Friday, December 15, 2006

Soon to disappear along with the white rhino: the African foreskin

Big, big news in HIV prevention research: clinical trials in Uganda and Kenya have indicated that male circumcision reduces risk of HIV transmission, from women to men, by about 50%. These results confirm the findings from last year's trial in South Africa, and will almost certainly move the WHO and UNAIDS to officially endorse the promotion of male circumcision in high HIV prevalence countries, particularly in non-circumcising regions of sub-Saharan Africa. With its vaccine-level protectiveness, male circumcision could potentially prevent millions of new HIV infections, and thereby save millions of lives.

Potentially. Research is one thing, implementation of research findings into real world situations is another, as one of the researchers in the Ugandan trial soberly points out. If men come to believe that circumcision offers them immunity, and they engage in more unsafe sex, then the protective effect will be lessened. It will also be lessened if men and boys have sex too soon after the operation, or if the operation is performed in unhygienic circumstances by under-skilled practitioners. There are many unknowns, such as unknowns about the acceptability of male circumcision or its wider cultural impact among traditionally uncircumcising groups, or the acceptability of circumcising at early ages among traditionally circumcising groups. The underlying biological mechanisms to explain how male circumcision prevents transmission of the virus are not entirely clear. But the Ugandan and Kenyan studies should greatly increase confidence in the idea that being circumcised helps protect a man somewhat from getting the virus from an HIV positive woman.

It is strange to see how many news reports make reference to what the findings mean for the USA, as if the story that male circumcision could save millions of African (or Asian) lives is not interesting enough. Given that most men and boys (some 77%) in the US are circumcised already, the effect of male circumcision on male to male transmission is unknown, that it does nothing for injection drug users, the new findings won't help the US epidemic much. But there are still some fascinating twists. These results are yet another blow to the 'intactivists', those who regard male circumcision as genital mutilation, something only permissable (but still frowned upon as irrational) when an adult male consents to it. Until last year, the intactivists were helping to slowly roll back the practice of routinely circumcising infants in the United States. Now they are on the ropes. Given that the rate of new HIV infections has not dropped in the US over the last years, it is possible that the American Academic of Pediatrics could start recommending routine neonatal circumcision again, and insurers start covering the operation again. It is amazing how many effects this faintly comical flap of skin is capable of producing.

Friday, December 08, 2006

Respecting the dead in a public health disaster

Sometimes public health imperatives conflict with deep human needs. Take respect for the dead: during the Ebola outbreak in Kikwit, Democratic Republic of Congo in the mid-1990's, international teams collected the dead in full protective gear, wrapped them in thick plastic bags, and unceremoniously buried them in pits. As Pulitzer prizewinner Laurie Garrett pointed out, traditional Congolese burial rites -- including washing the body of the deceased by family members -- helped spread this terrifying disease. Respect for the dead had to give way to epidemic control. Villagers could only watch as fearful aliens in bodysuits carted their dead loved ones away.

But it is not always the case, as the World Health Organization has pointed out this week. Dead bodies from natural disasters do not pose the same health risks as the corpses of those who have died from Ebola, though they are sometimes treated in analogous ways: doused in antiseptic, covered in lime, and dumped in mass graves. This, states the WHO, is totally unnecessary as far as disease spread is concerned, and undermines the mental health of the survivors. In an unintentionally amusing passage, the World Health Organization reassures the public that fatal victims of natural disasters are harmless, because they are really, really dead:

Those killed by natural disasters are generally healthy at the time of their death, and therefore very unlikely be a source of infection to others. The micro-organisms responsible for the decomposition of bodies are not capable of causing disease in living people. Most infectious agents of public health concern that may be present at the time of death will themselves die within hours of the person dying.

As far as post-disaster disease outbreaks go, survivors are far more likely to be their source than the dead are. That is why after a natural disaster occurs, the priority is to secure clean water and food for the living, rather than disposing of the dead in hasty and rude ways. Those who are doing this, please stop.