circumcision

Training Haitian physicians

Dr. Neil Pollock, second from the left, in Haiti. (photo from Neil Pollock)

Vancouver-based Dr. Neil Pollock has recently returned from a mission to Haiti, where he trained surgeons in newborn male circumcision to help fight against HIV.

Among other benefits, “circumcision reduces AIDs transmission by 60 percent and that would reduce a man’s risk of acquiring HIV. The reason is, the foreskin has receptor cells that selectively bind the HIV virus and promote its uptake into the body. So, by removing the foreskin, you remove the portal of entry for the virus,” explained Pollock, who specializes in circumcision and adult vasectomy.

Pollock was approached to lead the Haiti mission by Dr. Jeffrey Klausner, a medical doctor and professor of medicine at UCLA, specializing in infectious disease. Klausner volunteers with GHESKIO, a nongovernmental organization run out of the Centre for Global Health at Weill Cornell Medical College in partnership with the Haitian government.

In a phone interview with the Independent, Klausner said that, around 2007/08, “evidence became very clear that circumcision was a highly effective prevention intervention for HIV and the first priority was to get adolescents and young men circumcised. And, over time, we scaled up progress for newborns.”

After moving from South Africa to Los Angeles, Klausner started working in various countries. It was in Haiti in March 2012 that he connected with GHESKIO. He said it was one of the first NGOs to respond to the AIDs crisis in the early 1980s. Through GHESKIO, he was introduced to Haiti’s first lady, Sophia Martelly, in Washington, D.C., at the International AIDs Conference. Klausner said that, when talking to Martelly about the prospect of introducing newborn circumcision to Haiti, she said, “Absolutely, we’d love to do that, but we don’t have the resources, we don’t have the technical expertise, so we really need to rely on people like you to help us.”

Klausner returned to GHESKIO and worked to organize “a physical place, the proper clean procedure room … certain types of equipment and supplies and autoclaves, sterilized surgical equipment, and the tab was running into tens of thousands, about $50,000…. Once we had the supplies and materials, then the next step was to get the training, and I’m not a surgeon. I contacted the head of circumcision programs in Kenya, a guy named Robert Bailey.”

Bailey directed Klausner to Pollock. Klausner said he was “encouraged by [Pollock’s] enthusiasm and … set up a training program for May 2014.” (see jewishindependent.ca/vancouver-doctor-will-train-doctors-in-haiti-in-circumcision) However, the mission had to be postponed to November, as just days before they were set to depart, an “outbreak of chikungunya fever hit, which is a rare [virus] that causes fever, joint pain, and about one of 100 people can get lifelong arthritis.” In addition, “there was a fire in a supply room and we lost some of the tables we had bought and one of the autoclaves,” and “a box of supplies went missing.”

Despite these and other challenges in organizing and executing the mission, such as difficulties in communication due to power outages and poor internet connections, Klausner said, “I have been doing international work, research and programs for 25 years now and [obstacles are] par for the course. This actually went smoother than many other projects [in which] I have been involved.”

For the Haiti mission, said Klausner, “We had to make sure there were at least 200 parents and babies that were already pre-examined, pre-consented, pre-educated and prepared” because for “a training program like this to be successful you really need to do between 50 to 100 [surgeries] a day in a short period with a lot of cases to make sure the people you are training learn, and learn effectively so they can go on and do this independently and confidently.”

Pollock said he had “arranged to train two surgeons, in case one of them did not have the aptitude to succeed – in the end, one did not, and it was difficult of course to tell him that, but it was clear that it would not be safe to pass him and enable him to operate on patients.”

With the use of the technique he taught in Haiti, said Pollock, recovery time will be reduced compared to current Haitian practices “because there is so little trauma caused during surgery.”

Klausner offered three measures for the mission’s success. “One is the actual conduct of safe, well-done circumcision on the babies that Dr. Pollock and his colleague Pierre Crouse did. That’s an achievement in itself: they did over 100 infants in two and a half days. The second part is that the surgeon and the teams that were trained, they continue to do it themselves, so they have done an additional 100 since we left. And then the third piece is that we have trained the trainers, and now other teams are being trained” to perform the surgery.

Klausner’s and Pollock’s efforts in combating HIV and AIDs received notice from some high-profile celebrities. “I was quite surprised to get a text from Sean Penn on the day after we landed in Port-au-Prince that he wanted to come down and meet and observe what myself and my team were doing and discuss synergies between our global interests in promoting health care,” said Pollock. Penn was joined by Charlize Theron, “who was also interested in discussing collaborative efforts in association with her foundation helping improve health care for the people in her native country of South Africa.”

Klausner said, “I have been working in eastern South Africa, KwaZulu-Natal province … with the public health leaders there to introduce a similar effort where we would train surgeons, create a permanent resource, such as a training program, to expand the number of trained doctors or medical officers in newborn circumcision.” In that province, he said, “40 percent of people have HIV infection” and “75 percent of women aged 30 have HIV. So, right now, that part of South Africa … is in a complete, out of control, HIV epidemic. I helped introduce adult circumcision there, but I think, to have greater impact in the long term, we need to introduce newborn circumcision.”

He added, “I believe Dr. Pollock had a very positive experience [in Haiti] and I suspect he is optimistic about the possibility to go and do it again elsewhere.”

Zach Sagorin is a Vancouver freelance writer.

Circumcision evolution

The “scientizination” of brit milah, circumcision, has had several implications, according to Dr. David Koffman, assistant professor, department of history, York University.

photo - Dr. David Koffman — Dr. David Koffman (photo by Rebeca Kuropatwa)

Koffman spoke at the University of Manitoba on Sept 19, hosted by the university’s Hillel Winnipeg. He centred his talk around the influence of the interdenominational New York Board of Rabbis, which was founded in 1914 to train and certify mohels. The board centralized, coordinated, promoted and professionalized Jewish circumcisions in New York state throughout the 20th century, he explained. They trained mohels in the newest surgical techniques, methods of asepsis and hygiene, newly developed clamps and devices, provided malpractice insurance and acted as a guild/gatekeeper for Jews entering the profession. By the mid-1960s, the board opened a school to train mohels.

“Its job was to control the narrative, to keep it Jewish in the face of changing norms in America,” said Koffman. “By the 1940s, the popularity of circumcision, long seen as Jewish barbarism, began to skyrocket among gentile parents for their newborn sons.”

Circumcision changed from being mainly a religious rite to a surgical procedure in the 20th century.

“Secular medicine’s enthusiasm for circumcision put Jewish medical men along with many other Jews in a bind,” said Koffman. “On one hand, the growth of endorsing opinion by experts about circumcision from a variety of medical subfields offered the most gratifying validation mohels and clergymen could ever hope for. Urologists, surgeons, gynecologists, even psychiatrists, indicated the right vilified by Christians in America no less than elsewhere before the 20th century. Mohels eagerly then sought medical training and certification and proudly fused religious rhetoric about brit milah with newfound medical rhetoric on health advantages.

“On the other hand, medicine’s capture of circumcision and its popularity among non-Jews presented an entirely new set of problems for religious Jewish leaders of the non-Muslim world. The penis, concealed in public, but revealed when naked in private, remained a key sign of Jewish difference where it mattered the most, to make more Jewish babies. Perhaps more threatening than the erosion of the boundary between Jews and gentiles was that science itself might strip the fundamental religious meanings….”

With respect to Christianity, Koffman explained, “During the Second Great Awakening, Christians turned to circumcision as the foil to the conversion experience. The reborn, or born again, were circumcised by accepting Christ … they were as un-Jewish as they could get. This was a metaphor of circumcision.

“Keep in mind that Jan. 1st in the Catholic calendar was the Feast of Circumcision, eight days after Jesus’ Dec. 25th birth.” This is a practice that no longer exists, however, as it was removed by the Church in 1960 and renamed the Solemnity of Mary, he added.

“There was a striking discord between Jesus and his followers that Jesus himself was circumcised,” he pointed out. “Most questions had little to do with the Jews…. Where, for example, did Jesus’ foreskin go? Was he reunited with it during the rapture?”

Turning to the science, Koffman said, “By the 1920s, circumcision was becoming the mark of high social standing for many, for it indicated that a mother had the ability and means to deliver her baby in a hospital by an attending physician.”

In the first two decades of the 20th century, civic planners argued that universal circumcision would help restrict the spread of tuberculosis, syphilis and other venereal diseases. Before this development, said Koffman, circumcision was, for Jews, at its core, “a sign of the holy covenant between God and Israel, as prescribed to Abraham in Genesis 10 … and [of] God’s promise to Abraham’s descendants.

“In essence, mohels ‘scientized’ milah but, in doing so, they invited new predicaments for the Jewish body. Embracing medicine achieved many short-term gains. It accrued medical status for mohels, insisting that they were on par with physicians.

“Perhaps most importantly, embracing the science of circumcision [made it possible] for American Jews to make a broad public reckoning of their historic contributions to medicine and science.

“The transformation of circumcision from ritual once exclusive to Semites to a medical procedure available to all also posed a threat to American Judaism because medicine for all its power hollowed milah of its mysteriously potent spiritual power. For the first time in Jewish history, there was a very real possibility of huge numbers of illegitimate milah, circumcisions performed on boys by someone other than a mohel, or at the wrong time, or in the wrong manner. The Jewish penis would grow to be indistinguishable from its non-Jewish counterparts. All this helps explain why the board worked so hard to represent mohels at hospitals, aiming to control its narrative.”

The board conducted research in the 1930s and 1940s about hospital-regulated circumcision, which required that mohels be certified. It encouraged public and private hospitals to make circumcisions available and encouraged hospitals to provide space to perform the rite, as well as educational materials to obstetrics and gynecology professionals about the benefits of circumcision.

“Jewish parents were increasingly having their sons circumcised in hospitals, paid for by insurance companies, instead of at home or at synagogue,” said Koffman.

“By the 1960s, religious justifications began to give way to the anxieties about the infant’s pain,” said Koffman. “Mohels, wearing their medical hats, assumed it a given or perhaps an integral part of circumcision.” One manual produced in the 1950s, entitled Welcome Home Mother and Son, included no fewer than eight references to pain and anxiety.

The board also supplied a steady stream of support materials to agencies, synagogues and rabbinical associations interested in promoting circumcisions in other states and countries. By the mid-1960s, the board positioned itself not just as a regulator of New York State, but as the custodian of the practice and an advocate of circumcision.

“Milah literature doubled down on the medical benefits, but also emphasized the theological benefits,” said Koffman.

“The great scholar Elliot Wolfson called Jewish circumcision ‘the cut that binds,’” said Koffman. “It’s a severance that connects Jewish boys to their fathers and grandfathers, to Jews across time and borders.”

Rebeca Kuropatwa is a Winnipeg freelance writer.

Vancouver doctor will train physicians in Haiti in circumcision

Dr. Neil Pollock instructs a team of surgeons in Rwanda on carrying out his technique of circumcision. (photo from Dr. Neil Pollock)

Dr. Neil Pollock specializes in circumcision, from newborn to adult, and adult vasectomy. As a leading expert in circumcision, he has traveled around the world to train physicians and, this summer, he will head to Port-au-Prince, Haiti, to teach a team of doctors in medical newborn and infant circumcision.

“After carrying out 50,000 infant circumcisions and traveling recently to Turkey, China and Africa to exchange ideas, I have evolved my technique to make it applicable to infants, children, teenagers and adults,” Pollock told the Independent in a recent interview. “I have developed a technique to do circumcision in this older age group under local anesthetic without using sutures and using, instead, a cyanocrylate skin glue that closes the wound. Being able to do the procedure under local anesthetic and with skin glue instead of a general anesthetic in hospital provides for a much simpler, easier, quicker, safer and improved cosmetic outcome for patients.”

This method, he said, is unique. “I’m unaware of this approach being used anywhere in [Canada] except in my clinics. The older age group is currently requesting circumcision for reasons like reduction in disease transmission, preference of their partners and improved hygiene.”

In 2008, Dr. David Patrick was the head of the B.C. Centre for Disease Control. Pollock said he was asked by his colleague “to teach my surgical techniques for circumcision in Rwanda, where they were using scissors and stitches, without anesthetic, and their surgeons desperately required training in an alternative quick, safe and painless infant circumcision technique that would be accepted by their population. In coordination with their surgeons, I planned with my team a five-day surgical training mission that year and flew to Rwanda. I have been in contact with these surgeons by email since my trip and they have informed me that they are using my technique effectively and safely throughout the country now.

“The impact of our humanitarian effort became known in the international medical community, which led to Dr. Jeffrey Klausner, professor at [the University of California, Los Angeles] Medical School, contacting me recently and asking me to essentially replicate the work I did in Rwanda, but this time in Port-au-Prince, Haiti, where they are being overwhelmed by the number of patients requiring treatment for AIDS and would receive huge benefit from introducing a preventative strategy to reduce AIDS transmission, such as infant circumcision, which will reduce the risk of their circumcised infants later contracting AIDS when they hit sexual age, by over 60 percent. Its impact and effectiveness has been referenced metaphorically to be like a vaccine.” Circumcision, he added, “works to reduce AIDS by removing the portal of entry of the virus, which is the foreskin.”

Klausner, a professor of medicine in the division of infectious diseases and the program in global health at UCLA, is an advocate in the use of medical male circumcision for the prevention of sexually transmitted diseases and HIV. He volunteers with GHESKIO, an organization run out of the Centre for Global Health at Weill Cornell Medical College in partnership with the Haitian government. Operating primarily in Port-au-Prince, their work is supported by Haiti’s first lady and has a mission to combat HIV and improve conditions of maternal and child health. GHESKIO will host Pollock’s training in Port-au-Prince.

Raised in Winnipeg, Pollock explained that he decided to become a doctor “because I had a strong interest in sciences, medicine and surgery from a young age.” Early in his career, he decided to create a special focus on circumcision and vasectomy, and built a highly focused practice and a well-tested – and respected – technique.

“My interest in developing a safe, quick and painless approach to circumcision for the medical community in B.C. arose initially from some of the rabbis approaching me approximately 20 years ago and encouraging me to become a mohel in Vancouver,” Pollock said.

The benefits of newborn and infant circumcision are many, but the rates of the procedure vary from region to region, and remain contentious to those opposed to what’s seen as elective (non-consenting) surgeries for babies.

Pollock noted, “The most important change recently in how the medical community has come to view circumcision is expressed in the … consensus statement from the American Academy of Pediatrics released in late 2012 declaring that ‘the medical benefits of infant circumcision outweigh the risks.’ This is the strongest statement of support ever issued by the American Academy of Pediatrics.

photo - Neil Pollock in Rwanda with a happy patient. — Dr. Neil Pollock in Rwanda with an infant post-circumcision. *(photo from Dr. Neil Pollock)*

“The benefits of circumcision are multiple; they include reduction in the risk of urinary tract infection, which can lead to kidney infection and renal failure, reduced risk of cancer of the penis, cancer of the cervix in partners, reduced risk of balanitis (which is infection of the foreskin), and other foreskin-related problems, like phimosis.” As well, circumcised males also experience a “reduction of multiple sexually transmitted diseases, like HPV, herpes and AIDS transmission. The latter is exponentially more important in places like Haiti and Africa, where a large number of the population has AIDS in comparison to other regions of the world where AIDS is less common.” Possible risks include “bleeding and infection,” he added, “but, in experienced hands, risks are extremely low.”

Rwanda and Haiti share a history of national trauma, which has led in both countries to poor health outcomes. In 1994, at least 800,000 Rwandans were massacred by their countrymen in a genocide. In 2010, Haiti, already the victim of more than two centuries of extreme poverty, dictatorships and U.S.-led military interventions, experienced a 7.0 earthquake that resulted in the deaths of more than 100,000, and displaced 1.5 million of the tiny country’s 10 million people. Since then, Haitians have been hit by serious outbreaks of preventable disease, including cholera, tuberculosis and AIDS. According to the United Nations, life expectancy is 61 years for men and 64 for women.

The health challenges that Haitians are very similar to those experienced in Africa, and the training is seen as critical in addressing those obstacles. “Like there was in Rwanda, there is a need to train surgeons in Haiti to carry out a quick, safe and painless infant circumcision technique,” Pollock explained. “In regards to what accounts to gaps in circumcision rates, there may be a deficiency in trained surgeons to carry out the surgery in an acceptable manner, along with variations in social and cultural norms that influence the choice to have circumcision.”

The ultimate intention of the training, Pollock said, is “to set up a national program accepted by the population, to introduce infant circumcision safely and effectively, and have it evolve to become a widespread practice throughout the country, thereby reducing the transmission of multiple diseases, including AIDS.”

Pollock’s visit to Haiti will involve intensive training. “My goal is to carry out a similar plan to what we executed in Rwanda. I worked with physicians there weeks ahead to set up a surgical schedule of 20-to-30 infants per day, over four-to-five days of operating. After working with doctors on models that I brought to demonstrate the technique and do the primary teaching, they moved to assist me with the surgeries and eventually carry them out under my supervision on the infants booked for circumcision.”

The training in Haiti, part of a nongovernmental public health initiative, will be partially supported by charitable donations. “The commitment from my end for Haiti will include a week away from my practice and the commitment to help raise the $25,000 for the mission to take place. The plan is to raise $25,000 from the Vancouver community in the next seven days or so as to be able to launch the teaching mission in Haiti by the end of the summer. During the week in Haiti, I will train two physicians, who will then train other physicians once our team leaves. I will maintain follow-up with these physicians to help them manage any issues that should arise.” The goal is to create a sustainable public health campaign and donated funds not only will go towards covering the costs for the week, but also for “the next 500 infants once we leave.”

Readers who would like to donate to the effort “will support an initiative, which will undoubtedly over the years save thousands and thousands of lives,” Pollock said. “It’s intended that Haiti will become a training centre for circumcision in the Caribbean. It is likely that my technique, once taught in Haiti, will soon be shared with multiple countries throughout the Caribbean, multiplying its effect to save lives throughout the entire region. So, I’m asking readers and members of the community to reach deep and consider making a financial donation to help us raise $25,000 in the next [several] days to allow this mission to proceed.”

To make a donation, contact Dr. Neil Pollock at 604-644-5775 or [email protected]. “We will make it very easy for people to donate, and make arrangements for their cheques (made payable to the Vancouver Foundation) to be picked up by our team,” he said. Donations can also be mailed to 4943 Connaught Dr., Vancouver, B.C., V6M 3E8.