Read parts onetwothreefour, and five of Zeke Emanuel's Africa diaries.

Six boys sit on green plastic classroom chairs in gowns with their clothes neatly folded on a side table. Cloth booties cover their feet and lower leg. They smile nervously.

They are waiting to be called for a medical circumcision.

Eduardo says he is 16 years old, as is his friend sitting next to him. Why are they getting a circumcision? “For hygiene, and for HIV,” they tell us. And their classmates are getting one too.
This is the Military Hospital in Maputo, Mozambique. It serves civilians as well as soldiers and their families. Mozambique, which borders South Africa, Swaziland, Botswana and the other countries in the Southern Africa, is at the epicenter of the HIV/AIDS epidemic: Estimates suggest 2.4 million people, or 12.5 percent of its population, is living with HIV/AIDS. But the country’s epidemic is not uniform: It has hit the southern region more than the north.

Three separate randomized trials have shownthat male circumcision is among the most effective interventions against HIV/AIDS, reducing transmission by about 60 percent. This is a huge impact. As one AIDS researcher has said to me, if we had a vaccine that effective, we would be sparing no effort to distribute and administer it.

But widespread deployment of male circumcision has not yet occurred. In South Africa the rate of male circumcision is 35 percent. In Botswana, Zambia, and Swaziland, the rate is around 15 percent. While Angola and Madagascar have rates over 80 percent. These are largely unchanged since the research definitively proved circumcision’s potential preventive power.

The explanations for inaction are many. There is a shortage of trained manpower to conduct all the circumcisions. There are not enough facilities to perform all the necessary operations. The costs are too great. There are cultural barriers. Muslims in the north and west of Africa get circumcised at age 13. That’s probably one of the reasons the epidemic has not made significant inroads into places like Ethiopia, Senegal and Mali. In southern Africa, which is more Christian, men do not get circumcised and will not accept it the argument goes.

But the waiting room in Maputo Military Hospital gives the lie to all these excuses.

It is true that many countries in Africa have few physicians. In Mozambique there are just 1000 to 1200 total physicians for a population of 21 million people. But you don’t need a surgeon or general practitioner to perform male circumcisions. It is really a very simple procedure. In just two weeks—one of classroom study and one of supervised practice under a mentor-- a nurse or health officer is trained to perform male circumcision in Mozambique. And it may not even take anyone previously trained in a health field to do the simple procedure. The current complication rates (bleeding and infection) are below 1 percent at the Military Hospital.

In Mozambique, it is estimated that 800,000 to 1 million circumcisions of males from 15 to 44 are needed to alter the course of the epidemic. In Maputo, each trained nurse performs between 12 and 14 circumcisions per 8 hour day. Simple math shows that doing 10 per day, 4 days a week, requires just 400 trained personnel to conduct 800,000 circumcisions in 1 year. This is far from impossible.

Facilities? It would require just 400 surgical beds and they wouldn’t have to be in fully equipped surgical suites. As has been shown in Kenya and Swaziland, male circumcision can be done sterilely in mobile units or field tents.

Cost? At the Maputo Military Hospital, with renovation of the surgical suite, the total cost, including surgical beds, lights, sterilization facilities, surgical instruments, needles, syringes, sterile gowns and gloves, bandages, and salaries, is $75 per case. For all 800,000 circumcisions this amounts to $60 million. Today, in Mozambique, the United States government is contributing over $200 million per year to fight HIV/AIDS, and the Global Fund contributes tens of million more dollare. Just $60 million one time down payment with a few million more dolalrs each year is not prohibitive.

Cultural barriers? That men have not gotten circumcision does not mean they are against getting circumcision. Eduardo and his friend suggest cultural barriers are more imaginary than real. As part of a large health survey in Mozambique in 2003, well before circumcision was proven to prevent HIV, 60 percent of men reported they would get a circumcision. The Maputo Military Hospital has a waiting list of 300 people for the procedure, and recently expanded to Saturday surgeries to respond to demand. And this is without one bit of advertising or mass mobilization. It’s just word of mouth.

Four years delay in rolling out the most effective prevention strategy available is long enough. All of us working in HIV/AIDS must embrace circumcision with the same vigor as putting people on life-saving anti-retroviral treatment. Both interventions save lives.

***

This must be what the tuberculosis sanitariums of 19th Germany were like: Small buildings connected by covered walkways, on a hilly, quiet expanse of trees and gardens. But facility is on the northern fringes overlooking the hubbub of central Addis.

St. Peter’s is the country’s main TB hospital.  It is striving to be a center of excellence in TB, hoping to do research while hosting and training foreign medical personnel. It has twenty-two physicians—eleven of them fully qualified physicians, another eleven in training—plus nurses and other support personnel. It also has a lab, an x-ray machine, and an HIV/AIDS clinic dispensing anti-retrovirals. St. Peter’s has 250 beds right now. Forty-five are for in-patient multi-drug resistant TB patients and 150 are for regular TB patients.  The facility treats an additional 150 out-patients per day.

Walking through the resistant TB ward is depressing.  T.W. is a 13 year old double orphan (both parents have died) with a vacant look.  Like so many of the patients, she has had multiple side effects from TB medications, including nausea, vomiting, and depression.  Her room-mate, A. S. who is 18, has been re-admitted because she suffers from psychoses and could not cope outside the hospital.  The medication lists of the patients are often 20 or 30 entries long.

According to Dr. Yared Tedla, the medical director of St. Peters, the average cost of treating each resistant TB patient at St. Peter’s is at least $5,000. Of that, $3,000 is for an 18-month supply of the TB drugs. The other $2,000 is for room, food, lab tests, other medications for the hospital stays, which typically last 3 months.  The costs are higher for patients who are co-infected with HIV and need ARVs, not to mention those, like A.S., who need to be re-admitted for adverse effects or some reason.  For a regular TB patient the medication costs alone are $500 for the course of treatment.

This model seems neither scalable nor sustainable.  The WHO estimates Ethiopia has at least 500,000 regular TB patients and 5,000 people with resistant TB.  The doctors at St. Peter’s tell me they think the real number is even higher.  But even if the more conservative estimates are true, the cost for treating the entire TB population would be over $250 million per year.  You cannot spend 1/6 of a country’s health expenditures on 1/160th of the population, at least not if you are serious about addressing any of the country’s other health problems. And it seems unlikely the money will come from abroad, given the world’s limited enthusiasm for these sorts of investments and all of the other claims on global health money.

And money isn’t the only issue. Ethiopia has less than 2500 doctors. It would require the services of every single one to treat the entire TB population on the St Peter’s model. And many of the patients who leave the hospital never return to fully functional status. They frequently have no jobs—or, to use the language of the health system, no “income generating activity.”  They end up nutritionally deficient.  Others, like T.W. and A.S., end up returning because of side effects.  No one knows how many TB patients end up being cured and working again, how many drop out of main stream society, how many return requiring social services and on.

But we also cannot afford to ignore TB.  Unlike many other communicable diseases, TB travels. And resistant TB is a threat to the whole world. 

So what to do? TB is not my field of expertise. The WHO has suggested experimenting with new treatment models, like one from the Philippines in which people with resistant TB get outpatients care six times a week.  But the program wouldn’t lower costs that much because the drug costs alone are so high. And, in Ethiopia, where 85 percent of the population live in rural areas with both great distances and poor transport, getting someone to turn up at a health clinic or health post for medications 6 days a week for 18 months is completely unrealistic. 

The truth is, I don’t have the answer and, as far as I can tell, neither does anybody else. That is why my visit to St. Peter’s left me depressed.

Ezekiel J. Emanuel is special advisor for health policy to the Office of Management and Budget and the head of the bioethics department of the National Institutes of Health.