The problem with quick fixes is that they almost never work right and when they do work, it's temporary and you usually end up in a worse spot from where you started. The principal thing that can make a quick fix worse is when you double down and implement it as fast as possible. Although it will be difficult to see through the bureaucracy, perhaps, just perhaps, NGOs might start to see that.
Following the results of the African circumcision RCTs and the tacit premature and perhaps ill-advised approval of the WHO and UNAIDS, there has been a mad dash in Africa to implement what critics have described as at best a half baked solution to the AIDS crisis in sub-Saharan Africa. Countries such as Rwanda and Uganda continue to push forward plans for mass circumcision despite clear problems with both the trials and the implementation.
One of the major criticisms with implementation, aside from the clear ethical problems it presents, is the fact that these countries lack the required medical competency. Moreover, facilities are in dangerously short supply. Several editorials from health care professionals including a recent critique from members of the World Health Organization Regional Office for Europe cite that:
Difficulty in extrapolating the results outside the trial environment is making male circumcision particularly problematic as a public health intervention in resource-poor settings.
Green et. al. noted that virtually no attention was being given to surgical complications. While there were relatively low rates of complications reported in the RCTs, a realistic estimate of complications in an African mass circumcision campaign was perhaps 20.2%, which is a rate documented in a study of Nigerian neonatal circumcision by medical professionals.
Now a new study, Circumcision Problems Impair HIV Prevention, also reported by Aidsmap, confirms the predictions. Download WHO bulletin here [pdf].This study, conducted by Robert Bailey, one of the American proponents of circumcision and one of several authors of the Kenyan trial and authors Omar Egesah, a Kenyan expert, and Stephanie Rosenberg of the United States, chronicled a "shocking" set of complications coming in at very high rates, including:
- As many as 35% of males circumcised by traditional practitioners in Kenya's Bungoma district
- A rate of at least 18% of males circumcised in public clinics
- At least 6% of the complications were described as permanent or irreversible these events include: torsion (bending) of the penis, injuries to the glans, loss of penile sensitivity caused by scarring and erectile dysfunction
- At least 8% of the bleeding complications required IV fluids
- Infections ranging from swelling to life-threatening necrosis were very common and alarmingly even frequent in the medical setting occurring at a rate of at least 42% as compared to traditional circumcision were necrosis occurred at a rate of at least 50%
- Only 21% of traditional circumcisions and 10% of medical circumcisions healed in an average of 45 - 89 days
- Lack of proper equipment to sterilize tools and even sharp scalpels
- No deaths have yet been reported but there was at least one case where the victim would have died had he not made it to a regional hospital
- There is strong indications that these conditions are rife throughout this and other African countries
Complications suffered by these men, and presumably innocent boys, included bleeding, infection, excessive pain and erectile dysfunction, the WHO researchers found. "Other common adverse effects reported were pain upon urination, incomplete circumcision requiring re-circumcision, and laceration," they wrote, estimating 6 percent of patients had life-long problems as a result. Moreover, there has been increasing anecdotal evidence that newly circumcised men also believe they are immune from HIV though I am not sure if that counts as a complication.
In countries whose health care infrastructure makes it difficult to even get an HIV test let alone regular access to condoms, it is hard to see how reasonable leaders in these countries could promote a clearly dangerous and technically difficult to implement measure which is less effective in the fight against HIV infection. How many men will go out into the community and make matters worse because they think they are immune to HIV? How many men will suffer complications debilitating complications? How many men and boys will inevitably die? And most crucially, if we're charitable and allow the still uncertain protective affect of circumcision, how many avoidable HIV infections will be offset by deaths and ruined lives from quality of life destroying complications?
Editor's Note: Lest anyone get the idea Bailey is coming around to the reality, other sources have indicated that complications are not seen as a barrier to implementation. Rather they are instead a strong argument to continue to medicalize the procedure through the use of medical NGOs and other imported groups, such as that of the Israeli group, Operation Abraham.
