2006 - The year of circumcisions

For sure, the two greatest advances of humankind this year, as far as can be judged on this day of winter solstice, were on the genital front, although in opposite directions for the two genders involved.

The international public health establishment, still dominated by men, paid most attention to male circumcision. In fact, the publication of data indicating a clear protective effect of around 50% of this operation in relation to the risk of HIV/AIDS is wonderful news. Very good that WHO in its press statement[1] also draws attention to the downside which could perhaps be oversimplified as: DON’T go and get circumcised in order to double your sexual contacts afterwards. For more general information about male circumcision, its origins, consequences, risks, benefits and how to do it, I recommend the Wikipedia article.[2]

As expected, the general press (at least the pathetic Swiss tabloid I subscribe to) was more interested in the female side, but it really was heartening to see the headline news on the condemnation of female genital mutilation (FGM) by a meeting of leading Muslim clerics in Cairo on 22-23 November 2006. Der Spiegel published a good article online in English.[3] Female genital mutilation encompasses clitorodotomy (removal or splitting of the clitoral hood), clitoridectomy (removal of the clitoris), and infibulation (removal of the vulva) also known as pharaonic circumcision. The practice seems to have had its origin in ancient Egypt and is nowadays widespread in a number of African countries. It also occurs in some countries in Asia, but much less frequently. It has been estimated that 2 million girls and women are subjected to it every year, although it is possible that a decline has started. The severe effects of FGM on the health of the girls and women subjected to it as well as their offspring have been well documented in a multi-country study.[4] The Muslim scholars made it clear at the meeting in Cairo that not only is this practice not supported by Islam; it “contravenes the highest values of Islam and is therefore a punishable crime.”

The purpose of FGM is in general to prevent sexual desire in girls thereby improving marital fidelity. I would consider it one example of the cruelty systematically inflicted by men on women in so many cultural settings. It is akin to burning of witches in Europe, honour killings, burning of widows in India and, most strikingly, binding of feet in China. Most of these practices have been abandoned, but only after inflicting suffering beyond imagination on millions of victims.

The meeting in Cairo was instigated by a German non-governmental organization, Target.[5] . Although I find this NGO to be driven too much by one person, zum Überfluss a man, I find the intentions and results so laudable, that I have sent them a donation. Now I hope stronger local movements and networks will emerge, and that they can muster the right persons with the necessary willpower and understanding of local cultural and economic contexts to set and achieve targets for FGM elimination.

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[1] http://www.who.int/mediacentre/news/statements/2006/s18/en/index.html

[2] http://en.wikipedia.org/wiki/Circumcision

[3] http://www.spiegel.de/international/spiegel/0,1518,452790,00.html

[4] WHO Study Group on female genital mutilation and obstetric outcome (2006). Female genital mutilation and obstetric outcome: WHO collaborative study in six African countries. The Lancet 367, 1835-41

[5] http://www.target-human-rights.de/index.php

Article on malaria control published by The Lancet

The below text was published online by The Lancet on 7 December 2006, and in the printed journal on 16 December (The Lancet 2006; 368:2111-2113). As copyright has been assigned to The Lancet, the text may not be reproduced without written permission from The Lancet or me.

Subscribers to The Lancet can find the published article at http://www.thelancet.com/journals/lancet/article/PIIS0140673606698127/fulltext?isEOP=true

Comment

DDT: a polluted debate in malaria control

Allan Schapira,
Geneva, Switzerland.
a.schapira@bluewin.ch

A recent press statement from WHO about dichlorodiphenyltrichloroethane (DDT) and indoor residual spraying for malaria control¹ caused a considerable stir, despite the fact that, in terms of policy, it merely re-iterated WHO’s endorsement of DDT as a useful insecticide for malaria control, albeit in a highly promotional way. In this recurring debate, arguments for and against DDT, as before, have been heated and mainly based on considerations far removed from the realities of malaria control.

One group that criticised the WHO statement has inferred that my resignation from WHO’s Global Malaria Programme in September, 2006, was related to my opposition to its promotion of DDT.² This assumption is erroneous. For many years, WHO’s malaria-control professionals have fought hard against pressure from various sides to ensure access in malaria-endemic countries to DDT.³ Hopefully, the statement now issued by the Global Malaria Programme¹ will put an end to this debate, so that all countries that need DDT for malaria control will have unfettered access to use it in accordance with WHO guidelines and with the Stockholm Convention on Persistent Organic Pollutants, if they are signatories to the latter.

Meanwhile, remarks from the opposite camp have not lacked passion, conveying the impression that large-scale use of DDT for malaria control, so long held hostage to misguided concerns for the environment, will now save the lives of millions of people from malaria.⁴ This idea is not so simple. As pointed out in WHO’s new position statement, indoor residual spraying is an effective intervention, provided a programme infrastructure can be set up and maintained to include trained sprayers, supervisors, managers, stocks, equipment, and vehicles, that roads allow access to every village at the right time at least once a year, and that insecticides are not diverted to agriculture. The need to prevent diversion has been highlighted for DDT, but for malaria control it is equally important for other insecticides. Furthermore, especially in areas with intense and perennial transmission, it is essential to maintain the population’s long-term acceptance of spraying once or several times a year.⁵

In view of the difficulties encountered in maintaining indoor residual spraying, WHO has invested substantially in exploring other methods, especially insecticide-treated bednets. These nets have been effective in many rigorous trials,⁶ especially to reduce childhood mortality in Africa. Few trials have compared insecticide-treated nets and indoor residual spraying, but results so far suggest that the methods are more or less equal in efficacy.⁷ As pointed out by WHO,⁸ the two methods are similar in the way they work, although unlike indoor residual spraying, insecticide-treated nets can protect individual users or households. Few data exist for the use and cost-effectiveness of combining these two methods. In view of the substantial costs of prevention for the huge populations at risk, national programmes will generally need to choose one of these two methods for a specific geographical area.

The choice of insecticide is secondary. Since only pyrethroids can be used for insecticide-treated nets, and pyrethroid resistance is emerging as a constraint on their effectiveness,⁹ the fact that four classes of insecticides can be used for indoor residual spraying should be one of the main reasons justifying renewed interest in this method.

In the choice between indoor residual spraying and insecticide-treated nets, a WHO study group convened in 2004 noted that the decision should, in most cases, be based on operational factors.⁸ Because long-lasting insecticidal nets can be managed easily with minimum risk of diversion of insecticide, for most high-burden countries that have not developed an infrastructure for indoor residual spraying, the priority will be to ensure coverage of at-risk populations with such long-lasting nets. The renewed interest in indoor residual spraying could lead to interminable debates in countries about the pros and cons of DDT. Such discussions pit sectors against politicians when, in fact, a non-partisan commitment is needed desperately to protect individuals at risk of malaria with one of the two proven methods.

1 WHO. WHO gives indoor use of DDT a clean bill of health for controlling malaria. WHO promotes indoor residual spraying with insecticides as one of three main interventions to fi ght malaria. Sept 15, 2006: http://www. who.int/mediacentre/news/releases/2006/pr50/en/print.html (accessed Nov 15, 2006).

2 Pesticide Action Network North America. Global coalition of health and toxic experts demand that WHO stop irresponsible promotion of DDT. Sept 26, 2006: http://www.panna.org/resources/newsroom/stopWhoPromotionDdt20060926.dv.html (accessed Nov 15, 2006).

3 Schapira A. DDT still has a role in the fi ght against malaria. Nature 2004; 432: 439.

4 Stossel J. Hooray for DD T’s life-saving come-back. Oct 4, 2006: http://www.townhall.com/columnists/JohnStossel/2006/10/04/hooray_for_ddts_life-saving_comeback (accessed Nov 15, 2006).

5 Global Malaria Programme. Indoor residual spraying: use of indoor residual spraying for scaling up global malaria control and elimination. 2006: http://malaria.who.int/docs/IRS-position.pdf (accessed Nov 9, 2006).

6 Lengeler C. Insecticide-treated bednets and curtains for preventing malaria. Cochrane Database Syst Rev 2004; 2: CD000363.

7 Lengeler C, Sharp B. Indoor residual spraying and insecticide-treated nets. In: Murphy C, Ringheim K, Woldehanna S, Volmink J. eds. Reducing malaria’s burden: evidence of effectiveness for decision makers. Washington, DC: Global Health Council, 2003: 17–24.

8 Report of a WHO study group. Malaria vector control and personal protection. 2006: http://www.who.int/malaria/docs/WHO-TRS-936s.pdf (accessed Nov 9, 2006).

9 Etang J, Chandre F, Guillet P, Manga L. Reduced bio-efficacy of permethrin EC impregnated bednets against an Anopheles gambiae strain with oxidasebased pyrethroid tolerance. Malar J 2004; 3: 46.