Lessons from Swaziland: male circumcision
By Wilson Johwa
31 May 2010 | Government Policy | Circumcision | Prevention
We already know that male circumcision is the next biggest frontier in South Africa's fight against HIV-AIDS.
Enabling policy guidelines are still being finalised before the expected roll-out. This could be anytime soon, most definitely after the FIFA 2010 Soccer World Cup which, mind you, is expected to chew up an extra 1.5 billion condoms that the government is providing.
While doubts and counter arguments follow male circumcision, it is possible that South Africa can learn something from Swaziland. However, unlike South Africa which has a mixed experience regarding male circumcision, the Swazi kingdom has one of the lowest circumcision rates in the world, most of which are performed for medical reasons.
But the scale of the AIDS epidemic made it consider any intervention that would help reduce the scale of the AIDS epidemic. Swaziland has among the most acute HIV epidemics in the world, with HIV prevalence among pregnant women attending antenatal clinics estimated at 42% in 2008.
In July last year the country published its policy on male circumcision to prevent HIV. This followed the findings of three trials – Orange Farm, South Africa, in 2005; Kisumu, Kenya, in 2007 and Rakai District, Uganda, in 2007.
The outcome of the three studies have since been challenged by critics of medically-supervised male circumcision who argue that the studies were not conclusive. However, endorsement of male circumcision by WHO and UNAIDS provided Swaziland with enough reason to draw up its own policy.
The thinking is similar to that of authorities in SA who are considering offering male circumcision as part of a comprehensive package. This includes behaviour change communication, HIV testing and counseling and condom use.
Derek von Wissel, director of Swaziland’s National Emergency Research Council on HIV-AIDS, says male circumcision started with pilot programmes, encompassing “circumcision Saturdays”, that were meant to prepare for a mass roll-out. “We’re now reaching a level where we can say it’s an active programme,” he says. The target is 120 000 circumcisions over the next five years, targeting mainly 18-24 year olds.
Driving the intervention is the Swaziland Male Circumcision Task Force mandated to provide “technical guidance”. Among the members of the task force are health providers, policy makers, people living with HIV, the government’s partners in the health sector and even the media.
The policy says scaling up of male circumcision should be “sensitively handled, with respect shown for Swazi culture and gender implications.” It does not name these gender implications, or dwell on the likely cultural, social and sexual ramifications of male circumcision.
Instead it urges research into the “socio-cultural meanings and impacts of male circumcision” but also says “the need for ongoing consultation and social mobilisation should not hold back policy implementation.” Emphasis on a biomedical intervention is typical of the region’s response to HIV-AIDS.
The policy does not seem to sufficiently interrogate the possibility that support for male circumcision runs the risk of giving the impression that process makes condoms look like an unnecessary extra. This gap was no doubt left for counsellors to fill. Von Wissel says the messaging is strong on the point that male circumcision offers only 60% protection.
Swaziland’s policy on male circumcision came as the WHO and other agencies were already providing technical support to the Swazi government. For example, teams of Israeli surgeons — who circumcised thousands of adult men in keeping with religious traditions during the mass migration of Jews from the former Soviet Union in the early 1990s — had trained at least 10 Swazi doctors and backup staff on how to perform the operation quickly and safely with limited resources.
Inon Schenker, who coordinated the Israeli missions to Swaziland told the Associated Press in 2008 that his organization, the Jerusalem AIDS Project, had several dozen surgeons ready to help African countries scale up adult male circumcision by training local health workers in both surgical techniques and counseling.
As public policy scholars know, policy intentions and consequences barely ever amount to the same thing. South Africa would do well to closely study the Swazi experience before promoting male circumcision as a barrier against HIV. However, Von Wissel says each country must look at its own circumstances, providing for decentralisation and adequate human resources. He plays down the social effects of male circumcision, saying the process is not entirely new to the country. “Swaziland is a country that used to circumcise. The social aspects are not an impediment,” he says.
Wilson Johwa is an HIV/AIDS and the Media Project fellow.
Media must provide context when tradition and medicine collide
1 October 2005 | Government Policy | Circumcision | The Media and HIV/AIDS
Two traditions that bear an impact on HIV/AIDS prevention have caught the attention of the press over the last few weeks.
The National Council of Provinces (NCOP) is scheduled to hold public hearings on the Children's Rights Bill, which is stirring controversy amongst traditionalists because of its proposed outright ban on virginity testing. But it is not only traditional culture that is at stake, according to some, but also the HIV-prevention benefits of these practices.
Bongani Mthethwa's report in the Sunday Times on September 25 noted the challenge the Children's Rights Bill poses.
“Under a section on social, cultural and religious practices, the Bill condemns anyone who takes part in what it calls genital mutilation and calls for the prosecution of such people under criminal law.”
While some hail the benefits of virginity testing for HIV/AIDS prevention, others say human rights are violated by the practice.
“[Promoting virginity] is a good cause, given our current Aids pandemic, but we still need to take a stand as a country aspiring to be fully democratic. Like many parts of the developing world we face difficult choices and they are often choices that appear to be conflicts between tradition and modernity,” University of KwaZulu-Natal anthropologist Suzanne Leclerc-Madlala told the Sunday Times.
But according to the report, the Bill does not ban traditional male circumcision practiced by Xhosas, creating perceptions of double-standards and even tribal bias.
Male circumcision has hit the headlines for different reasons recently, with HIV/AIDS expert, Francois Venter, advocating circumcision as probably being the “ best available AIDS vaccine against the virus in the country”. In an Associated Press(AP)article, Venter, who is clinical director of the Reproductive Health Research Unit at the University of Witwatersrand, encouraged the TAC to promote circumcision as a prevention tool given that existing methods were “failing to slow the spread of the epidemic”.
Venter told a congress of health activists in the Treatment Action Campaign that a recent survey in Soweto indicated that circumcised men were 65 percent less likely to contract AIDS than those who had not been circumcised.
"We dream of a vaccine which has this efficacy," said Venter. "The results are phenomenal."
The APreport highlighted the dangers of traditional circumcision in terms of HIV/AIDS prevention. Some traditional communities in South Africa practice circumcision, but there have long been calls for tighter medical controls to limit health risks from blunt and contaminated instruments.
"We don't want our men to go to the chop shop but have medical circumcision," said prominent HIV/AIDS activist and head of the TAC, Zackie Achmat.
While using “blunt and contaminated instruments” is a concern in traditional male circumcision, the identification of virgins could pose another dilemma. Although promoting abstinence, virginity testing can also pinpoint likely victims for men who believe the myth that sex with a virgin will cure them of HIV/AIDS.
The Sunday Timesarticle presents a fairly well-rounded story; but one interesting aspect not explored in the article is what our own Health Minister, Manto Tshabalala-Msimang, thinks about these issues. What is her take on the various initiatives that people are taking to save their communities from the devastation of AIDS?
Unfortunately an extensive search revealed that Tshabalala-Msimang has been tip-toeing cautiously, being mindful of her every move. It appears she has not said anything publicly about either of the contentious issues of virginity testing or circumcision, preferring to stick to her familiar chant of “Garlic diet! Garlic diet!”
(Tshabalala-Msimang's medically unsubstantiated olive oil and garlic campaign diet has fuelled public confusion since it was first reported by the South African Press Association among others in 2003. But this needs to be the subject of another blog all on its own …)
Back to the Sunday Timesreport: it would've been interesting to hear what the Health Minister's stance is on a Bill that the article claims has taken on “tribalistic undertones”. The same Bill has many virginity testers in KwaZulu-Natal arguing that the government has double standards as it continues to protect male circumcision.
The media's role is vital, as it is with any other issue, but especially in this instance where two worlds seem to be at loggerheads with one another: the traditional versus the medical. Each side is arguing that their methods are the better option in AIDS prevention. In this context of confusion and contestation, it's imperative that the media provide clear, considered reporting for the many South Africans personally affected, and for the politicians currently designing new laws that will have a long-lasting impact on all of us. - Lunga Madlala
Will our nurses ever come home?
23 September 2005 | Government Policy | Healthcare | The Media and HIV/AIDS
South African nurses are deserting our shores in search of a monetary shot in the arm due to poor pay and working conditions, several media reports have noted recently.
According to a City Press article on September 4, getting ill nowadays could be more serious than ever, especially if you're from the Eastern Cape. About 5000 nursing posts lie vacant there alone, with many more across the country, as South African nurses go overseas in pursuit of financial first aid.
You might visit a hospital but never lay eyes on a nurse, especially at night when the nursing staff is in even shorter supply than during the day.
Countries like the United Kingdom, Canada, Australia and Saudi Arabia are the targets for underpaid nurses and other medical professionals, providing better working conditions and more money.
The City Press article states:
“The number of vacancies could be close to 20000 countrywide … Eastern Cape is the hardest hit with 5000 vacancies according to the provincial health department. Limpopo needs 1767 nurses, Mpumalanga 650, while Northern Cape and North West each has 1500 vacancies.”
Most of the nurses who are going abroad are from public health institutions, where the workload is heavy and the meagre reward doesn't provide much motivation.
The Health Systems Trust reports that nurses are unevenly distributed, especially in rural areas where there are fewer qualified nurses compared to urban areas.
Health Minister Manto Tshabalala-Msimang met with about 200 South African nurses in the UK recently to try lure them back home, according to a Sapa report. In the meeting, she apparently told them that South Africa would be employing a lot more nurses. But it's rather easy to doubt the minister's powers of persuasion regarding this issue. “ How will the short-sighted captain flog her trip to our runaway Florence Nightingales? What crew will agree to sail this sinking ship?” asked Maureen Isaacson in Sunday Independent.
Limpopo health department spokesperson, Phuti Seloba, told City Press: “One nurse usually does the work of three or four nurses. Imagine what the situation is like when she goes on leave or attends a course. It means the remaining nurses will handle the workload of eight people.”
The situation is bleaker when that nurse is permanently lost to an overseas employer. City Press reported that one nurse who had been working at Chris Hani Baragwanath for 30 years took home only R5500.
And poor pay is coupled with terrible working conditions. Nurses often have to do menial tasks such as pushing patients on stretchers. Chris Hani Baragwanath Hospital human resource director, Thulane Madonsela, told City Press that even though menial positions such as cleaners, messengers, porters, and ward and linen attendants are vacant, there isn't much which can be done without contravening rules laid down by a public sector clause.
“We are restricted by the ‘Resolution 7′ adopted in 2002. It says the public sector is bloated and as such we must get people who are in excess in the entire public sector and place them where they are needed.”
So no-one from the outside can be hired. It's a logistical stalemate which has forced many public hospitals to run on empty.
South Africa isn't alone. Poor and developing countries all over the world are experiencing the brain drain, too. In Asia, according to a Sapa report carried in News24, the hardest hit appear to be Nepal, Bhutan, Papua New Guinea, Afghanistan, Cambodia and Indonesia. News24 notes that a recent article in the British medical journal The Lancet focusing on the problem.
South African nursing colleges don't seem to be churning out graduates as fast as they should be, exacerbating the shortage. In places like the Eastern Cape , where the nursing crisis is worst, the department advertises posts monthly, but gets no more than 50 or so applications, according to News 24. The same article notes that in Mpumalanga, 40 nursing posts were advertised recently, but only one person applied.
Of course nurses are not the only medical professionals contributing to the trend: doctors, radiographers, dentists, social workers and physiotherapists are also part of the brain drain. For example, about half of all recent graduates of the Durban Institute of Technology's radiography department have already left, according to the student website, Dut.ac.za.
What's a cause for concern is who will be around to help with the ARV treatment rollout. The World Health Organisation had estimated that by December last year, about 840,000 people in South Africa needed antiretrovirals (ARVs), but that only 7% of them (between (47,000 and 62,000) were actually receiving the drugs. (See more about this in the Journ-aids treatment factsheet.)
What is going to happen to the millions of HIV-infected people who are waiting for ARV treatment, if no-one is there to distribute them?
At the same time, do we blame nurses for leaving, when it's clear that South Africa and many other Southern African countries don't have much to offer them, except swollen ankles, and a pat on the back – if they're lucky? – Lunga Madlala
