By Frederick Klaits and Serara Mogwe
If in the year 1985, all Batswana men and boys had been circumcised, HIV/AIDS might never have reached pandemic proportions in this country.
This is the startling conclusion suggested by a growing body of public health research in Africa and elsewhere, carried out by Drs. Daniel Halperin (Univ. of California - San Francisco), Robert Bailey (Univ. of Illinois - Chicago), and others. In countries like Nigeria and Ghana, where nearly all men are circumcised, less than five percent of people between ages 15 and 50 are HIV-positive. By contrast, in Botswana, Zimbabwe, and Namibia, where only a small percentage of men are circumcised, HIV infection rates range from twenty to thirty percent, or even higher. Dr. Halperin suggests on the basis of such evidence, and his own preliminary research in Mochudi and Molepolole, that a national policy to circumcise men and boys would be likely, over the medium to long term, to substantially lower HIV rates in Botswana.
Being circumcised is no guarantee against AIDS. However, scientists have shown that if a man has not been circumcised, the AIDS virus is more likely to enter the body during heterosexual intercourse. This is because the delicate foreskin tissue contains a large number of immune cells that are easily penetrated by HIV. These immune cells are believed by some scientists to be highly vulnerable to the unusually virulent strain of HIV common in southern Africa. In addition to HIV, intact foreskins make men more susceptible to genital-ulcer diseases, such as chancroid, syphilis, and herpes, which themselves enhance transmission of HIV.
There can be no doubt that novel approaches are sorely needed to bring the AIDS pandemic to a close. The time has come in this country for public discussion about making circumcision widely available in clinics on a voluntary basis, and strongly recommended for all boys under age 15. Circumcision in clinics would be a safe, rapid, and minimally painful operation performed under local anaesthetic. Although circumcision was an important element of traditional Setswana culture, reviving bogwera now would be a controversial step for many reasons. Under the proposed policy, circumcision would be a strictly public health measure carried out by medical personnel.
Male circumcision has been commonly practiced in many parts of the world as a way of preventing disease without reducing sexual pleasure. By being circumcised, Batswana men would reduce their risk of either contracting or transmitting HIV.
Make no mistake -- you can still be infected by HIV even if you are circumcised, and you must continue to take all safe-sex precautions. Circumcision should not be seen as replacing the safe-sex message summed up by "Abstain, Be Faithful, Condomise." It does, however, reduce the risk of transmission, so that it would be an effective means of reducing HIV infections on a population-wide basis. Clearly, it is not men alone who would benefit from a circumcision policy, since if fewer men are infected, women and children would become less vulnerable as well.
Preventing HIV transmission through safer sex or abstinence remains key. But let's face it: for the most part, public health efforts to prevent AIDS by changing individuals' sexual behaviours have failed to reduce infection rates in Botswana. Providing circumcisions at minimal cost -- or ideally, for free -- to all men in clinics on a voluntary basis, and strongly recommending that all boys be circumcised before they begin having sex, would be a radically different approach. The aim of such a circumcision policy would be to change not individual behaviours, but instead the conditions under which individuals act. In general, public health programs that change the conditions under which people act are far more effective than those that attempt to change their behaviours directly.
Think of it this way. Suppose the Gaborone City Council had decided not to supply clean water to all residents' taps, but instead instructed them how to boil and purify contaminated water themselves. There would be far more water-borne disease than there actually is, since the Council would be trying to change people's water-drinking behaviours directly, rather than providing clean water for all. Likewise, one reason that AIDS prevention efforts have tended to fail in Botswana is that up to now, they have set themselves the intrinsically difficult task of changing individuals' behaviours directly.
In the same way that government has made the decision to supply clean water so as to reduce the risk of exposure to water-borne diseases, it should consider a circumcision policy in order to reduce the population's risk of exposure to sexually-transmitted diseases, including AIDS. As a public health policy, circumcision would work by changing the conditions under which people transmit HIV in heterosexual intercourse, and would thus stand a greater chance of being effective over the long run. In addition, circumcision would be very inexpensive, far less so than the AIDS medications now being developed, which are far beyond the means of most Batswana. A circumcision policy would not produce an immediate drop in HIV infection rates -- nothing, it seems, can do that -- but would likely do so over the medium to long term. In particular, by circumcising all boys before they begin to have sex, the youth of Botswana would gain a measure of protection against HIV. Formulating and implementing such a policy require political will and courage, which must not be lacking among those who wish to stem the tide of death overwhelming this country.
Frederick Klaits is an American anthropologist who has worked in Gaborone since 1993. Serara Mogwe is a leader of the nursing profession in Botswana. Replies may be e-mailed to the authors at firstname.lastname@example.org.