Amazon Warfare

How an anti-circumcision fringe group waged an ideological attack against AIDS scholarship. page for 'Tinderbox: How the West Sparked the AIDS Epidemic and How the World Can Finally Overcome It.''
The page for Craig Timberg and Daniel Halperin’s book, Tinderbox

In March of this year, Penguin Press published Tinderbox: How the West Sparked the AIDS Epidemic and How the World Can Finally Overcome It, by Washington Post journalist Craig Timberg and University of North Carolina epidemiologist and medical anthropologist Daniel Halperin.

Tinderbox explores the role of the West in igniting and helping to spread the HIV epidemic. From HIV’s emergence in central Africa and its later transplantation to Haiti, Western colonialism helped create the conditions and policies in which the lethal virus was able to spread across the world, taking tens of millions of lives with it. During the “Scramble for Africa” near the turn of the 20th century, commercial adventurers blazed new routes through the jungle in search of rubber and riches, sending African porters into remote regions rarely traveled before. It was here, during the age of European conquest, that humans first contracted the strain of HIV that would eventually cause 99 percent of AIDS deaths around the world.

Subsequent Western donor policies further cemented the epidemic’s grip on countries where the disease spread fastest. For example, George W. Bush created the President’s Emergency Plan for AIDS Relief (PEPFAR), which greatly expanded access to AIDS treatment, but at the same time his administration insisted on abstinence as a major method of HIV prevention instead of more realistic measures.

One of the preventive measures discussed in the book, male circumcision, has become an unexpected source of controversy. Anti-circumcision activists have hijacked’s “peer review” comments section, which allows readers to vote on which book reviews are helpful. This system has morphed into a vicious game of character assassination by conspiracy theorists who reject decades’ worth of scientific evidence, showing how easy it is for a concerted crusade to squelch good science.

The evidence that circumcision can prevent the spread of HIV is unequivocal. Circumcision reduces the risk of HIV infection by about 70 percent—making it more effective than most flu vaccines—and it is being promoted by global health authorities such as the World Health Organization and the Centers for Disease Control and Prevention as a simple, permanent, and effective way to help prevent HIV infection. The American Academy of Pediatrics issued a statement last month emphasizing that the health benefits of newborn male circumcision outweigh the risks, and recommended physicians discuss circumcision’s benefits and risks with new parents nationwide.

Even more than using condoms alone—which must be used correctly every time one has sex over the course of a lifetime—male circumcision as part of a range of HIV prevention interventions has the potential to significantly slow the spread of AIDS in the worst-affected parts of Africa. At a fraction of what it would cost to maintain AIDS treatment for an HIV-positive individual over the course of a lifetime, male circumcision is a permanent and inexpensive prevention method that, when coupled with condoms and counseling, makes sense for countries where HIV is spread mainly through heterosexual intercourse.

Many men in regions with high incidence of HIV are interested in undergoing the procedure. In western Kenya, for example, more than 400,000 men have volunteered for the procedure over the past two years.

Professional reviews of Tinderbox, such as an Editor’s Choice selection by the New York Times, have been favorable, and several media outlets, such as PBS News and the BBC, interviewed the authors.  Most of the initial readers’ reviews on Amazon gave the book the maximum number of five possible stars. After co-author Craig Timberg was interviewed for NPR’s Fresh Air, Tinderbox’s ranking on the Amazon sales site jumped to within the top 150 and stayed high in the rankings for several weeks.

Although male circumcision occupies less than 10 percent of the book’s pages, it was enough to spark outrage among a tiny but passionately vocal fringe group, many of whom call themselves “intactivists.” They argue that the procedure is a grave human rights violation and are lobbying to ban the procedure in many countries.

Although tens of thousands of men who were circumcised as adults and were studied in several large-scale clinical trials (and in a Slate series) reported no loss—and in many cases an increase—in sexual pleasure and function, the intactivists claim that male circumcision is equivalent to female genital mutilation, a practice whose purpose is to constrain a woman’s sexuality and impair sexual function. In one of its worst forms, a pre-teen girl’s clitoris and entire external genitalia are cut, scraped, or burned out, which can cause severe pain, infection, life-long incontinence, obstructed labor and delivery, and even death. To be truly equivalent, one would have to cut off a man’s entire penis in order to produce the same effect, rather than a small flap of skin.

Infuriated by the authors’ inclusion of male circumcision among effective HIV prevention approaches, anti-circumcision activists launched a smear campaign to discredit the book and its authors by spreading misinformation on Amazon. The intactivists co-opted Amazon’s normally informative readers’ reviewing system through a sudden mass-posting of viciously negative, one-star reviews. These reviews were then rated en masse as “helpful,” which made them rise to the top of the book’s webpage. At the same time, all the positive reviews of the book were marked “unhelpful,” instantly pushing them into obscurity. Anyone who ventured to the site would see a string of negative reviews urging the potential buyer not to bother wasting their money on this “misguided propaganda” for the practice of male circumcision.

As a public-health professional interested in male circumcision and other aspects of HIV prevention, I asked co-author Daniel Halperin if the intactivists’ campaign seemed to have had any noticeable effect. He noted that immediately after the viral attack began in late March, the sales ranking of the book on Amazon plummeted.

What is particularly telling about the negative reviews is that they focus almost entirely on male circumcision, rather than the main focus of the book, which is the history of AIDS in Africa. Most of the negative reviewers appear not to have read the book. Several reviews also appear tinged with anti-Semitism, accusing Halperin of pushing a religious agenda just because he is Jewish.

Intactivists have a long history of hounding Halperin and other researchers. Years ago, they attempted to have him removed from the faculty of the University of California at San Francisco. They alleged that he was guilty of scientific fraud and was a “promoter of genital mutilation.” (After university administrators were forced to waste many hours investigating the charges, Halperin was cleared of any wrongdoing.)

HIV researchers are not the only ones who have been targeted by anti-science campaigns on Amazon. Recent books on childhood vaccination have been stigmatized through the review system by activists who believe that vaccines cause autism or other negative health issues. Rigorous studies have thoroughly disproven any link between autism and these vaccines—which save millions of lives each year across the globe—yet conspiracy theorists persist.

Where does all of this leave us? Two diligent and dedicated authors spent years researching the origin, spread, and potential prevention of AIDS in Africa. Two minutes and a few clicks were all that was required for a passionate extremist group to obfuscate and delegitimize their findings in front of one of their most important and public audiences. Having failed to prove their beliefs through scientific evidence, the intactivists decided to have circumcision, and this entire book, judged in the court of public opinion. Unfortunately for the public, this jury was rigged.

Authors who fall victim to ideological warfare by fake peer reviewers have little if any opportunity for recourse. Amazon’s response to inquiries about this case was that the company is unable to take any corrective action. In the same way that negative reviews can seriously impact book sales, the personal or financial interests behind positive reviews can go undisclosed. “Any one review could be someone’s best friend, and it’s impossible to tell that in every case,” said Russell Dicker, Amazon’s Director of Community in a New York Times article last year.

Last year Cornell researchers created an algorithm designed to root out what they called “deceptive opinion spam”—in other words, fake reviews. The authors found that reviewers on popular sites such as Amazon, TripAdvisor, and Yelp had been paid, offered free trips, or given free products in exchange for positive reviews. New books by undiscovered authors are often rated more highly than Tolstoy, and small restaurants and hotels surpass the Ritz.

Undoubtedly, reviewer systems can help consumers make sense of a complex array of options by providing what others “just like them” have said about a product. However, the very real potential of such systems to be held ransom by a politically-motivated fringe group should be enough to give anyone pause before purchasing (or not purchasing) a product based solely on these reviews.

Paul Meade, president of Clear Point Health (a health care consulting company), contributed significantly to this article.