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The Politics of MC



Bill Weintraub

Bill Weintraub

The Politics of MC

12-20-2006

MC is the epidemiological abbreviation for "male circumcision," and last week the press was full of reports describing MC as a "breakthrough" in AIDS prevention in sub Saharan Africa.

For example, MC was the lead story in the NY Times on 12/14/06, while an accompanying editorial trumpeted Rare Good News About AIDS, and proclaimed:

The announcement yesterday about the results in two African studies of male circumcision may be the most important development in AIDS research since the debut of antiretroviral drugs more than a decade ago. The National Institutes of Health halted studies in Uganda and Kenya when it became overwhelmingly clear that circumcision significantly reduces menís chances of catching H.I.V.

The LA Times, the SF Chronicle, and other major dailies carried similar stories with similar enthusiasm.

But, the question must be asked, why was the announcement deemed of such import in 2006 and not in 2003 or earlier?

It was in 2003, after all, that the results of a massive study in India were announced which made clear that MC was protective against HIV:

Reynolds SJ et al. Male circumcision is protective against HIV-1 in India. (2003). 41st Annual Conference of the Infectious Diseases Society of America, San Diego.

That study, and others like it, were well known.

Indeed, in reporting that study, I blistered those in the gay male community who were still opposing MC -- not only because the results of the study were decisive, but because I was in email correspondence then -- and now -- with one of the top researchers on MC.

Who'd told me -- and a lot of other people -- that there was no doubt about MC.

And that was 2003.

Truth is, reports of MC being efficacious had come in as early as 1988 -- a full EIGHTEEN years ago, as this article excerpt from Dr. Green makes clear:

Green, E. C., "The Participation of African Traditional Healers in an AIDS/STD Prevention Program." Tropical Doctor, Suppl.1, pp.1-4, 1997.

Bongaarts and his colleagues found a positive statistical correlation between lack of male circumcision and HIV sero-prevalence in the capitals of 37 Africa countries (Bongaarts et al 1989:373-5). Although most geographically localized studies of risk factors have not considered circumcision, a few have and have also discovered positive associations between HIV infection and lack of male circumcision (e.g., Greenblatt et al 1988). It is not known what the causal connection is between these factors but Barton (1989:13) notes that "post-coital abrasions in the foreskin is common in uncircumcised males."

Apparently unaware of the discussion of epidemiologists, some traditional healers at a November 1992 workshop in South Africa spontaneously reported they had discovered the importance of male circumcision through their own clinical experience (Green, Zokwe, and Dupree 1992). They noted that male repeat STD patients tend to be uncircumcised. Many such patients are said to have rashes, "dirt," or infections under their foreskins. Healers from societies that practice circumcision (e.g., Xhosas, Sothos) reported advising clients from non-circumcising societies (e.g., Zulus, Swazis) to become circumcised as a way to prevent STDs, and perhaps AIDS. Such clients were said to be complying by visiting hospitals or traditional healers to become circumcised. When asked about cultural resistance to circumcision in non-circumcising societies, a traditional healer observed, "When tradition and the health of our people are in conflict, it is tradition we must sacrifice."

Further research is warranted to determine the extent to which men in South Africa, and possibly elsewhere, are becoming circumcised as a result of preventive STD and/or AIDS education from traditional healers.

References:

Barton, Thomas, Sexuality and Health in Sub-Saharan Africa: an Annotated Bibliography. Research Triangle, North Carolina. Family Health International/AIDSTECH, 1989.

Bongaarts, J., P. Reining, P. Way and F. Conant, "The relationship between male circumcision and HIV infection in African populations." AIDS, 3(6):373-377, 1989.

Green, E.C., Zokwe, B., Dupree, J.D., "The Role of South African Traditional Healers in HIV/AIDS Prevention and Management." Arlington, Va.: Family Health International, AIDSCAP Project, Dec. 1992.

Greenblatt, R.M., Lukehart S.A., Plummer, F.A., Quinn T.C., Critchlow C.W., Ashley R.L., D'Costa L.J., Ndinya-Achola J.O., Corey L., Ronald A.R., "Genital ulceration as a risk factor for human immunodeficiency virus infection." Aids. 2(1):47-50, 1988.

Dr. Green's 1997 article appeared in a relatively obscure journal.

But Bongaarts et el published in the prestigious HIV journal AIDS in 1989: Bongaarts, J., P. Reining, P. Way and F. Conant, "The relationship between male circumcision and HIV infection in African populations." AIDS, 3(6):373-377, 1989.

A decade later, in 1999, with basically nothing happening, a couple of leading researchers managed to get an article in the Lancet asking their fellows to take MC seriously.

And then there was more silence.

So: why is it only now that papers like the Times are focusing on MC?

Why did it take so long?

What's the politics behind it?

The answer is not complicated.

For decades, the prevention paradigm applied to the heterosexual epidemic in Africa has been a Western paradigm -- specifically the gay male paradigm developed for the MSM epidemic in the US and EU.

That gay male paradigm has at its core the protection of anal penetration, promiscuity -- and non-circumcision.

Which has been an article of faith among gay men since the 1970s.

Circumcision has long been viewed by gay male ideologues as a patriarchal plot to deny men sexual pleasure.

So non-circumcision was simply not something which could be discussed.

Instead, all would depend on the condom, which was viewed, paradoxically, as the least invasive intervention.

As I said earlier, I've been in email correspondence for the last three years with one of the world's leading MC researchers.

Why do I never mention his name?

Because he doesn't want me to.

And that's because he fears the power of gay male functionaries in UNAIDS and to some extent in USAID as well.

In an email on December 16, this researcher said,

there's still a LOT of resistance [to MC] among the more "human rights"/"gender and women's empowerment"/"poverty causes AIDS," etc. camps, even more resistance than to "B" [Be faithful] ... There are some people (mainly white gay "social scientists") who have sent [UNAIDS head] Piot a letter, and UNAIDS is meeting with them soon; they claim MC is an "ethical violation" and so on... (And have you noticed Piot's notable/total silence on MC this week?? Can you imagine if a 50%+ effective vaccine or microbicide had just been proven? He'd be talking his head off, don't you think??...)

Did the meeting between Piot and the anti-MC forces take place?

I don't know, but I do know that yesterday -- December 19 2006 -- Piot threw the full weight of UNAIDS behind MC:

U.N. urges circumcision in AIDS-hit southern Africa

By Kamil Zaheer

Tue Dec 19, 2006

NEW DELHI (Reuters) - AIDS-stricken Southern African nations should develop a policy of mass male circumcision to fight the disease, the head of the United Nations anti-AIDS agency said on Tuesday.

Several recent medical studies have reported circumcision cuts the risk of HIV infection among men by 50-60 percent, and the findings have been backed by UNAIDS.

"These (African) countries should now prepare how to introduce circumcision on a large scale," UNAIDS chief Dr. Peter Piot told Reuters. "The science is clear."

Baby boys should be targeted first but then attention should switch to adolescent boys and adult men, said Piot, who is in New Delhi to meet Indian officials on how they plan to tackle the world's largest HIV/AIDS caseload.

In 2005, UNAIDS said that more research was needed into the possible benefits of circumcision before it could be promoted as part of national HIV programmes.

One U.S.-Ugandan study found male circumcision also reduces infections in female partners by 30 percent.

Muslim and Jewish men have to be circumcised according to religious beliefs, and Piot said that UNAIDS understood advocating mass circumcision was a religiously and culturally sensitive issue for many people.

"Changing that is touching very much on the core of values. That is going to make it more complicated than any other medical issue that I can think of."

But he said given the grim HIV situation in southern Africa, it was important to promote the idea of widespread circumcision.

"We are faced with an absolute crisis where you have 20-40 percent of adults being HIV-positive ... you need to use every scientifically proven method to bring down the new infections."

South Africa, Botswana and Nambia are among the worst hit countries in the region, while Swaziland has an infection rate of around 50 percent, UNAIDS says.

Piot said that even if large-scale circumcision was introduced, countries should continue to promote condom use as well as abstinence.

[emphases mine]

It's actually partner-reduction, not abstinence, but nevermind -- Piot knows his audience.

By using the word "abstinence" he manages to inflame his secularist allies while placating the Bush admin -- not a bad trick.

Why did Piot decide to endorse MC?

Well, without question, the science is there.

However, the science is also there on partner-reduction aka "B" -- be faithful.

It's been established beyond a shadow of a doubt that what's driving the epidemic in southern Africa is promiscuity -- specifically, networks of concurrent partners.

It's those networks that the original Ugandan "zero-grazing" program disrupted, and that's why HIV prevalence fell in Uganda for 12 years straight.

And let's be clear that the Ugandan program was not "Christian."

As you can see from the Tropical Doctor article, Dr. Green's primary interest is in native African healers.

Dr. Green is a medical anthropologist, with like I say an intense interest in native African healers, shamans, "witch-doctors," etc; and he was very intrigued by the way the Ugandans had come up with a completely indigenous African program to fight HIV infection -- a program which was spectacularly successful.

Where Western-style condom campaigns had failed so utterly.

What happened in Uganda was not "Christian" per se -- it was a mobilizing of the population, including ministers, imams, native healers, and other folks -- against HIV.

So the religious right has mis-read Uganda.

As has the analist left.

In both cases --

Purposefully.

And as a consequence, the one intervention which we know will work, and is LEAST invasive -- partner reduction aka FIDELITY -- is still given the short end of the stick.

In an email to me on Dec 16, Dr Green predicted that just that would happen:

AIDS Inc. will nevertheless jump happily into MC: it's a medical, technical intervention, and it leaves sexual behavior alone (unless specifically added). Watch as everyone jumps on the MC bandwagon and compare this with acting on the news that decline in # of sex partners (esp. concurrent) is the crucial behavioral factor needing to be addressed.

The White Folks here in Uganda have succeeded in removing "Be faithful" targets and impact indicators and even mention from the latest Uganda Natl Strategic Framework for HIV AIDS, even though the latest DHS showed clearly that # of partners was strongly associated with HIV status

IN SUM:

Traditional African healers have understood that non-circumcision was a factor in HIV transmission from the git-go.

Western and other scientists working on AIDS in southern Africa observed and PUBLISHED ABOUT the protective aspect of MC as early as 1988.

A full EIGHTEEN YEARS AGO.

UNAIDS and USAID sat on its hands.

Dr. Green published about MC in 1997.

In 1999 a group of other researchers begged, in the Lancet, for more attention to be paid to MC.

The Indian study was conducted in 2003, and was conclusive.

But AIDS Inc declared that it would have to see studies proving that NEWLY circumcised men were protected.

Which studies were terminated a couple weeks ago.

EIGHTEEN YEARS!

Why did Piot and UNAIDS come aboard -- despite the opposition of "white gay social scientists" and the poverty-gender-inequity-causes-AIDS crowd?

My guess -- my VERY STRONG suspicion -- is because of the NY Times endorsement.

Just as the NY Times endorsement of comprehensive and what is de facto compulsory HIV testing for all Americans was crucial earlier this year.

The Times has the heft to over-ride certain of the more extreme elements within AIDS Inc when it wants to.

And certainly the non-circumcision crowd is extreme.

Does this have any bearing on us?

Oh yes.

Because the Dutch demonstrated the efficacy of non-anal -- specifically masturbatory -- alternatives for MSM in 1987.

Twenty years ago.

AIDS Inc and ANAL Inc have gotten away with protecting anal in the US and EU because of the development of HAART and because society is rich enough in the US and EU to make widespread deployment of HAART possible.

And relatively effective.

Will that always be the case?

I don't know.

No one knows.

But I want you guys to be clear, when you read newspaper articles about "breakthroughs" like MC, that they are NOT breakthroughs.

That we've known for years -- indeed decades -- how to end this epidemic.

And that AIDS Inc aided and abetted by ANAL Inc -- has chosen not to.

Instead, AIDS Inc / ANAL Inc have

1. sought to maintain their version of the sexual revolution in the affluent West; while

2. fighting the sexual culture wars on the backs and literally over the dead bodies of African peasants.

Bill Weintraub

© All material Copyright 2006 by Bill Weintraub. All rights reserved.


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