For an effective medical campaign, first study the target community

Even a cursory glance at the data from the  National Aids Control Council clearly shows that the four counties that make up Luo Nyanza account for nearly half of Kenya’s HIV burden.

In 2014, the council estimated that 25.7 per cent of the people in Homa Bay were HIV positive. And the figures for the other three counties —  Kisumu (19.3), Siaya (23.7) and Migori (14.7) — were not encouraging either, compared with the national average of 6.4 per cent.

While these figures had come down since 2007, these counties remain among those with the highest prevalence rates.

In 2008, there was a ray of hope when the Ministry of Health, borrowing from a 2006 World Health Organisation (WHO) research showing that circumcision could reduce the rate at which men acquired the virus by 60 per cent, decided to launch  a voluntary medical male circumcision (VMMC) campaign  in the areas hard-hit  by aids in Nyanza.

In March this year, eight years after the exercise was rolled out, DN2 sought to know how much of an impact voluntary medical male (VMMC) circumcision had made.

The first stop was Homa Bay Town. For a disease that is not spread through coughing or a handshake, it was hard trying to grasp that one in every four people in the little group standing at a bus stop could be HIV-positive.

One might have thought that with the high incidence of HIV/Aids in the region, men would be keen to embrace any intervention, including VMMC, as long as it offered any hope of slowing down the infection rates.

But initially, they did not, to the dismay of those carrying out the campaign. Politicians, religious leaders and the Luo Council of Elders vehemently opposed the campaign, saying it went against the local culture.

Healthcare workers still recall how they were chased away from some villages when they attempted to pitch camp there to offer the services.

It was only after a consultative meeting in Kisumu that brought together more than 200 people including the clergy, politicians and the elders, where Mr Raila Odinga endorsed the cut saying it was a personal choice, that the campaign began -to be accepted.

A LOT HAS CHANGED

But a lot has changed since then. Widespread acceptance of the intervention has seen its opponents dwindle, such that most of them would speak to DN2 only on condition of anonymity.

The people’s opposition to this relatively cheap solution to the aids menace can be a little difficult for an outsider to understand.

Relying on statistical facts

They might wonder whether those opposed to the cut ever consider the additional cost of looking after HIV patients in a healthcare system that is already strained, not to mention  the children orphaned by Aids and the drain on the economy as able-bodied men succumb to the virus.

And therein lay the problem. While launching the project, the initiators of the campaign relied on hard, statistical facts but ignored the cultural and economic issues in the region.

As at 2014, the Global Aids Progress Report from national programmes prepared by UNAids and the World Health Organisation (WHO) showed that Kenya had surpassed the 80 per cent (860,000) target, having circumcised 108 per cent of the number initially targeted.

While the jury is still out on whether these numbers point to the success of VMMC in Nyanza — whether it has reduced the number of infections — it was an undertaking that made many researchers ask why seemingly well-planned and adequately-resourced public health projects fail.

There are several factors one might wish to consider.

TIMING

Launching the VMMC campaign right after a hotly contested presidential election that had led  to bloodshed was not wise. But what do elections have to do with a medical procedure sponsored by donors? one might ask.

In Kenya, male circumcision is usually performed in cultural settings, and is a rite of passage to adulthood in nearly all Bantu communities.

The Luo Council of Elders initially rejected circumcision saying it was not part of the culture of the community, which has been perhaps the most vocal members of the Opposition in post-independent Kenya.

And notably, Luo men have been ridiculed in  the political arena as well as in social circles for not being men enough from as far the 1960s,  in the days of Jaramogi Oginga Odinga.

Mr Samuel Ogada Ogira, the council’s treasurer, told DN2: “That we do not circumcise does not mean that our culture is inferior.”

The issue of circumcision has been a component of the tribal animosity between the Kikuyu, whose presidential candidate had won the elections, and the Luo, whose political supremo, Raila Odinga, lost the 2007 election.

HARDLY SURPRISING

So it was hardly surprising that many Luo men felt there was more to the campaign than met the eye. 

Mr Dennis Mboya, the technical adviser at Family Aids Care and Education Services (Faces), who was part of the team that the government had constituted for the campaign, clearly recalls the kind of sentiments they encountered when the programme was launched in early  2008.

 “One of the reasons for the opposition that we encountered in the field was that the men questioned how ‘convenient’ the timing of the rolling  out of the cut was,” he says, adding: “We heard statements like ‘They used NGOs to rob us of the presidency and now they have brought them again to finish us.’”

Arguing from this narrow perspective, the opinion leaders drawn from elders, religious leaders and other members of the community opposed to the exercise gave the men a reason to reject the intervention.

The chair of the Luo Council of Elders, Mr Nyandiko Ongadi, told DN2: “That we are not circumcised has always been used against us to make us feel we are not worthy of a chance at national leadership so when they introduced the cut, we felt our pride in being unique as Luos was being taken away from us.”

Approach

But Prof Agot Kawango, the lead researcher of the WHO-supervised study that had formed the decision to roll out circumcision as a prevention package, disagrees with this line of reasoning.

In 2003, three years before the 2006 randomised trial, she had conducted a study on the Nomiya Church, the only Luos who practice male circumcision, and the results were illuminating.

MUCH LOWER PREVALENCE

“The prevalence of HIV among the Nomiya people was much lower compared with the whole Luo community”, she told DN2 at her office in Kisumu.

Besides, Nyanza is surrounded by communities that practice male circumcision, whose prevalence rates were as low as 3 per cent.

These findings, and the randomised trial, are what Prof Kawango and her team would rely on to convince the men targeted by the campaign.

But even this approach was flawed.  In her book, Letting Them Die: Why HIV/Aids Prevention Programmes Fail, social psychologist Prof Catherine Campbell of the London School of Economics notes that researchers operate on a model of giving people facts and waiting for them to embrace it.

However, she notes, this is based on a model only successful in predicting how people behave in controlled academic research studies, and not in a community where HIV exists as a mixture of biomedical, behavioural and social factors.

A better approach, medical anthropologist Dr Salome Bukachi of the University of Nairobi says, is to know and understand the community before rolling out any public health campaign. For instance, she says, the researchers and healthcare workers needed to know a few things about the local community: the level of education of the people targeted by the campaign, the power relations, and the socio-economic settings in which they operated.

Indeed, a detailed study of the Luo was carried out, but it is not clear whether it was done after the researchers encountered opposition in the field since each of the eight technical people DN2 spoke to offered a different explanation. Some said they deliberately set out to learn about the Luo from the first day, while others said it was an afterthought, when they realised that the men were opposed to the cut.

Knowledge such as Prof Kawango’s needed to be understood as part of a puzzle, where new bits of information add to that of studies  that had been done earlier.  “There is a danger in information being all new to extinguish what has already been learnt because that gaping chasm in an illiterate lot is  perfect ground for propaganda that will later hurt the community,” Prof Campbell warns in her book.

For instance, Oguta (he gave only one name), 34, in Kanyada in Ndhiwa Constituency in Homa Bay County, did  not undergo the cut.

He told DN2 that he heard about the medical procedure on radio, and then from community mobilisers, and that all that he learnt left him confused.

MYTHS AND STIGMA

Oguta says that he believed that if a circumcised man bathed in their land, it would cause the “skies to close up and deny them of rain.”

“But here weredoctors  telling us that it would protect us from the bad disease,” he offered.

Then there are myths and stigma  the community attaches to the foreskin and morality.

For instance, Elizaphan Ager Kirowo, an elder from Homa Bay, told DN2 that only people who engage in  irresponsible sex needed such interventions, adding that circumcision greatly reduces a man’s sexual prowess.

Of this distancing themselves from the intervention, Dr Bukachi says: “The people targeted by the intervention should own the project so that there is a social environment from which they can derive maximum benefits from it.”

Meanwhile, Maurice Odhiambo*, a teacher from Nyatike  opposed to the cut because he believes it perpetuates immorality, said he resented the way the healthcare workers approached him when they wanted to sell the idea of VMMC to him.

“I felt as if they were telling me I was stupid and they were bright, yet I have survived here without the virus and I have not undergone cut”, he said.

There will probably never be a consensus regarding how the campaign should have been conducted, but there are a several lessons that the Ministry of Health and the healthcare fraternity can learn from the challenges encountered during the VMMC campaign.

*Not his real name

***

Funding: a sore point in many projects

The voluntary medical male circumcision campaign was funded by  the President’s Emergency Plan for Aids Relief (Pepfar) — the largest healthcare programme from a single country — and the Centres for Disease Control, among others.

Between 2009 and 2013, external funding accounted for over 70 per cent of the government’s expenditure on HIV.

The government contributed 17 per cent, with private and household spending making up the remaining 13 per cent. However, none of this money was spent on VMMC.

During a training session on VMMC organised by the International Centre for Journalists and the Bill & Melinda Gates Foundation in Nairobi early this year, Prof Kawango said that, while external funding might have saved the government money, it needed to do more in order for the project to be sustainable, given that donors sometimes pull out of such projects.

There were also other issues regarding the funding.

“When the people heard that the money was from America, they associated it with [President Barack] Obama and then started asking for it,” Mr Mboya of Faces told DN2.

He added that initially, the budget for each patient was $75 (Sh7,575), but this  was later reduced to $60 (Sh6,060). This brought discontent among healthcare workers.

“Other government-funded health programmes such as maternal care are poorly funded, and then here comes a project with a well-ventilated, well-equipped room, with the medics working on it well remunerated,” Mr Mboya explained their grievance. 

Most donor-funded programmes have this us-versus-them antagonism, with the local staff usually feeling that their benefits from programmes are merely tokens.

Then there was the competition among the organisations that were carrying out the exercise to meet the targets set by the donors, leading to duplication.

Prevalence rates (2014 - %)

National average  6.4

Homa Bay 25.7

Siaya 23.7

Kisumu 19.3

Migori 14.7