The uncoordinated orchestra – Malawi’s circumcision conundrum

For 33 years now, Reverend Levi Nyondo, as God’s anointed ‘shepherd,’ has watched HIV/AIDS decimate his ‘sheep.’ Although his homilies have urged sexual abstinence and fidelity, which should slow spread of the disease, he grudgingly admits that the heavy loss of his parishioners to the pandemic is a clear sign that these messages are falling on deaf ears.banner ccap circumcisiona photoa photo

The problem may be that he and his colleagues in the Church of Central Africa Presbyterian pointedly fail to advocate two of the strategies health experts say hold the most promise of stemming the disease: medical male circumcision and condom use.

Paradoxically, Researchers from the University of Malawi’s College of Medicine found out that many men who took part in the VMMC programmes later went on sex sprees, arguing that they could not catch the virus since they had been circumcised.

In truth, circumcision reduces the infection rate by about 60 % or so, but does not prevent infections in every case. The scholars point out to a lack of proper communication about these issues.

“We do not allow voluntary medical male circumcision even though we know that Jesus got circumcised. We stress biblical abstinence,” says the Reverend.

His office, with walls adorned with portraits of his predecessors as Secretary Generals of the church and colourfully decorated brass and golden crusted crucifixes, exudes the church’s ambience of the promised deliverance.

Swivelling in his leather, hard-back chair, he summarizes church doctrine on condoms in a single sentence: the church allows them for HIV-positive couples, but not “boys, girl, spinsters, bachelors or the divorced.”

Similar mixed or partial messages emanate from other sectors. In most of Malawi, circumcision has not been practiced traditionally, and leaders like Rev. Nyondo are reluctant to go against the tide.

In Malawi, traditional ritual circumcision is mainly practiced in the southern part of the country where there is a migrant labour population with a high HIV prevalence rate.

The region accounts for about 70% of the country’s HIV infections, according to ministry of health statistics.

In the northern region circumcision is considered a taboo or an alien practice.

“In my village it will be a surprise to many people to persuade them to have circumcision. They will tell you it’s not part of their culture. Who am I to defy culture? ” Nyondo asks.

Government, meanwhile, lists promoting circumcision and condom use among its HIV-prevention strategies, but the effort so far has been haphazard and largely ineffective.

Malawi’s roll out of medical male circumcision, in short, is akin to an orchestra where the woodwinds, brass, percussion, and strings have been belting out different tunes for more than five years while the conductor, the Malawi government, is either lost in a stupor or watching with resignation.

As a result, although the country set out five years ago to see about 2.5 million males in all 28 districts throughout the country get circumcised by December 2016 – 60 per cent of all males aged between 10 and 34 years – to date, only 260,188 men have undergone the procedure.

With US$23 million from the World Bank and PEPFAR down the drain, the Malawi government concedes that its target to circumcise 2.5 million males remains a mirage.

` Most of the people in the community believe that medical circumcision should be done to young men (5-10) and older men normally are coming in low numbers. Potentially we have difficulties creating demand among older men 25-35yrs, ` said Ministry of Health spokesperson Adrian Chikumbe.

Chikumbe claims Malawi has the overwhelming support of the religious and traditional sectors in its lofty ambitions to put a third of the country`s male population under the blade.

But publicly available figures and views on the ground show another picture.

Reverend Nyondo epitomises the Presbyterian Christians’ and the fractured cultural blinkered view prevalent in the country`s three regions..

On the other hand, the country`s Catholic bishops recommend male circumcision in order to help fight new infections but oppose the use of condoms, a much safer way of preventing the spread of HIV.

And 650 Km away from Nyondo’s office in a remote village in the southern district of Zomba, two traditional leaders  broke the jinx by being circumcised at a VMMC camp at the district Hospital much to the chagrin of their peers and fellow villagers.

Through their gesture, the camp surpassed their target of circumcising 450 men by 84 during the weeklong exercise in March 2016.

“My sons hated the traditional way and they went for VMMC and later inspired me. As a chief I am supposed to help government in such campaigns but how do I urge people to go for VMMC if I did not go myself. I need to know what I talk about when I engage my people on VMMC,” Village Headman Chimbalanga said.

The ministry of health blames the slow pace of the programme on several bottlenecks which includes campaigning, communication and lack of human resources.

However, investigations in some of the country’s hospitals and clinics in the northern and southern regions of the country revealed that while officially they offer medical male circumcisions free of charge, in reality, optional circumcisions are considered a priority to other surgical procedures.

When Malawi developed its five year VMMC communication strategy which started in 2012 and is expiring in 2016, it left out two permanent and influential institutions of the social fabric of Malawi, the religion and tradition.

The fatal omission disregarded the fact that the majority of circumcisions in Malawi occurs in the context of religious and traditional rites.

“The communication strategy has been developed as the formal national VMMC communication strategy in Malawi. All senior ministry of health personnel, international local NGOs… should use this document t guide and inform their work,” reads part of the document.

Social Activist Moses Mkandawire says interventions in Africa need to include religious institutions and traditional systems of governance because these are permanent institutions.

Mkandawire noted that religious institutions wield a lot of power because the majority of people believe in God.

“Traditional systems of governance have been there since time immemorial. What traditional leaders do or say carries more weight among their people. Even in urban areas we have traditional leaders,” he said.

There is no indication from the government  on either it is reviewing the VMMC communication strategy to incorporate the divergent and inconsistencies issues that are in Malawi as a means to scale up uptake of VMMC.

` We are working with local leaders, media , musicians , youths , footballers, the corporate world, faith organizations and role models to help in mobilizing males for VMMC,` said Chikumbe.

  • The International Center for Journalists (ICFJ) supported this story. Collins Mtika is one of the 2016 fellows for the HIV Prevention Reporting Fellowship which sponsored by the Bill and Melinda Gates Foundation.
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11 thoughts on “The uncoordinated orchestra – Malawi’s circumcision conundrum”

  1. TECNO says:

    Everyone has a choice to be circumcised or not but there’s no clear reason for this type of programme because you can still contract the disease.

  2. LUHA says:

    Hot debate!

  3. Boko says:

    That male circumcision reduces the risk of contracting HIV by 60% is a BLUE LIE. To conduct research that would lead to such conclusion would require the following research design:
    1. Take 2 groups of 10 men each. One group should be circumcised, the other (control) uncircumcised.
    2. Let the 2 groups have unprotected sex with HIV-infected women.
    3. Test the 2 groups for HIV after some time, e.g. 2 years.
    4. The results should show that 6 out of the 10 circumcised men are HIV-negative, whereas the control group should have all its men become HIV-positive.
    Was such research done? Where?
    I know why this male circumcision drive came in. It Islamic and is financed by Moslems whose culture it is to circumcise men. Islam wants to impose its culture and religion on people of other beliefs. We reject Islam. We refuse to join the religion of war or Jihad. We totally rebuff the Boko Harams, Janjaweeds, El Shababs, ISIS, Al Quaida, Hamas, Muslim Brotherhood, Hisbolah, etc. This government of Malawi stinks.

    1. Boko number 8 is an idiot says:

      Boko, You are an idiot.

  4. Ron Low says:

    HIV is twice as prevalent in the mostly-circumcised USA as it is in non-cutting Europe. Clearly, having men give up the best part of their genitals in a risky procedure is not necessary or sufficient to thwart AIDS.

  5. nanga says:

    Kanyimbi, men should do the job during sex. Its ridiculous for Malawian and African men to demand that women should `perform` during sex. Mzungu bola amachengetera chikondi – amaphika, kuyang`anira ana, kukonza panyumba, foreplay so that when it comes to sex time mkazi sakhala otopa. We need to wait until our Malawi and African men become civilized and modernised for women to perform during sex otherwise its not fair. Amuna a ku Malawi and Africa kuzolowera – sadziwa reciprocal and dual enjoyable sex. By the way, do men carry pregnancy? Go into labour and push a baby out? No. So why should women be overburdened from sex, pregnancy to labour. Mamuna ayenera kugwira ntchito basi!

  6. GilbertK says:

    My comments on this campaign

    1. In general, we do not remove healthy body parts without an urgent and specific medical reason. And even then, we normally are quite reluctant. For example, although many women may develop breast cancer, healthy breasts are rarely amputated as a precautionary measure. As any healthy uncircumcised man can confirm, the male foreskin is very sensitive and plays an important role in sexual acts. As such it has a biological function. It is a generally accepted principle that in the case of preventative medical interventions, such as the removal of a healthy body part, there needs to be a clear individual or public health benefit which cannot be achieved in another, less intrusive way.

    2. The medical benefits as cited by the article and the WHO have been disputed by many scientists and are therefore questionable. Furthermore, just like any other surgery, circumcision implies the risk of medical complications. In addition, psychological and sexual problems have been reported. See the viewpoint of the Royal Dutch Medical Society: “Even if there were slight medical benefits connected with circumcision for medical preventative reasons, it is questionable whether these possible medical benefits would compensate for the risk of complications. There is no convincing evidence that circumcision is useful or necessary in terms of prevention or hygiene. Partly in the light of the complications which can arise during or after circumcision, circumcision is not justifiable except on medical/therapeutic grounds”. The viewpoint notes: “That the relationship between circumcision and transmission of HIV is at the very least unclear is illustrated by the fact that the US combines a high prevalence of STDs and HIV infections with a high percentage of routine circumcisions. The Dutch situation is precisely the reverse: a low prevalence of HIV/AIDS combined with a relatively low number of circumcisions”. See for the full document:
    http://knmg.artsennet.nl/web/file?uuid=579e836d-ea83-410f-9889-feb7eda87cd5&owner=a8a9ce0e-f42b-47a5-960e-be08025b7b04&contentid=77976&elementid=771754

    3. Even supporters of preventive circumcision admit that this practice does not fully prevent HIV-infections but reduces chances of getting infected by about 60%. They therefore emphasize that circumcised men should still apply other precautions such as safe sex, sticking to one partner or abstinence. However, as this campaign means to reduce HIV-infections, it is actually aimed at uncircumcised men practicing unsafe sex with multiple partners! After all, men consistently practicing safe sex or sticking to one partner have a far smaller chance of getting infected. How likely is it that men with a currently dangerous sexual behavior who take the trouble of getting circumcised, will change that behavior? Is it not more likely that many such men take the treatment to continue their behavior or even do it more often than before? Particularly since they are told by the doctor that the treatment will significantly reduce their chance of catching HIV! In one of the trials (in South Africa) on which the WHO-recommendation is based, 18% of the newly circumcised men reported more sexual contacts after treatment. The actual percentage is probably higher (see Kalichman et al, Circumcision for HIV Prevention: Failure to Fully Account for Behavioral Risk Compensation, http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0040138 )

    4. My conclusion: for both medical, ethical and purely practical reasons, routine male circumcision to prevent HIV-infections is not a good idea.

  7. Mark L says:

    Malawian men are *more* likely to have HIV if they’ve been circumcised:

    7.9% of intact Malawian men have HIV
    10.3% of circumcised Malwian men have HIV

    (figures from MeasureDHS)

    There are at least nine other African countries where men are *more* likely to be HIV+ if they’ve been circumcised. Why then is male circumcision being promoted to prevent HIV?

    ABC (especially Condoms) is the way forward. Promoting genital surgery seems likely to cost African lives rather than save them.

  8. adam cornish says:

    It is a lie that circumcision prevents HIV. Nearly a million American men have died of AIDS, and almost all of them were circumcised.

  9. Chisala, M. L. says:

    You are lying to the general public about male circumcision having any positive beneficial effect! It has none! The health community must be ashamed to be propagating such lies without even bothering to read the abundant objective research out there clearly disputing every nonsense they put out! What happened to evidence-based health policies touted by the Ministry?!!!

  10. Kanyimbi says:

    This reverend is saying the truth, women from his region do not perform in bed (they just stay idle) while the man should do all the work (similar to how a cow, female goat or female dog do when mating) so for a man who has been circumcised, this will be a tough job. So as the ministry is trying to teach men to be circumcised, it should also help these women to know how to drive a circumcised penis. otherwise ………………………..

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