Doubt, defiance, and identity: Understanding resistance to male circumcision for HIV prevention in Malawi

Abstract

Global policy recommendations to scale up of male circumcision (MC) for HIV prevention tend to frame the procedure as a simple and efficacious public health intervention. However, there has been variable uptake of MC in countries with significant HIV epidemics. Kenya, for example, has embraced MC and has been dubbed a 'leader' by the global health community, while Malawi has been branded a 'laggard' in its slow adoption of a national programme, with a strong political discourse of resistance forming around MC. Regardless of any epidemiological or technical evidence, the uptake of international recommendations will be shaped by how a policy, and the specific artefacts that constitute that policy, intersect with local concerns. MC holds particular significance within many ethnic and religious groups, serving as an important rite of passage, but also designating otherness or enabling the identification of the social and political self. Understanding how the artefact of MC intersects with local social, economic, and political contexts, is therefore essential to understand the acceptance or resistance of global policy recommendations. In this paper we present an in-depth analysis of Malawi's political resistance to MC, finding that ethnic and religious divisions dominating recent political movements aligned well with differing circumcision practices. Political resistance was further found to manifest through two key narratives: a 'narrative of defiance' around the need to resist donor manipulation, and a 'narrative of doubt' which seized on a piece of epidemiological evidence to refute global claims of efficacy. Further, we found that discussions over MC served as an additional arena through which ethnic identities and claims to power could themselves be negotiated, and therefore used to support claims of political legitimacy.

Appeals to evidence for the resolution of wicked problems: the origins and mechanisms of evidentiary bias

“…a reduction in risk of 10 % does not equate to a 90 % chance of something occurring, yet it might be interpreted as such. One example of this was recently illustrated by Parkhurst et al (2015) in a study looking at the use of evidence within the political debate over male circumcision for HIV prevention in Malawi. While clinical trials had measured a reduced (relative) risk of HIV infection in circumcised men of around 60 % (Mills et al 2008), a local politician rejected this on the (inaccurate) grounds that there was still a 40 % (absolute) chance of infection in circumcised men.…”

Voluntary medical male circumcision for HIV prevention in fishing communities in Uganda: the influence of local beliefs and practice

“…A number of studies have compared uptake of VMMC in societies with and without a tradition of male circumcision (Katisi & Daniel, 2015;Ngalande, Levy, Kapondo, & Bailey, 2006; Rennie, Perry, Corneli, Chilungo, & Umar, 2015; Weiss, Quigley, & Hayes, 2000;Westercamp & Bailey, 2007;Wilcken, Keil, & Dick, 2010). These studies show that the introduction of VMMC in societies where male circumcision is not part of religious or cultural practice has not been without challenges because of the association of the act with ethnic and religious identities (Ahlberg & Njoroge, 2013;Parkhurst, Chilongozi, & Hutchinson, 2015). In Zimbabwe, where the majority of ethnic groups do not practice circumcision, Hatzold and colleagues and Moyo and colleagues (Hatzold et al, 2014;Moyo, Mhloyi, Chevo, & Rusinga, 2015) describe the social and cultural barriers to introducing VMMC.…”

Breaking out of silos – the need for critical paradigm reflection in HIV prevention

“…The biomedical response to HIV has also been criticised for a 'political myopia' that fails to engage with the social and political meanings embedded within HIV interventions (such as male circumcision) (Parkhurst, Chilongozi, and Hutchinson 2015) and that abstracts from the structural inequalities that condition access to treatment and prevention. As Nguyen et al (2011) explain: in the rush to paradigm shift, gamechange, rollout and scale-up [ .…”