Where's the money: The role of the KZN Government
The Tara Klamp is unsafe, more expensive, and only marginally faster to use than standard methods of circumcision. Also, standard surgical techniques work very well in mass circumcision programmes. For example, a Zimbabwean programme, with a team of two doctors and three nurses, has been optimised to do ten surgical circumcisions an hour.1 Why then did the Kwazulu-Natal (KZN) health department start using the clamp?
On 12 July 2010 the Treatment Action Campaign (TAC) sent a letter outlining our concerns to KZN MEC for Health Sibongiseni Dhlomo. His reply was astonishing, "What we have explained to the Minister and now indirectly to you is that we are committed to massive Medical Male Circumcision in KZN as directed by His Majesty our King. We will do it medically as the Majesty instructed us. The king has instructed us that no one should die as a result of our MMC intervention but he did not instruct us that no one should have pain." This is the only response we have had from Dhlomo. Various attempts to meet with him and Premier Mkhize to discuss the Tara KLamp have so far failed to materialise.
On 3 August we asked the department for details on the contracts relating to the purchase of the Tara KLamp. We did not receive a reply. On 3 September the Mail & Guardian ran an article titled "Tender details get the klamp".2 It outlined how they too failed to obtain financial details on the purchase of the clamp.
In October, in reply to questions asked in Parliament, the national Minister of Health wrote that the KZN government had purchased 22,500 Tara KLamps from Intratrek as of 30 September at a total of R4.4 million excluding VAT.3 KZN paid R188 (ex. VAT) per device for the first 2,500 but then started paying R195, much higher than the Carpe Diem price of R160. A KZN official explained in a telephone conversation with TAC that the province did not need to call for a tender for the clamp because there was only a single supplier. This is confirmed in the national Minister of Health's Parliamentary answer. Either Carpe Diem has been abandoned by the Malaysian manufacturer or the claim of a single-supplier is false. Even if Intratrek is the only supplier, a motivation for the purchase must still be made public.
As part of the circumcision drive in KZN, the province has held several circumcision camps, where young men gather at a hospital venue and are circumcised. Most of these camps have used forceps-guided circumcision, but the Tara KLamp is also being used.4 Apparently to compensate for the increased pain caused by the clamp, health workers in at least one of these camps were instructed to administer a higher dose of a strong pain killer, bupivacaine. Although this would relieve the worst pain experienced from the clamp, which usually occurs in the first 24 hours, it adds to the cost. The health workers were also instructed to prescribe antibiotics to offset the device's risk of infection. The KZN government intends to do millions of circumcisions over the next few years. If it gives antibiotics routinely to men circumcised with the clamp it will risk creating antibi otic resistance for no good reason.
Following a letter from TAC to Health Minister Aaron Motsoaledi describing our problems with the device, Motsoaledi met with TAC and the Southern African HIV Clinicians Society. In response to our concerns, he established the Medical Male Circumcision Steering Committee.
As a compromise, the committee, which includes people from the WHO, HIV Clinicians Society, KZN and national government, is trying to do a rapid assessment of the clinical outcomes of patients who were circumcised with the clamp in KZN. But this should have been a secondary objective; stopping the use of the device should have been the first priority. Even so, the committee, which has met a few times, has missed its deadlines for conducting the assessment. Furthermore, we have learned that the record keeping of the Tara KLamp circumcisions conducted in KZN over the last few months has been poor so it is unlikely that the rapid assessment can be done properly.
Sandile Tshabalala of the KZN Health Department was quoted by SAPA claiming that "More than 5000 people have been circumcised by this clamp and not even a single person has died. ... No-one has complained that his penis has been cut."5
Meanwhile, TAC has received reports, including cell phone video clips, of people injured by the Tara KLamp. We also have a first-hand account of the immense pain a man experienced. We release photos of Tara KLamp caused injuries in KZN over the last few months. Please note these are very disturbing (see here and here).
It has also been reported that the KZN Health MEC has committed to rolling out the Tara KLamp in prisons and that 148 such circumcisions have already been carried out in Qalakabusha Prison.6 But the reasoning behind this decision is difficult to understand. Medical male circumcision has been shown to reduce the risk of HIV-positive women transmitting the virus to men. No prevention benefit has been shown in populations of men who have sex with men.
This is a terrible situation. Companies selling the Tara KLamp are making money by inflicting injuries and suffering. The KZN government's adoption of the clamp is, in the best case scenario, deeply suspicious and unscientific.7
To be continued...
1 Hatzold K et al. 2010. Models to increase volumes and efficiency (MOVE) in Zimbabwe's male circumcision program. XVIII International AIDS Conference. http://pag.aids2010.org/Abstracts.aspx?SID=433&AID=11622
2 Faull L. 2010. Tender details get the KLamp. http://www.mg.co.za/article/2010-09-03-tender-details-get-the-klamp
3 National Assembly. Question No. 2523. http://www.tac.org.za/userfiles/QuestionsAndAnswersInParliamentAboutTaraKLamp20100913.doc See also National Assembly. Question No. 2461.
4 We have learned that approximately 7,000 forceps-guided circumcisions have been carried out since the programme was launched. The KZN Health Department released a statement claiming that a total of 10,229 circumcisions have been conducted since April 2010 and the target for 2010/11 is 372,754. http://www.info.gov.za/speech/DynamicAction?pageid=461&sid=13648&tid=22281
6 SAPA. 29 October 2010. KZN government to circumcise prisoners. http://www.timeslive.co.za/local/article733337.ece/KZN-government-to-circumcise-prisoners
7 In a statement published On 14 October a group of over 20 civil society organisations, including MSF, the World AIDS Campaign, Black Sash, SECTION27 and TAC demanded that the Deputy President and the Minister of Health intervene with utmost urgency to halt the use (and purchase) of the Tara KLamp until a Voluntary Medical Male Circumcision policy based on sound medically proven procedures can be adopted nationally. See here.
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