never been a more permanent and prominent professional let-down than one fragrantly displayed by our health professionals and health policy makers in veering from evidence-based health policy promulgations to health policy formulations blinded by extreme greed and baffling insensitivity.
Contribution by: Chisala, Maxwell L.