In the Zimbabwe campaign Lindsay wrote about yesterday, public health messages have the look of a party invitation for the modern man – and his female partner. An attractive couple looked out from a breezy ad offering a free “summer snip.” A group of legislators underwent the operation in a makeshift clinic outside the Parliament building in Harare. Celebrity musician Jah Prayzah got circumcised and then gave an interview wearing a shirt reading: “I DID IT. Why haven’t you?”
A study in the new PLOS VMMC Collection, Barriers and Motivators to Voluntary Medical Male Circumcision Uptake among Different Age Groups of Men in Zimbabwe, describes the intent of this campaign to portray circumcised men as “confident, outgoing, sexually appealing, and set to succeed in life.” No question this is a cultural or “social norm” appeal. And, although progress in Zimbabwe is slow, this message, built as it is around modernity and personal attractiveness, may yet work. Read more about the Zimbabwe VMMC campaign, and in particular the roles played by women, in Lindsay Kobayashi’s recent post.
But another paper in the new PLOS VMMC Collection, Attitudes, Perceptions and Potential Uptake of Male Circumcision Among Older Men in Turkana Couny, Kenya Using Qualitative Methods, suggests that staying away from such a cultural pitch in favor of a strictly health promotion message may prove to be a more viable way to reach different, particularly rural, and older audiences.
In Kenya, circumcision rates are generally already high, but men from certain ethnic groups are still vulnerable because they traditionally do not circumcise. One such group, the Turkana, is native to a semiarid area in the northwest corner of Kenya. There is a county headquarters and a few small towns, but most Turkana live outside of them, raising whatever livestock the minimal grass and water supply can support—often camels—and fending off raids from neighboring ethnic groups with whom they’ve been at war for decades.
Minding A Significant Gap Between Generations
Among the Turkana, some of the younger men are buying in, but circumcision is very rare in those over the age of 25.
Kate Macintyre set out to find out why. Macintyre, with Moses Natome, a young researcher from Turkana, put together a team of Turkana-speakers to conduct interviews and focus group discussions, asking community leaders to refer people to the study. They spoke with men who weren’t circumcised and men among the 5-10% of Turkana who are. They spoke with women about their opinion of circumcision in their male partners. And they spoke with people in a range of settings, rural, urban, and in-between.
HIV rates are high in this corner of Kenya; the trade route from Sudan and the one that brings fish from Lake Turkana into the desert may also be highways of HIV transmission. Geographically remote and socially isolated, Turkana are hard to reach with public health interventions. Poverty is rampant, and the area includes only a handful of hospitals and health centers. “They have been very isolated and apart from the social development of the country in the last 50 years,” says Macintyre.
Macintyre’s survey showed a range of opinion as to why older men might not want to get circumcised, and confirmed a major barrier: the fact that so many of the Turkana’s neighbors and enemies circumcise. Of Kenya’s 45 ethnic groups, the Turkana are one of just three that don’t practice circumcision as a traditional rite of passage. Natome sums up the consensus: “If you are an older, rural man, to get circumcised is to be ridiculous and to side with your enemies.”
In the interviews, many of the Turkana men explained that their culture’s ritual of Asapan holds the same significance that circumcision holds for the other groups. You can watch a video of Asapan here: it’s a ceremony that celebrates the social promotion of a man to senior elder status, and it is considered a great honor and privilege to go through it. One older uncircumcised man told Macintyre’s researchers: “On my side, God gave me ‘Asapan’ and circumcision to the other tribes as their culture.” Undergoing both, said several men, could cause a person to go mad from being caught between cultures.
But the Turkana may already be caught between cultures: urban and rural. Younger men who live in or near the big towns increasingly see circumcision as a social norm; to them, says Macintyre, forgoing the surgery is old-fashioned. While older rural men fear ridicule from circumcising, younger urban men fear it from not doing so. One described his friend persuading him: “Let’s go and circumcise. How can we continue like this and let other people ridicule us?”
Typical public health campaigns, like the one in Zimbabwe, aim to tie interventions to culture. But Macintyre warns that circumcision won’t take off in the remoter rural communities unless it’s presented as a purely medical intervention. It may not be traditional, but neither is the devastation of AIDS. A circumcised man described the shift:
We used to hear our parents say ‘it’s the Pokot, Samburu, Borana and Somali who circumcised.’ But somewhere between there emerged this “Lokwakel” (HIV/AIDS), which wiped out families leaving destitute children. We cried and we decided to circumcise because it was important for us to take care of ourselves and our families.
This is the message Macintyre thinks will get through: protecting your family by making a healthy choice.
“It’s an extremely sensitive topic at the moment,” says Macintyre, but not as much as it was even five years ago. She believes some leaders in the rural areas see circumcision as the way of the future, but few are ready to say so publicly. “There’s still considerable resistance in the remotest areas the study reached,” she says. “It depends on leadership, and who’s talking, and whose son has been away to Nairobi and told them about life outside, and whether they see HIV as a risk close at hand.”
The circumcision campaign’s success also depends, she says, on the quality and consistency of health services. Many of the area’s health centers have no running water; ensuring that they can safely perform the operation is possible, but logistically complicated. The better the services the first few men see, she says, the more confidence everybody will have and the more men she expects to come forward.
The Public Health Perspectives introductory post to this series, Part 1: How Male Circumcision Can Get Us Closer to an “AIDS-Free Generation”
Go here to find all the papers in Voluntary Medical Male Circumcision (VMMC) for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Services during an Accelerated Scale-up.