Opinion: Male circumcision alone won’t solve Africa’s HIV problem

Editor’s note: Africa has the world’s largest number of HIV infections and AIDS cases. Across the continent the disease is being battled with public education and antiretroviral drugs. A new additional strategy is male circumcision. Several tests show that circumcised men have substantially reduced risks of contracting HIV. In response, several campaigns have been launched to circumcise men.

GlobalPost has investigated this public health effort in eastern and southern Africa. The series starts in Kenya in the fishing villages by Lake Victoria and includes a video of a circumcision. Also, a Kenyan doctor describes his work running a circumcision clinic and a South African doctor describes the circumcision campaign in several southern African countries.

PRETORIA, South Africa — Never before has the African penis been so scrutinized and discussed, and so much money — hundreds of millions of dollars — thrown at it.

In this discourse, penises come in two kinds: circumcised or uncircumcised. Some tribes and some religions circumcise, at birth or as initiation rite into manhood. Some don’t. Those who do, think it is good. Those who don’t, think it is awful. Each thinks its version of the penis is superior and makes men manly.

Now a new tribe — the AIDS donors and bureaucrats — says that circumcision can save lives. Three studies show that it may offer some protection against HIV infection — around 60 percent lower rates of infection. This tribe says: Let’s cut off the foreskins of as many African men as possible to stop AIDS. The new silver bullet is a sterile knife.

Disclosure: I do not have an anti-circumcision agenda. In fact, I like circumcised men. They hold erections longer. This is a scientific fact, buried among the many recent studies and surveys on sexual pleasure with or without a foreskin.

So a massive rollout of male circumcision is spreading across the continent, pushed and funded by donors, especially in southern Africa, the region hardest hit by AIDS.

In South Africa alone, 5.4 million people are HIV positive. By March, just before the World Cup 2010, 1 million South Africans will be popping pills daily to stay alive. AIDS is a catastrophe. I hear despair in the voices of doctors who advocate mass male circumcision.

I hear skepticism in the voices of gender analysts. Will it benefit women? The evidence is unclear in terms of protecting them from infection. Even murkier is how this will affect power relations.

Circumcision is not like wearing a permanent condom, not like tattooed eyeliner. You still need to use condoms in risky sex.

Already it is hard for wives and sex workers to negotiate using a condom, because so many southern African men do not like using condoms. Circumcised men could argue they are fully protected and throw condoms away. Mass male circumcision could lead to mass male complacency.

The programs have ambitious targets such as the goal to circumcise 500,000 men over the next five years in Botswana where the total population is less than 2 million — and oddities such as the project which flies teams of Israeli surgeons to Swaziland to train local surgeons on "Fast Snip" procedures for the Circumcision Sundays.

In a poor suburb of Johannesburg, a team of 13 doctors, nurses and suture technicians performs 80 operations a day. Working 300 days a year — that is, 24,000 operations. Just to circumcise all 14-year-old boys in Soweto, however, would require 80,000 operations.

Can Africa’s staff-starved public health system afford this? Mozambique has less than 600 doctors for nearly 21 million people. Nationwide, there is one doctor per 44,000 people and in remote Cabo Delgado province the ratio is one to 60,000. The average in Sub-Saharan Africa is one doctor to 22,000 people.

Are we robbing Peter to cut Paul?

Is this an example of the West’s fixation with quick technological fixes to solve intractable problems? Counseling, routine testing, multiple concurrent partners — every five years a silver bullet to kill the AIDS vampire appears.

Male circumcision cuts (no pun intended) across Africa’s tribal and religious fault lines. During Kenya’s ethnic violence two years ago, the Luo and the Kikuyu traded hateful insults around being circumcised and civilized and vice versa.

In South Africa the circumcised Xhosa look down on the uncircumcised Zulus. “He is an uncut boy,” is an insult among politicians.

People feel strongly about it, to the point of violence.

Bonani Yamani, 21, a Xhosa man and a born again Christian, refused the traditional circumcision rite because it goes against his beliefs. Instead, he had a medical circumcision in hospital.

His parents had him abducted and forced through the ritual. The young man sued his father and local traditional leaders. Last week he won recognition of his right to choose the manhood test and an apology from the traditional leaders.

Through history, male circumcision has been used as a tool to control, conquer and separate peoples, from the Romans to the Arabs. It is central to the concept of masculinity and belonging to a community.

This is why a medical intervention like mass male circumcision should not be de-linked from Africa’s cultural context.

More GlobalPost dispatches on male circumcision in Africa:

A report from a fishing village on Lake Victoria, a video of circumcision, a Kenyan doctor gives his personal thoughts about circumcision, a South African doctor talks about the drive in southern African countries.