Rwanda Imposing a Foreskin-Free Generation

Posted: December 17th, 2011 | Author: | Filed under: "Voluntary", Ethics, HIV, Logic, Public Health | 5 Comments »

On Monday the Washington Post published a propaganda piece by Rwandan Minister of Health Agnes Binagwahois. She talks writes of “an opportunity to lay the foundation for an AIDS-free generation,” which inevitably means a primary focus on “voluntary, adult” male circumcision. It’s a matter of faith that this will solve everything, and as a result, there must not be any ethical issues to discuss. Anyway, they’re only implementing “voluntary, adult” male circumcision. Just believe.

Experience demands a closer inquiry. When public health officials speak of “voluntary, adult” male circumcision, they never mean voluntary or adult. They say it, as Binagwahois does. That phrase is mandatory. They do mandatory very well.

We have the capacity to save nearly 4 million lives in sub-Saharan Africa, the hardest hit region in the world, by scaling up voluntary medical male circumcision — the best tool we have for HIV prevention. But the only method widely approved for funding is the surgical method, which is expensive and impractical for countries lacking physicians and surgical infrastructure.

She didn’t say adult yet, but that shows up. She writes that “[p]ublic health officials set a goal to reach nearly 20 million men ages 15 to 49 by 2015…”. I’d quibble over a 15-year-old being an adult, but I also think a 15-year-old is capable of informed consent. If only her statement were true.

In the essay she links to a paper outlining Rwanda’s “national goal”, which can be summed up as a willful violation of human rights. From page 61:

High coverage of male circumcision has been shown to be effective in reducing heterosexual transmission of HIV infection. Under this Outcome, circumcision will be promoted to adult males, with the aim of increasing the prevalence of circumcision. In addition, although circumcision of newborn boys will not contribute to the result of reduced sexual transmission of HIV during the period covered by this NSP, it is nonetheless an important long-term strategy for reducing susceptibility to HIV infection in the Rwandan population.

In case it isn’t quite clear enough, the report includes this table:

Figure 18

Then it’s summarized:

Output 1.1.2.1. Newborn boys, adolescents and adults have increased access to circumcision

Key strategies:

  • i. Advocacy for integration of circumcision in minimum package of health centers
  • ii. Promotion and provision of male circumcision for adolescents and adults
  • iii. Promotion and provision of male circumcision for newborn boys

She also links to the WHO’s 2011 revised report, Progress in scale-up of male circumcision for HIV prevention in Eastern and Southern Africa: Focus on service delivery. On page 14 the WHO describes Rwanda’s current “Service” delivery strategy.

Plans include the integration of MC into existing services with campaigns and mobile services to increase coverage. Service delivery has begun at selected sites, including military settings. Neonatal and adolescent MC is articulated in the longer-term plan.

About that “long-term” plan. Rwanda keeps saying “long-term”, but a close look at Figure 18 shows its definition. Rwanda’s target for 2012 is 50% of all newborn males. Rwanda is actively circumcising newborn males now. The limitation is clearly not intent. I believe they are sincere in focusing on adults, although less so on the “voluntary” aspect. But it’s obvious where the real focus is. Fear of HIV in the presence of effective-but-elective non-surgical interventions leads to a blatant disregard for the rights of children. It is disgusting.

Since there is a national plan to circumcise newborn and adolescent males without their consent, why does Binagwahois not say so explicitly? Instead, she pretends that the current focus is only on adults and limits herself to advertising for the “non-surgical” PrePex device. Since she doesn’t know the meaning of voluntary or adult, it isn’t particularly surprising that she doesn’t understand the definition of surgery. The ability to limit bleeding does not mean it is non-surgical. Condoms are non-surgical. Foreskin removal is surgical. It’s not refuted just because the device’s manufacturer says so. Regurgitating marketing material is not supposed to be the job of a public health official.

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For consideration relevant to the ethics and practicality of the PrePex rollout, Figure 6 in the study (NSFW) Binagwahois’ essay links suggests to me that there will be complications when use of this device is scaled to 20 million men in field settings. And to be fair to Circ MedTech, it promotes PrePex for adult male circumcision. We’ll see if their focus remains on voluntary, adult male circumcision.


5 Comments on “Rwanda Imposing a Foreskin-Free Generation”

  1. 1 Ron Low said at 10:54 pm on December 19th, 2011:

    What sort of mass hypnosis allows this thinking to be practiced in a country like Rwanda where it is the CIRCUMCISED who have a markedly higher HIV incidence?

  2. 2 Joseph4GI said at 7:03 pm on December 20th, 2011:

    We’ve been saying it since 2006, haven’t we?

    It’s what it’s always been about, isn’t it?

    This nothing more than the imposition of cultural ritual under the guise of medicine.

    It has absolutely nothing to do with the prevention of HIV/AIDS.

    Were this about female circumcision and any “studies” that showed “potential benefit,” the tune would be slightly different.

    We will look back on these times as some of the most disgraceful in the history of science and medicine.

    This is absolutely despicable.

  3. 3 Joseph4GI said at 7:09 pm on December 20th, 2011:

    Let’s talk a little bit about the “long term benefits” of circumcising non-consenting children.

    80% of US males are circumcised from birth, and yet we have THE HIGHEST rates of HIV transmission in the industrialized world.

    Circumcision hasn’t stopped HIV in our own country.
    http://data.unaids.org/pub/Report/1998/19981125_global_epidemic_report_en.pdf

    And, it hasn’t stopped other STDs either.
    http://www.reuters.com/article/2009/01/13/us-infections-usa-idUSTRE50C5XV20090113?pageNumber=1&virtualBrandChannel=0

    In America, the majority of the male population is circumcised, approximately 80%, while in most countries in Europe, circumcision is uncommon. Despite these facts, our country does poorly.
    http://www.advocatesforyouth.org/index.php?option=com_content&task=view&id=419&Itemid=177

    In fact, AIDS rates in some US Cities rival hotspots in Africa. In some parts of the U.S., they’re actually higher than those in sub-Saharan Africa. According to a 2010 study published in the New England Journal of Medicine, rates of HIV among adults in Washington, D.C. exceed 1 in 30; rates higher than those reported in Ethiopia, Nigeria or Rwanda. (HELLO???)
    http://www.nejm.org/doi/full/10.1056/NEJMp1000069

    The Washington D.C. district report on HIV and AIDS reported an increase of 22% from 2006 in 2009.

    According to Shannon L. Hader, HIV/AIDS Administration, Washington D.C., March 15, 2009, “[Washington D.C.’s] rates are higher than West Africa… they’re on par with Uganda and some parts of Kenya.” Hader once led the Federal Centers for Disease Control and Prevention’s work in Zimbabwe.
    http://www.washingtonpost.com/wp-dyn/content/article/2009/03/14/AR2009031402176.html

    One would expect for there to be a lower transmission rates in the United States, and for HIV to be rampant in Europe; HIV transmission rates are in fact higher in the United States, where most men are circumcised, than in various countries in Europe, where most men are intact. It is telling that the HIV epidemic struck in our country in the 1980s, 90% of the male population was already circumcised. Somehow, we’re supposed to believe that what didn’t worked in our own country, or anywhere else, is going to start working miracles in Africa.

    I have reason to believe that leaders in Africa say what they do because they’ve been paid to do so by PEPFAR, Bill Gates, PrePex etc.

    Donors of funds who want to see circumcision proliferated tell African leaders to dance the circumcision dance or they don’t get funds.

    This has got to be the human rights disaster of the century, and in more ways than one.

  4. 4 Hugh7 said at 1:49 am on January 18th, 2012:

    Here in New Zealand, we’ve been using a device like the PrePex for decades on (under-age, non-consenting) sheep. I guess you could call it “non-surgical” too. But it’s not used on their foreskins. It’s called the Elastrator.

  5. 5 The New York Times Links to a Fetish Site | Choose Intact said at 6:34 pm on January 30th, 2012:

    […] month the Washington Post ran a commercial masquerading as an editorial. Today, the New York Times follows suit, but ups the offensiveness in […]


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