World Health Organisation-recommended campaigns to circumcise millions of African boys and men to reduce HIV transmission are based more on systemic racism and “neo-colonialism” than sound scientific research, according to a critical appraisal published in Developing World Bioethics.
More than 25m men and boys have already been circumcised as a result of voluntary medical male circumcision (VMMC) campaigns in eastern and southern Africa, implemented by the US government and Western non-governmental organisations (NGOs).
The critical appraisal examined the history and politics of these circumcision campaigns in the context of race and colonialism, and found that they had been started in haste and without sufficient contextual research.
The paper concluded that the campaigns have been carried out in a manner that implies troubling assumptions about culture, health and sexuality in Africa. Africans were underrepresented in the decision-making process, and needed a greater voice in the planning of such an intimate health intervention.
Max Fish, lead author and founder of the VMMC Experience Project in Oakland California, a grassroots effort to elevate African voices about the effects of the campaigns on their lives, said: "There has been a global spotlight on systemic racism – and racist institutions – following the death of George Floyd, an African American man, at the hands of a White police officer in May. However, unethical human experimentation on Africans and African Americans remains a pervasive problem in Western medicine that has received relatively little attention."
"Africa was targeted, and it is still being targeted," said Cleophas Matete, a Kenyan bishop interviewed by the VMMC Experience Project, who is quoted in the study. "It is used as a continent to experiment. Should they introduce anything that is (morally questionable), they want to experiment in Africa. So, I believe that the entire process of trying to test it in Africa was wrong from the beginning, and I say no to it."
Dr Arianne Shahvisi, senior lecturer in ethics at Brighton and Sussex Medical School and second author, said: "We believe the decision to implement the circumcision campaign in southern and eastern Africa was not based on robust scientific evidence, but instead assumed that the results from clinical trials would safely “scale” to the real world without thinking through the cultural implications. We argue that as a surgically corrective measure, the present circumcision campaigns hinge on racist, homogenising assumptions about the sexuality of those who are targeted, as well as a belief that HIV risk-behaviours can be appraised independently of poverty and systemic factors."
There has been a long history of unethical medical research conducted on Africans and African Americans, including the infamous "Tuskegee Study of Untreated Syphilis in the Negro Male," in which African American syphilis patients living in rural poverty were observed but not treated, leading to suffering, the spread of infection and widespread death, and subsequent concerns about medical exploitation among these communities.
The decision to implement the circumcision policies in Africa was based on three clinical trials conducted in South Africa, Uganda, and Kenya, which showed that circumcision reduced men's HIV risk by 50-60% over two years. However, critics have alleged that the trials had serious limitations: they could not be placebo-controlled, and participants were explicitly informed of the study's aim to establish a lower HIV incidence following circumcision.
In addition, HIV prevalence at the start of the campaign was higher in circumcised than uncircumcised men in 10 out of 18 countries where such data was available, including five countries that were targeted for mass circumcision.
A fourth trial seeking to establish an HIV risk reduction for women allowed HIV-positive Ugandan men to infect unknowing partners – one of Tuskegee's ethical violations. This trial was stopped early for "futility" after partners of newly circumcised men became infected at a 55% higher rate, although this has received much less attention from the global public health community.
The critical appraisal was conducted by ethicists, legal and medical experts from the UK, US, Cameroon, Zimbabwe and South Africa.
Campaigns to circumcise millions of boys and men to reduce HIV transmission are being conducted throughout eastern and southern Africa, recommended by the World Health Organization and implemented by the United States government and Western NGOs. In the United States, proposals to mass‐circumcise African and African American men are longstanding, and have historically relied on racist beliefs and stereotypes. The present campaigns were started in haste, without adequate contextual research, and the manner in which they have been carried out implies troubling assumptions about culture, health, and sexuality in Africa, as well as a failure to properly consider the economic determinants of HIV prevalence. This critical appraisal examines the history and politics of these circumcision campaigns while highlighting the relevance of race and colonialism. It argues that the “circumcision solution” to African HIV epidemics has more to do with cultural imperialism than with sound health policy, and concludes that African communities need a means of robust representation within the regime.
Max Fish, Arianne Shahvisi, Tatenda Gwaambuka, Godfrey B Tangwa, Daniel Ncayiyana, Brian D Earp
Full Medical Xpress report
Developing World Bioethics abstract