Why a U.S. Circumcision Push Failed in Swaziland
EZULWINI, Swaziland | At a working men’s bar in a down-at-the-heel part of town, a group of laborers are ordering a round after a long day when the talk turns to the uncomfortable subject of adult male circumcision. The procedure is being carried out as part of a campaign to reduce the spread of HIV here in this tiny kingdom in southern Africa, which has the world’s highest prevalence rate for the AIDS virus.
For S.K. Maseko, a 41-year-old father of five who works as a caddie at a local golf course, the decision to lose his foreskin in March was a good one.
Like most men interviewed for this story, Maseko explained that apart from a moment of pain from the jab of a localized anesthesia and a bit of discomfort for a few days of healing, the process of circumcision was relatively painless. And, he added, there are distinct benefits beyond that fact that it affords protection against HIV.
“Sex is better now,” he says.
“With circumcision, my wife is happy,” he adds with a smile.
But his drinking buddies at the Makhonkhosi Wine & Malt bar are not convinced and not certain they would volunteer for the procedure — even if it could save their lives at the epicenter of the AIDS epidemic in southern Africa.
Billy Saulus, 49, an auto mechanic, has refused to go, fearing that he may already be HIV positive.
”What if I go along to be circumcised and the doctors insist I be tested? What if I am HIV positive and the wound does not heal properly? I think I will just continue with condoms,” said Saulus, who has three grown children.
In an ambitious goal — some would say audacious — the United States wants to accelerate the pace of male circumcisions to support 4.7 million procedures in the developing world by the end of next year, up from 1 million at the beginning of this year. But its failures in Swaziland have given everyone — even the U.S. global AIDS Ambassador Eric Goosby — great pause whether that goal announced by President Obama can be reached.
Late last month, Goosby said the U.S. could still do it, but he acknowledged that scaling up male circumcision was much harder than expanding AIDS treatment or protecting newborns from infections by their mothers.
The goal here was to circumcise 80 percent of all men aged 15 to 49 in a year. The result was that roughly one in four underwent the procedure.
What went wrong? What are the lessons from this landlocked country between Mozambique and South Africa with a population of just 1.3 million?
Here, say experts, a concoction of long-entrenched local traditions, false rumors, economic pressures, and gender imbalances added up to falling far short of the goal.
But there was another problem: the U.S. government and others simply misjudged how long it takes to institute a procedure in a culture that has no history with circumcision. U.S. experts set expectations far too high, many believe.
Since 2007, the United States, through the President’s Emergency Plan for AIDS Relief (PEPFAR), has spent more than $140 million from 2007 through 2011 on every aspect of the battle against AIDS in Swaziland, including institutional support, training, care and prevention. But prevalence rates have remained high. Among men between 15 and 49 years of age, 26 percent are HIV positive.
Based on evidence from other African countries that female-to-male transmission of the virus can be reduced by 60 percent if men are circumcised, PEPFAR last year added an additional $15.5 million in funding for an ambitious ”accelerated saturation initiative” to circumcise 80 percent of HIV negative men between ages 15 and 49. A year later, 23 percent had undergone the procedure. Some critics suggest the campaign, called Soka Uncobe (”circumcise and conquer”), may have been counter-productive to on-going efforts to promote condom use and behavior change.
Muhle Dlamini, a 50-year-old environmental health scientist with the Swaziland National AIDS Programme, which is part of the health ministry, said that officials knew the campaign would be a tough sell.
”We are not, culturally, a circumcising country, though some people believe the practice was current until the 19th century and was stopped because the king, in war time, could not afford for his warriors to lose time healing,” he explained.
”In 2006, when we started circumcising on a routine scale, 8 percent of Swazi men were circumcised — generally for health or religious reasons — and sometimes because they had worked in South Africa where the practice is often a rite-of-passage to manhood. In some South African workplaces, for example mines, Swazis are bullied and called ‘boys’ if they are found to be uncircumcised,” he said.
Migrant work, which causes men to spend months at a time away from home, has contributed to the spread of AIDS. Swaziland may be ranked as a middle-income country but its economic heyday dates back to the years leading up to the mid-1990s, when it was a haven of tranquility between war-torn Mozambique and apartheid South Africa.
In the aftermath of those conflicts, Swaziland’s economy depends on its own sugar and fruit production and custom dues it collects from transit traffic. Indian investors recently reopened an old iron-ore mine, but the country has very few natural resources. According to the United Nations, 52 percent of people in the 15-to-24 age group are unemployed, 63 percent of the population lives in poverty and 29 percent is food insecure.
The country is culturally polygamous, but economic hardship has led to the decline of legal marriages in favor of sex with multiple partners.
”Men cannot afford dowry payments,” said Dlamini, ”but they continue to have sex … So you find that multiple concurrent partners are increasingly the norm. Economic pressures also lead to more inter-generational sex with so-called ‘sugar daddies’ and other sex for money or favors.”
Many Swazi men aspire to be dubbed ”inganwa,” a word that roughly translates as a ‘playboy’ with several girlfriends. But traditionally, a man would not have penetrative sex with his girlfriends before marriage. Within this cultural context, the only Swazi man permitted to do otherwise was the king who, for reasons justified by the importance of succession, did not have to marry a girl until she became pregnant.
A range of rituals also exist to protect the chastity of girls. Virgins proudly still wear colorful sashes, called ”umcwasho” and it is incumbent on men to respect them. Once a year, boys pick a shrub, called ”lusekwane” which they are expected to tend or face embarrassing accusations that it had wilted because they had had sex. While the rituals still exist, including an annual ”reed dance” at which thousands of Swazi maidens dance before King Mswati III, their meaning is slipping away.
The 2011 mass circumcision effort started from a low base, and there appeared to be considerable demand from men. The government, as well as several non-government organizations — such as the long-established Family Life Association of Swaziland (FLAS) and Population Services International (PSI) — had begun promoting and offering adult male circumcision in 2006.
Zelda Nhlabatsi, director of the Family Life program, said her organization could not keep up with demand.
”People had heard of the Orange Farm experience, a celebrated study in South Africa in 2002 to 2004 which found that circumcision cut transmission (by as much as 60 percent). South Africa being next door, people felt that if it worked for them it could work for us. The government brought in Israeli doctors to train Swazi doctors in how to circumcise under local anesthetic. PEPFAR supported the renovation of our clinics. Demand was enormous. We were really keen to take the program to scale.”
Enter the Futures Group, a Washington, D.C.-based company that was awarded a contract by PEPFAR for the $15.5 million circumcision program without a competitive tender. The project management firm was tasked with using the $15.5 million in funding to turn the culturally conservative, non-circumcising Swaziland into a land where 160,000 men would be willing to volunteer for the procedure. It was a tall order to begin with.
U.S. Army mobile surgical tents were brought in and about half the total budget was spent on hiring expatriate surgeons to train 200 clinicians. Celebrity endorsements were secured from a leading musician and from “Mr. Swaziland,” the annual winner of a national pageant for men. Matchboxology, a South African advertising agency with a track-record in AIDS messaging, produced films, livery for minibus taxis, flyers, and billboards.
The Futures Group seemed to have thought of everything, including royal backing. In July 2011, King Mswati III stood before an audience of 3,000 people and declared, ”Soka Uncobe must be the motto now for all men to go for male circumcision.”
Yet ask Swazi AIDS professionals about the campaign and many will privately — for fear of jeopardizing future U.S. funding — term it a ”disaster,” a ”nightmare” and ”an exercise in bullying.” Prominent AIDS activists said the regular meetings they attended were used by Futures Group to rubber stamp decisions, rather than consult.
Mahlubi Hadebe, prevention coordinator with Swaziland’s National Emergency Response Council of HIV/AIDS (NERCHA), was among those critical of the Futures Group and its approach.
Hadebe said, ”It went wrong from the outset. Futures Group just would not listen. The promotional materials featured drawings of people. But I as a Swazi, want to see a real Swazi’s face. The demand-creation approach was all wrong: To convince a Swazi man you need time, you need to go and see him. You have to identify thought leaders in communities and use them to convey the message. Billboards do not work.
”Some of the messaging hit the wrong note. ‘Lisoka lisoka ngekusoka’ — which literally means ‘the lover boy is a lover boy thanks to circumcision’ — appeals to the playboy in the man. It is off-putting to married men,” said 47-year-old Hadebe.
Family Life’s Nhlabatsi said the Soka Uncobe name sent the wrong message.
”To me it does not to so much mean ‘circumcise and conquer’ but more ‘circumcise and be done with it’ which is a dangerous message. It could be interpreted as meaning that once men are circumcised they no longer need to use condoms,” said Nhlabatsi.
Studies in South Africa, Kenya and Uganda have found that circumcised men are at least 60 percent less likely to pick up HIV. Still, the groups carrying out the circumcisions must grapple with conveying the message that even after the procedure — which requires men to abstain from sex for six weeks — condom use remains crucial.
Rhoy Shoshore is a 31-year-old doctor with the Family Life association who has carried out the procedure on more than 1,000 Swazi men.
He said, ”We talk to the clients about the importance of condoms before the operation. … But you can never be sure how much they are taking in. And with teenagers it is difficult as the Education Ministry does not want us to talk about condoms in schools, only fidelity and abstinence.”
Emma Llewellyn, the British HIV technical services director at PSI, previously worked in Kenya, where she spearheaded the country’s first ”rapid results” circumcision campaign in 2009, but she said Swaziland’s culture has presented challenges to the campaign.
In Kenya, she explained, ”We did 30,000 men in 30 days. The campaign is now repeated by local organizations during every Christmas holiday. But Kenya is very different. The majority of the country’s 42 tribes traditionally circumcise.”
Futures Group’s Shannon Hader, the organization’s director of health and systems solutions, told GlobalPost that the results of Soka Uncobe had indeed been something of a disappointment. But she dismissed most of the criticism of Futures Group’s approach, and particularly its failure to consult the Swazis themselves.
Hader said, ”This was the first time any country, starting from a fairly low base, tried an accelerated saturation initiative aiming to capture essentially a whole population in 12 months. We learned — and this was a global ‘learn’ that will serve us elsewhere — that it is not because you build the service that you create the demand.”
She specifically denied that the campaign had led to risky practices, adding, ”I have not seen any evidence that that is what played out.”
At the U.S. embassy in the capital, Mbabane, PEPFAR country coordinator Chris Detwiler insisted that Soka Uncobe had been born out of a request from the Swazi government in February 2010. He explained that Futures Group was awarded a contract without a competitive bidding process based on the need to ”implement a stand-alone, time-limited campaign that did not overburden an already strained health system.”
Detwiler denied the campaign had misfired, saying, ”We have heard that accusation but the process was not a top-down approach. It was driven by the Swazi government and came with extensive consultation in the form of weekly and monthly meetings. We will do better going forward.”
Around the country, three months after the Soka Uncobe campaign ended, publicity material is still visible on some billboards and minibuses. Clinics have large boxes full of its distinctive orange leaflets. But PSI and others say they are in a ”taking stock” phase.
”We have to look at how to move forward,” said Llewellyn. ”We need to look at what we do with the Soka Uncobe brand, which after all, the king launched.”
Both PSI and the Family Life association are concentrating on ‘back to school’ campaigns.
‘Teenagers are an easy target group,” said Nhlabatsi. ”You get parental approval and then you have a busload of them.”
The future, said NERCHA’s Hadebe, is in expanding the circumcision of baby boys within seven days of birth.
”I think we may just have to accept that we are going to miss much of the population which is currently sexually active,” Hadebe said. “I think we need to put our energy into neo-natals. But even there we have obstacles to overcome. We are still legally obliged to obtain paternal approval to circumcise a boy. This is a challenge given the number of single women giving birth.”
The men at the bar in Ezulwini have other concerns. One man, a divorced 45-year-old lawyer who did not wish to be named, said he used condoms with all his partners, except his steady girlfriend. ”She does not want me to be circumcised because she thinks it will make me reckless,” he said. “She believes I will take less care to use condoms. Personally, what makes me reluctant is the requirement that you have to go without sex for six weeks. I would find that difficult.”
The motor mechanic Saulus added that he had heard stories of circumcision clinics selling foreskins to witchdoctors. Someone he had spoken to knew someone who had become sterile, he claimed. Saulus and several other people at the bar also said the book of Deuteronomy in the Hebrew Bible, or Old Testament, condemns the practice. In fact, the Hebrew Bible is consistently in favor of circumcision, which is still observed in modern secular and religious Jewish communities.
But Maseko dismissed his buddies’ claims. Sex, he insisted, was better than ever and he said he would be sure to continue telling his friends.
Asked whether he had continued to use a condom since the operation, he said he hadn’t because he had only had sex with his wife.
”They are all just afraid of the pain,” he said of his drinking buddies. “They will come around to it.”
To view additional stories in the GlobalPost/NewsHour series “AIDS: A Turning Point,” click here. GlobalPost’s reporting on global heath is made possible in part through a partnership with the Henry J. Kaiser Family Foundation as part of its U.S. Global Health Policy program.