Male circumcision campaigns in Africa to fight HIV are a form of cultural imperialism

September 10, 2020

World Health Organization-recommended campaigns to circumcise millions of African boys and men to reduce HIV transmission are based more on systemic racism and 'neocolonialism' than sound scientific research, according to a critical appraisal published in Developing World Bioethics.

More than 25 million 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 United States 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, 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.
About the authors:

* Max Fish- Founder of the VMMC Experience Project, a 501(c)(3) nonprofit which aims to provide a voice to communities adversely affected by mass circumcision campaigns.

* Arianne Shahvisi- Senior Lecturer in Ethics at Brighton and Sussex Medical School.

* Tatenda Gwaambuka- a legal practitioner with the High Court of Zimbabwe, who published a recent article likening circumcision campaigns in Africa to Western colonialism.

* Godfrey Tangwa- emeritus professor of the University of Yaounde 1, Cameroon, where he was Head of the Department of Philosophy from 2004-2009.

* Daniel Ncayiyana- emeritus Vice Chancellor of the Durban University of Technology, emeritus Deputy Vice Chancellor of the University of Cape Town, and emeritus Editor-in-Chief of the South African Medical Journal.

* Brian D. Earp- Associate Director of the Yale-Hastings Program in Ethics and Health Policy at Yale University and The Hastings Center, Research Fellow in the Uehiro Centre for Practical Ethics at the University of Oxford, and Associate Editor of the Journal of Medical Ethics.

University of Sussex

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