Notebook: NYC Edition

I'm here in New York City, rubbing shoulders with people from every imaginable corner of the world. It's an experience that makes you think about the meaning of acceptability, a concept that has a lot to do with the promotion of circumcision in Africa -- and in developed countries.

A great deal of the news one hears about HIV/AIDS is characterized by its dire tone, desperation, guilt inducing pleas for sympathy, and calls for money. Calls for circumcision over the decades have shared many of these qualities, particularly the direness, the desperation, and the guilt trips. Leave it to Robert Bailey and Daniel Halperin to add the money element.

Money is a funny thing. Price something too cheaply and it appears, seems, and may even look cheap without regard to the reality. Give it away and it often goes begging. Price it too high and desirability rather than quality suddenly becomes the issue. A high price seems to actually induce buying.

Something for free? Take it or leave it. The illusion is of abundance and that one can always come back.

Cheap? You get what you pay for. It won't last. We'll just have to replace it or do it again whatever it is.

Expensive? How can we afford it? How can we rearrange not just our finances, but our very priorities.

What does all of this have to do with the controversy over circumcision as an HIV prevention? Bailey and Halperin have called circumcision an HIV prevention as opposed to a risk-reducing measure, claimed an absurd 75% protective effect, and deflected the controversy by claiming no personal interest in the subject other than helping people. Halperin has said to me personally and elsewhere that most of his writings are about behavior change. But of course, this is subject-changing and deflection to slip his agenda passed lowered defenses. And one he will not be able to honestly make for much longer.

The economics of it are this. Claim an outsized value on something, and get people to pay dearly by buying into what is essentially a genital mutilation. The analogy is not perfect. It breaks down in developed countries when you consider that the value is claimed to be very high while the personal and financial costs are offered as inconsequential. The reality is that the value is close to nil in real world settings while the high cost is disguised.

The analogy is much better suited to Africa. Circumcisions are astronomical in cost both in actual money terms and in the over all resource loss to the medical system while providing no real prevention. It's basically a zero sum gain for prevention and a net loss for the provisioning of not just HIV testing, treatment and prevention services, but for basic medical services in maternity, vaccination, education, and other essential areas of health care. And the personal cost is rightly perceived as very  high because adults are the target and circumcision is not common in the targeted areas. Hence, the promise of a discount for later generations, if only the current targeted group will only pay high now, by the introduction of infant circumcision where it has been unknown before.

So Bailey and Halperin have gone shrill in their calls for money, calling for expensive mobile circumcision services, and their alleged rightful share of the HIV pot to fund them. After all, circumcisions aren't going to perform themselves. And so, the campaigning for cash has begun.

So what can we do? A lot is the short and hopeful answer.

The interest of people of conscience should be two-fold. First, HIV prevention, education, and the integrity of any system that purports to participate in this endeavor. Second, providing these services at the lowest possible cost to the individual and society without dictating how individuals should go about their prevention strategies. And the irony is that working towards the lowest possible cost to the individual is ... you guessed it, expensive.

Therefore, I will be placing all contributions to the Tip Jar and my own personal contributions in trust, pending the formation of an entity that will provide the financial wherewithal and emotional, political, and personal moral support to do this work. We can make a difference, get the attention this cause deserves, and compete (yes, I mean literally compete) with the likes of Halperin and Bailey, who by the way have the full authority and economic support of their institutions behind them.

Finally, I would like to thank Joe Pellegrino for being our second contributor to the Tip Jar. Your contribution is more than financial. It encourages us all. Thanks.

[REVISED third paragraph.]

Comments

[SunkenShip]

Sounds good. Where can we send donations?

[J]

SunkenShip -
It's easy really just click on the 'Tip Jar' link under 'Help Us Promote This Site' in the right hand panel.

[Joe in CA]

HIV Arrived In US From Haiti, New Study

http://www.medicalnewstoday.com/articles/87047.php

You know, "studies say" that circumcision is supposed to prevent HIV. In 1969, about 80/90% of men were already circumcised in the US.

http://www.cirp.org/library/statistics/USA/

Why, what EVER could have happened.

[Jake]

Joe,

Firstly, while about 80-90% of US males born in 1969 were circumcised, the percentage of adult males who were circumcised at that time was somewhat lower - perhaps 60%.

Secondly, even if circumcision were 100% effective in preventing HIV (which is not the case), any non-zero percentage of uncircumcised males would have been sufficient to allow the first male to be infected.

Thirdly, since circumcision reduces, but does not eliminate the risk of HIV, and you surely know this, what exactly is your point? Do you actually understand the distinction?

[David]

Jake,

Circumcision may delay, but does not reduce the risk necessarily as other factors come to bear on the actual reduction in infections, such as increased sexual risk taking, number of partners, etc. Surely, you know this. So are you baiting the other posters on here or do YOU have a point? Baiters will not be tolerated and may be banned from posting.

Thanks,

David

[Jake]

David,

Frankly this is your site and I would not be surprised if you were to ban me. If you prefer, you'll find that I'll honour a request not to post.

I'd like to know whether you really mean the statement labelled 'About' in the left-hand column. Do you actually intend to "provide a place for ... debate", or not?

If you do wish to provide such a place, then surely it must be possible to criticise and dissect others' arguments. Without such a facility, debate is essentially impossible. Wouldn't you agree?

[David]

Jake,

You must post with respect. Post with respect and you are welcome to continue.

David

[Joe in CA]

Firstly, while about 80-90% of US males born in 1969 were circumcised, the percentage of adult males who were circumcised at that time was somewhat lower - perhaps 60%.

Somewhat? Perhaps? One must wonder how exactly you have come to that conclusion. Could you provide a source please?

Secondly, even if circumcision were 100% effective in preventing HIV (which is not the case), any non-zero percentage of uncircumcised males would have been sufficient to allow the first male to be infected.

But circumcision would not exactly be 100% effective in preventing HIV. Would it now, Mr. Waskett. How the hypothetical scenario of only intact men being vulnerable to HIV is of any relevance is beyond me.

Thirdly, since circumcision reduces, but does not eliminate the risk of HIV, and you surely know this, what exactly is your point? Do you actually understand the distinction?

My point is precisely that even if the conclusions of the recent "studies" were credible, circumcision would not elliminate the risk of HIV. It fails as any kind of preventative strategy against HIV, esp. given the fact that condoms have been proven to do a better job whether a man be circumcised or not.

I mention the fact that HIV managed to infiltrate the US despite its pre-existing high circumcision rate as a de facto example.

I grow continuously tired of pro-circumcisionists who pretend to be concerned about HIV prevention, when in reality, all they care about is that somehow mass circumcmision be implemented globally.

Even IF the recent HIV/circumcision studies were 100% accurate, condoms are a far more effective alternative. How is it sound reasoning to leave a proven method of HIV prevention for one that would only protect 60% of the time if studies were true?

[Joe in CA]

I realize I could have summarized my point without going off on a tangent, and for that I beg to be pardoned.

Let me try again.

The point I was trying to make is that even if the recent studies were correct (that circumcision reduces the rate of HIV infection by 60%), mass circumcision has not proven to be an effective method of HIV prevention. This is evidenced by the fact that we have had an existing HIV problem despite this country's pre-existing high rate of circumcision.

My point is that mass-circumcision fails as an HIV preventative strategy.

Condoms do a better job, but ignorance in Africa is already leading people to believe that they can stop using them, because circumcision will make them immune to HIV. As such, mass circumcision will prove to be a disasterous strategy for HIV prevention.

I think it is also worth noting that while studies on the one hand suggest that circumcision reduces the rate of HIV contraction, a separate study has shown that the langergans cells found in the foreskin actually provide protection.

http://www.cirp.org/news/healthday2007-03-05/

[tomcat]

I think the hype will eventually die down and people will begin to take a more sober look at what is being proposed by the circumcision lobby (for lack of a better word). It won't be long until the backlash against this idea, along with more sober research, will swallow this rational for circumcising healthy males... just like every other rational before it that has come and gone in the past hundred years.

Circumcision advocates are grabbing onto this one like the flotsam from a sinking ship... and are losing credibility with each passing year as they try to recycle old ideas that simply do not gel with modern bioethics principles, or come close to being a sane prevention for many of the ailments it is said to prevent.

There's a reason that they have to try and equate the removal of anatomy to a vaccine... because doing so is the only way the promotion circumcision can be considered to be ethically defensible. esp when considering the rights of minors.

But the bottom line is calling something a vaccine doesn't make it so... A vaccine is a needle injection - and usually one that works fairly consistently... circumcision is neither.

[Joe in CA]

Some African men are going to wake up to a cruel reality when they realize that circumcision did not immunize them against HIV.