This op-ed was originally published in The Monitor (Kampala) on
12 November 2007
Dr. Moses Bateganya
I write to share my opinion with others following an article that quoted President Museveni’s speech to the youth. I write to add my voice on the issue of “the role of male circumcision in Uganda’s fight against HIV.”
Male circumcision is a promising addition to Uganda’s HIV preventive strategies and once implemented it has potential to reduce HIV infection among circumcised males. Uganda and the rest of the world are fortunate to have an additional intervention that will support the fight against the epidemic. However wide-scale implementation is premature in Uganda.
First, although several research studies that compared circumcised and uncircumcised males in several African countries including one from Rakai district in Uganda showed that circumcised males were less likely to acquire HIV than their uncircumcised counterparts, there is a big difference between what can be achieved in a study setting and the results of a public health intervention. Conditions in a clinical trial are carefully controlled and results may not really be as glowing as those from a study situation where both the study staff and participants are well motivated.
For example while side effects from surgery were minor under study conditions, they may be enormous under field conditions given the current challenges faced by Uganda’s hospital surgery departments such as few and less motivated personnel, lack of proper equipment, shortage and frequent stock out of drugs and consumables.
Secondly, there may be behaviour disinhibition where people who are circumcised may incorrectly assume they are not at risk of HIV infection. Such an incorrect conclusion may lead individuals who are HIV-negative at the time of circumcision to maintain or increase their current level of HIV-risk behaviour putting themselves and their sexual partners at risk.
Similarly, HIV positive individuals may seek surgery and incorrectly think they will not transmit HIV. Hospitals implementing circumcision may not have the capacity to screen all their clients for HIV before offering circumcision, thus circumcised males may create another risk category in HIV prevention.
Male circumcision may also take away resources and attention from other prevention methods that have effectively reduced the HIV prevalence in Uganda, namely abstinence, faithfulness and condom use. In fact, those prevention efforts have already earned Uganda the coveted position as an international success story in reducing the number of people being infected with HIV (though this assertion is still being questioned and is an open debate; what worked in Uganda?).
The cost for each circumcision in the Rakai study was over $60. This is a cost ten or more times the annual budget for health for an individual. Is it worth diverting the prevention budget away from methods that seem to work for a fraction of the cost to try something that has only been tested in a study setting? I don’t think so.
Dr. Moses Bateganya is based at the University of Washington, Seattle
Thursday, November 29
Sunday, November 25
Punishing an Entire Population
Hello everyone!
I wrote the op-ed piece below to fulfill one of the assignments for my Problems in International Health course with Dr. Steve Gloyd. As many of you know, Dr. Gloyd encouraged us to submit our work to newspapers for publishing. We'd love to post your published/unpublished work on IHP blog too. Please feel free to contact me with any questions on how to do this if you are interested.
Looking forward to reading you. Amineh
Punishing an Entire Population
Following Hamas' takeover of the Gaza Strip last June, Israel tightened its siege over the area to an unprecedented level. Israel declared Gaza a “hostile entity’ in September, threatening to impose economic sanctions against the territory and to further restrict the passage of food, supplies and people. Israel’s policy of collective punishment will only deepen an already dire humanitarian crisis, and lead to grave public health consequences in the most densely populated area in the world.
In late October, Israel commenced its policy of fuel cuts and reduction of Gaza's electricity supply in order to pressure Hamas in response to cross-border rocket attacks. Israel also closed border crossings into Gaza, leaving only one of six entrances open. Since the so-called disengagement in 2005, Israel has been restricting access and controlling borders to Gaza, while denying responsibility for the still-occupied people there.
Sanctions will reduce gasoline imports by about 50% and fuel for Gaza's power plant by 12%. These resources are critical for the livelihood of the already impoverished Strip. Gaza relies on Israel for all its fuel and most of its electricity needs. Fuel is required to produce the electricity that Gaza generates locally. Electricity is needed to pump water and to operate sewage management plants, as well as hospitals and other infrastructure. According to the Humanitarian agency Oxfam International, seven water wells in Gaza City did not operate as usual due to fuel shortage, which decreased the quantity of water supplied to 50,000 people by about 75%. The restrictions on the entry of goods into Gaza have also caused shortage of materials needed for repairs and maintenance of sewage plants. Sewage plants must operate 24 hours per day to prevent sewage floods and spread of disease.
Israel claims that its policy of fuel cuts of up to 15% is a “non-violent” way of increasing pressure on Hamas. An ongoing state of siege that cuts off food, medicines and fuel is not a “non-violent” act. According to the World Health Organization, most of the population is already living under the poverty line, and suffers from malnutrition. Starving civilians as a method of warfare is illegal under article 54 of the Fourth Geneva Convention.
At what expense do we play politics with the health of an entire population?
Our experience with sanctions in the Middle East has taught us that subjecting a population to economic embargo does not work. Such sanctions primarily harm innocent people. Why is this a lesson unlearned? Looking back at the sanctions against Iraq, we know that restricting the imports of medicine and food into the country caused terrible public health consequences. Malnutrition among children became widespread, and according to UNICEF, child mortality tripled in the first year of sanctions. Water-borne infectious diseases such as cholera and typhoid spread and accounted for 50 percent of total deaths among children. 500,000 Iraqi children under age five died due to the economic sanctions in Iraq.
The Israeli siege has severely reduced the flow of fresh food, especially fruits and dairy products into Gaza. Exports are also greatly restricted, resulting in paralysis of the territory's economy. Prices have more than tripled, causing severe hardship for the poorest sector of the population. The unemployment rate now stands at 50%, and poverty has surpassed 85 percent. Critically ill Gazans seeking to leave to receive life-saving medical treatment in Israel or Egypt are trapped within Gaza. Dr. Mustafa Barghouthi, president of the Palestinian Medical Relief Society and former Minister of Information stated that at least ten patients have died since last month because they were denied access to treatment. Such conditions also have serious mental health consequences. The majority of Gazans are suffering from feelings of anxiety, frustration, and hopelessness, according to Dr. Eyad El-Sarraj, president of the Gaza Community Mental Health Program.
The international community should speak out against the deteriorating humanitarian situation in Gaza and hold responsible key players accountable for protection of civilians. Israel should have earnest goodwill at the upcoming peace talks and must fulfill its obligations under international law by lifting the siege on Gaza and opening its borders immediately. The United States would do well to play a more sincere role in peacemaking in the Middle East, and involving other parties who are serious about seeing peace prevail in the region. After all, a genuine and viable peace is the only solution to Israel’s dilemma, not sanctions.
I wrote the op-ed piece below to fulfill one of the assignments for my Problems in International Health course with Dr. Steve Gloyd. As many of you know, Dr. Gloyd encouraged us to submit our work to newspapers for publishing. We'd love to post your published/unpublished work on IHP blog too. Please feel free to contact me with any questions on how to do this if you are interested.
Looking forward to reading you. Amineh
Punishing an Entire Population
Following Hamas' takeover of the Gaza Strip last June, Israel tightened its siege over the area to an unprecedented level. Israel declared Gaza a “hostile entity’ in September, threatening to impose economic sanctions against the territory and to further restrict the passage of food, supplies and people. Israel’s policy of collective punishment will only deepen an already dire humanitarian crisis, and lead to grave public health consequences in the most densely populated area in the world.
In late October, Israel commenced its policy of fuel cuts and reduction of Gaza's electricity supply in order to pressure Hamas in response to cross-border rocket attacks. Israel also closed border crossings into Gaza, leaving only one of six entrances open. Since the so-called disengagement in 2005, Israel has been restricting access and controlling borders to Gaza, while denying responsibility for the still-occupied people there.
Sanctions will reduce gasoline imports by about 50% and fuel for Gaza's power plant by 12%. These resources are critical for the livelihood of the already impoverished Strip. Gaza relies on Israel for all its fuel and most of its electricity needs. Fuel is required to produce the electricity that Gaza generates locally. Electricity is needed to pump water and to operate sewage management plants, as well as hospitals and other infrastructure. According to the Humanitarian agency Oxfam International, seven water wells in Gaza City did not operate as usual due to fuel shortage, which decreased the quantity of water supplied to 50,000 people by about 75%. The restrictions on the entry of goods into Gaza have also caused shortage of materials needed for repairs and maintenance of sewage plants. Sewage plants must operate 24 hours per day to prevent sewage floods and spread of disease.
Israel claims that its policy of fuel cuts of up to 15% is a “non-violent” way of increasing pressure on Hamas. An ongoing state of siege that cuts off food, medicines and fuel is not a “non-violent” act. According to the World Health Organization, most of the population is already living under the poverty line, and suffers from malnutrition. Starving civilians as a method of warfare is illegal under article 54 of the Fourth Geneva Convention.
At what expense do we play politics with the health of an entire population?
Our experience with sanctions in the Middle East has taught us that subjecting a population to economic embargo does not work. Such sanctions primarily harm innocent people. Why is this a lesson unlearned? Looking back at the sanctions against Iraq, we know that restricting the imports of medicine and food into the country caused terrible public health consequences. Malnutrition among children became widespread, and according to UNICEF, child mortality tripled in the first year of sanctions. Water-borne infectious diseases such as cholera and typhoid spread and accounted for 50 percent of total deaths among children. 500,000 Iraqi children under age five died due to the economic sanctions in Iraq.
The Israeli siege has severely reduced the flow of fresh food, especially fruits and dairy products into Gaza. Exports are also greatly restricted, resulting in paralysis of the territory's economy. Prices have more than tripled, causing severe hardship for the poorest sector of the population. The unemployment rate now stands at 50%, and poverty has surpassed 85 percent. Critically ill Gazans seeking to leave to receive life-saving medical treatment in Israel or Egypt are trapped within Gaza. Dr. Mustafa Barghouthi, president of the Palestinian Medical Relief Society and former Minister of Information stated that at least ten patients have died since last month because they were denied access to treatment. Such conditions also have serious mental health consequences. The majority of Gazans are suffering from feelings of anxiety, frustration, and hopelessness, according to Dr. Eyad El-Sarraj, president of the Gaza Community Mental Health Program.
The international community should speak out against the deteriorating humanitarian situation in Gaza and hold responsible key players accountable for protection of civilians. Israel should have earnest goodwill at the upcoming peace talks and must fulfill its obligations under international law by lifting the siege on Gaza and opening its borders immediately. The United States would do well to play a more sincere role in peacemaking in the Middle East, and involving other parties who are serious about seeing peace prevail in the region. After all, a genuine and viable peace is the only solution to Israel’s dilemma, not sanctions.
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