Ethics of implementing male circumcision in Swaziland
During downtime in the Hotel Cardoso, I noticed this piece about implementation of male circumcision initiatives in Swaziland. Apparently, these HIV prevention initiatives have not come close to reaching their targets, after millions of dollars have been spent, causing both soul-searching and finger-pointing. (The program spent almost 500 dollars per circumcised male in a country which has an average per capita annual income of roughly $5000). I've thought for a long time that much more bioethics attention -- to its detriment -- has been spent on research ethics than the ethics of implementing research results into practice. The latter has its own particular conundrums, such as: what do you do about a (less than) half-implemented program? Particularly when part of the reason why the implementation was partial is due to significant community reluctant/resistance towards the very idea of male circumcision for HIV prevention? Where should you go from here?
Community concerns about male circumcision and HIV prevention include: why do circumcised men still get counseling about using condoms? What happens with the foreskin? Is there any connection between these circumcision programs and witchcraft? Why must men need to refrain from sexual activity for some time afterward? Other forms of resistance or reluctance, in the Swazi case, reach up to the highest levels of policymaking. Local public health authorities may have been interested in gaining funds and collateral benefits from male circumcision initiatives, while being skeptical about the value of the intervention itself. Low community and governmental 'buy in' (as they call it) can derail any public health program. Add to this the work of the anti-circumcision groups and individuals worldwide, who can be found on the comments section of any news item on male circumcision and HIV, whipping up fears and debunking the science. For the latter, the ethics of implementing male circumcision programs is simple: just make it stop.