Less Time. No Stitches.
Less Time. No Stitches.
The Unlikely Chinese Journey to Improve Male Circumcision in Africa against HIV.
Just off a plane from Africa in 2012, Bill Gates visited Stanford University to discuss three innovations. One of them, shown in his hand below, is the Shang Ring.
Today, we feature a recent talk by the Chinese manufacturer of, according to Gates, “the piece of plastic that completely changes the training required and complexity” of male circumcisions. At YiXi, a Ted-style talk in China with input from the Center for Global Development and Health Communication Research at Tsinghua University, Shang Jingjing tells the story of her father, leading their small company in central China to make the seemingly small invention that had gone on to enable nearly 700,000 male in Africa to prevent HIV.
The video of Shang's speech and its transcript are available on YiXi's website.
神奇的同心圆
Magical Concentric Rings
Hello everyone, I am Shang Jingjing from Wuhu Snnda Medical Treatment Appliance Technology Co., Ltd., a medical device manufacturer in east China's Anhui province.
The person in this photo is someone everyone recognizes—Bill Gates. This was taken in 2012 when he was giving a lecture at Stanford University on innovating aid.
The pink ring he's holding is Snnda's product, the "Shang Ring," a device used in circumcision. Gates believes that these two small pink rings can play a significant role in HIV prevention.
This product was invented by my father, Shang Jianzhong.
In the beginning, I wasn't entirely sure what my father was working on—I just had a vague idea that he was developing a product specifically for men. Almost every day during my holidays at home, a group of men would come over for dinner, filling our ten-person round dining table. After dinner, they would all move to the living room, sitting in a row on the sofa. Then, one by one, they would take turns entering the bathroom—one man would go in, come out after a while, and then another would go in—until the last person finally came out.
So, when my dad told me in the summer of 2009 that the product he had been working on was about to be exported, and that he had hired a few graduates with international trade degrees, asking if I wanted to come back and help, I immediately got a graphic picture in my mind, and my first reaction was that this business wasn't for me.
My father explained that I had misunderstood, saying the product had great potential and would soon be exported to Africa to help prevent HIV.
I thought, "Is this real? Are you hallucinating?" How could a method for preventing HIV suddenly appear out of nowhere, and why would it involve something my father invented? It all sounded ridiculous.
Seeing that I didn't believe him, my dad gave me a popular science lecture: HIV targets many types of cells (Langerhans cells, dendritic cells, CD4+T cells, and macrophages) on the preputial mucosa of the penis. The mucosal environment is very moist, providing an ideal condition for these HIV target cells to thrive. After circumcision, the moist environment is disrupted, making it difficult for these targeted cells to survive.
Seeing that I was getting the idea, my dad began outlining his grand vision (I'll omit the thousands of words he used). And that's how I joined Snnda Medical Treatment Cooperation. At the time, I didn't realize how meaningful the work I was about to do would be.
01
My dad isn't a doctor and has no medical background. He came up with the idea of inventing a product because he underwent laser circumcision in 2002.
The procedure went something like this: you lie on the operating table with a curtain draped around your waist, and all you can see in front of you is a field of whiteness.
Although the anesthesia prevented any pain, he was fully conscious and could see the laser flashing, accompanied by the distinct smell of burning flesh. After the surgery, he endured a long and painful recovery. Beyond the pain, he couldn't bathe and had to regularly visit the hospital to change dressings, take antibiotics, and receive IV drips. This ordeal lasted around three weeks, leaving him miserable.
He asked the doctor, "Wasn't this supposed to be painless circumcision? Why is it so painful?"
The doctor explained that this was the most advanced surgical method at the time, and other methods were even worse.
So my dad came up with the idea of improving the procedure.
At that time, my dad was already a well-known tradesman in our local area and a member of the municipal Chinese People's Political Consultative Conference (CPPCC). Discussing circumcision was somewhat embarrassing 20 years ago, and it was even more unusual to develop a medical device to improve the procedure after being dissatisfied with the original procedure. My aunt, who was an obstetrician, thought too that my dad should stick to what he knew and leave the specialist stuff to the pros.
But my dad is incredibly persistent. He has had a rich life experience—he's been a carpenter and a factory worker, then he got involved in city mapping and finally engaged in wholesale.
The same year my father underwent circumcision, he also opened a mosquito coil factory in Shanghai. He believed his life held infinite possibilities, convinced that there are no insurmountable tasks, only people who fail at them. So, in his late 50s, he purchased numerous medical books and began researching ways to simplify circumcision procedures.
There are many methods for performing circumcision, which can be easily found online. In traditional circumcision, the first step is to cut off the foreskin. Since the foreskin is a tubular structure with both an inner and outer layer, the doctor lifts the foreskin, creating four layers of skin stacked together. The doctor then cuts one side first, followed by the other.
You can imagine cutting four relatively thick pieces of paper stacked together. After cutting, you'll find that the edges might not be perfectly aligned—they might be slightly staggered.
Given the elasticity of skin, achieving a clean and even cut is particularly challenging, and suturing can only be performed after the cutting is complete. Therefore, the aesthetics of a circumcision depend not only on the doctor's suturing skills but also significantly on the precision of the initial cut.
In China, a skilled urologist, without the aid of specialized instruments, typically takes about 25 to 30 minutes to complete the procedure, as managing bleeding and suturing during surgery requires time.
Having gone through the procedure himself, my dad focused on identifying the "pain points" from his own experience. He believed that improving the surgery involved several key aspects: First, the surgery should be quick; second, no suture; third, frequent dressing changes should be avoided; fourth, the patient must be able to bathe; fifth, the pain should be minimized as much as possible; and sixth, the outcome should be aesthetically pleasing, with no scarring.
My dad quickly came up with the design of two concentric rings.
I've always suspected that he was inspired by the embroidery hoop I used for cross-stitch since it also consists of an inner and outer ring that stretches the fabric in place, but I have no proof.
Since my father had experience as a carpenter, he quickly made two rings out of wood. To test his design, he first experimented on our dog and then borrowed some friends' dogs, conducting about eight or nine trials successfully.
The specific procedure is to place the foreskin between the inner and outer rings. Before locking the outer ring, the length of the foreskin to be retained can be adjusted. Once the inner and outer rings are properly aligned, the outer ring is locked, and the extra foreskin is trimmed.
At this point, you'll notice that cutting the foreskin, which was originally the first step, is now the final step. Therefore, the doctor no longer needs to worry about making a perfectly even cut, as the two layers of skin will eventually heal along the area clamped between the inner and outer rings.
Because the rings clamp both the skin and blood vessels, there is no need for hemostasis during the procedure—only bleeding occurs from the portion of the foreskin that is removed. Suturing is also unnecessary. In this way, the surgery time has been reduced from the original 25-30 minutes to 5 minutes.
Furthermore, the inner and outer rings compress the nerves, so even after the anesthesia wears off, the pain is still slight.
To ensure that the inner and outer layers of skin fuse properly, the ring needs to be worn on the body for a few days before removal. Due to the placement of the two rings, the wound cannot be bandaged as in traditional surgery. However, my dad quickly realized this was not a defect. Without the need for bandages, there is no requirement for dressing changes, and the patient can bathe—as long as they dry off afterward—making post-operative care much easier.
My father was extremely satisfied with his invention. He believed the two rings were revolutionary and would transform the entire circumcision process, so he named them the "Holy Ring." He even came up with a slogan: "Making circumcision as simple as having a cup of coffee or a fast food meal."
In 2005, my dad established a company and even mortgaged our house to secure an international patent. He set aside all his previous business to fully dedicate himself to this new career.
At the time, circumcision was primarily associated with religious practices or the treatment of existing diseases. It hadn't yet been widely recognized in the medical field as a "surgical vaccine" for preventing reproductive tract diseases. As a result, there was little interest in his new device.
Our entire family tried to talk him out of it, assuring him that he had given it his best effort and that we wouldn't blame him if the design didn't succeed. But he insisted that his invention would eventually find its advocate.
One day in 2007, my dad came home and told my mom that a company was interested in his invention and was willing to invest $10 million for him, but only if he conducted an evaluation report at a location the company assigned. Seeing the investment as a rare opportunity, my dad took 30,000 yuan [$4203.62] and went to the designated institution for evaluation.
After the report came out, the investment company disappeared—my dad had been scammed. However, it is also a blessing in disguise. The evaluation report contained a critical piece of information: "Circumcision can prevent HIV." So, while my dad had been tricked, he was also pointed in a new direction.
02
How was it first discovered that circumcision can prevent HIV?
Initially, there were observational studies that showed a negative correlation between circumcision and HIV infection rates.
This evidence led to the initiation of three randomized controlled trials between 2005 and 2006 in South Africa, Kenya, and Uganda, involving over 10,000 HIV-negative men aged 15 to 49 who had not been circumcised. The participants were divided into two groups: one underwent circumcision immediately, while the other was circumcised after the study. The trials demonstrated that circumcised men had up to a 60% reduced risk of acquiring HIV through heterosexual intercourse.
When the conclusion that "circumcision can prevent HIV" was announced, it quickly garnered global attention. Time magazine even ranked it the top medical breakthrough of 2007.
As we all know, there is still no vaccine for HIV, and once infected, the only way to prolong life is through lifelong medication.
According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), by the end of 2021, 25.6 million of the 38.4 million people living with HIV worldwide were in sub-Saharan Africa—a region facing the most severe shortages in medical care and access to medication. Given these challenges, preventive measures to reduce new infections offer a more direct and effective approach compared to relying solely on medication to contain the virus.
Since 2007, the World Health Organization (WHO) and UNAIDS have recommended "Voluntary Medical Male Circumcision (VMMC)" in countries where HIV prevalence is high, transmission occurs primarily through heterosexual intercourse, and circumcision rates are relatively low. Circumcision has since become a key HIV prevention strategy, alongside the use of condoms and timely testing and counseling.
It's important to note that circumcision is not a standalone preventive measure and should not replace other strategies. All necessary safety precautions must still be taken.
In many African countries, where the urban population is low, it's not feasible for everyone to access hospitals for circumcision. As a result, many surgeries are performed in mobile clinics.
Traditional circumcision surgery is time-consuming, limiting the number of operations that can be performed each day. Additionally, the scarcity of professional urologists in Africa makes it unrealistic to quickly increase the number of doctors to meet the circumcision targets. This situation created a demand for surgical devices for male circumcision. While some devices existed, they were primarily designed for infants and young boys and lacked clinical data for use with adolescents and adult men.
In March 2008, the WHO, in collaboration with UNAIDS and the Bill & Melinda Gates Foundation, hosted a workshop in Uganda titled "Meeting the Demand for Male Circumcision." During this event, the WHO established selection criteria for circumcision devices, focusing on safety, surgical quality, acceptability, and cost-effectiveness.
03
How was the "Holy Ring" selected by the WHO? It was indeed a very serendipitous and fortunate thing.
In 2007, the same year that circumcision was recognized by Time magazine as the top medical breakthrough for its role in preventing HIV, my father was introduced to Professor Philip S. Li by Professor Zhu Jichuan, then President of the Chinese Society of Andrology, a specialty society under the Chinese Medical Association.
Professor Philip S. Li at Weill Cornell Medical College was immediately impressed when he first encountered the "Holy Ring." However, as an academic, he emphasized the importance of clinical data in validating the value of any medical product. He called Professor Zhu and said, "If there is clinical data to support this device, this could be the most significant achievement in Chinese andrology in the past half-century."
To validate the safety of the "Holy Ring," Professor Li led the formation of a multicenter clinical team for circumcision in 2008. This expert team conducted research and analysis on various factors, including surgery duration, blood loss, pain levels, and complications. The study concluded with a 99.7% patient satisfaction rate, with most individuals able to return to normal work on the same day as the procedure.
At that time, the WHO had identified around 20 to 30 different circumcision devices globally, but the clinical feedback on these devices was not particularly satisfactory. In 2009, the WHO organized a consultation meeting on circumcision devices in Nairobi. During this meeting, Professor Philip S. Li presented domestic clinical data from China and recommended the "Holy Ring" to the WHO. Impressed by the data, the WHO accepted Professor Li's suggestion. To honor the inventor's contribution to circumcision, the WHO decided to rename the device from "Holy Ring" to "Shang Ring," after the inventor's surname.
However, the WHO also raised a question: while the data of "Shang Ring" had been proven safe and effective in China, how would it perform in Africa?
So since 2009, with support from the Gates Foundation, Professor Li led several randomized controlled clinical trials in Africa.
Conducting clinical trials in Africa is far more challenging than expected. Many participants lived in remote areas, and the clinical team often had to travel long distances on motorcycles to follow up with patients.
Despite the challenging circumstances, all clinical trials were completed by 2012.
After the results were submitted, the WHO established an independent expert review panel. The panel randomly selected 1,983 samples from 14 clinical sites for examination. The results revealed that the incidence of serious adverse reactions among these samples was zero, indicating that the Shang Ring is safe and effective for more than 99% of men who undergo the procedure.
The WHO determined that the Shang Ring met their requirements for circumcision devices and issued an invitation for prequalification, with plans to conduct an on-site inspection of our production facility. WHO prequalification is essential for a product to be eligible for purchase on the international public procurement market.
When we received the notification, we were thrilled, but our excitement quickly turned to concern. At that time, Snnda company had only about a dozen employees, and none of us had any experience with international audits. My dad then said, "We've come this far. The Gates Foundation has invested so much, and Professor Li and his team have made countless trips to Africa. This is the final step. If we drop the ball now, it would be an enormous joke."
To enhance our quality management capabilities, the Gates Foundation invited experts from various professional backgrounds to conduct a pre-inspection for our product. With their guidance, Snnda implemented a series of corrections and improvements. By the time the WHO arrived for their on-site inspection, our quality management system included over 300 documents to ensure the quality of these two small rings.
In June 2013, the WHO conducted its first inspection of Snnda. They sent four inspectors for a five-day inspection. At that time, Snnda's production area was less than 1,500 square meters, so this thorough inspection essentially turned the company inside out.
I was impressed by two things from the inspection.
The first was related to the stools used by employees in the workshop. At the time, our stools were made of stainless steel—sturdy and easy to clean. However, the WHO issued a non-conformance notice regarding them. Puzzled, I asked the inspector for clarification. He explained that while the material of the stools was acceptable, the issue lay in the fixed height. The stools needed to be adjustable so that employees of different heights could find the most comfortable seating position. He emphasized that if employees aren’t comfortable while working, it could compromise the quality of the products they produce.
The second issue was about hand disinfection in the workshop. The inspectors noted that the placement of the disinfectant was not aligned with the movement patterns of the employees, making it inconvenient for them to follow proper hand disinfection procedures. They provided a recommendation to correct this issue.
These two incidents profoundly deepened my understanding of quality management. Every person and every action directly impacts product quality, and no aspect of production can be taken lightly. Quality is something that is produced, not merely tested.
After several rounds of corrections, our product finally obtained WHO prequalification in June 2015.
While China had previously secured prequalification for products such as pharmaceuticals, vaccines, and in vitro diagnostic reagents, Snnda's product was the first circumcision device to achieve this status. Moreover, since the Shang Ring was a product of independent intellectual property, it became the first original Chinese circumcision device to obtain prequalification.
04
Although the Shang Ring simplified circumcision surgery, standardized training was still crucial.
Professor Philip S. Li always emphasized, "Training first." Initially, I didn’t fully understand his insistence, as the procedure seemed straightforward—something doctors could learn by simply watching a video. I questioned whether hands-on, on-site training was truly necessary.
It turns out I was too simplistic in my thinking. There was a period when our company received negative feedback domestically, primarily because we hadn't maintained proper training efforts. While using the Shang Ring for circumcision isn't inherently difficult, the procedure involves many details that require careful attention, and each patient is unique. On-site training is essential to ensure that these key points are fully understood.
In response, we rethought our approach, established a dedicated training team, and created a post-operative care guide. Today, in addition to training doctors in China, we also train physicians from countries like the United States, Canada, and Australia. After learning how to use the Shang Ring, these doctors have successfully applied it in their respective countries with excellent results.
With the Shang Ring, not only doctors but also trained nurses can perform circumcision surgery independently, which is particularly significant in Africa where there is a shortage of doctors.
Jairus is a nurse from Kenya, who lost several family members due to HIV. In 2009, he came to China to receive training on the Shang Ring and became one of the first batch of people in Africa to use the Shang Ring to perform circumcision. Until now, Jairus is still a strong advocate for the Shang Ring.
When I met Jairus in Nairobi last year, he had just returned from training others in Mozambique. He told me that with the help of the Shang Ring, he can now perform 20 circumcisions in a single day.
During the training in Zambia, there was one day when our team was about to head out to the training site. The elevator doors opened, and three soldiers carrying assault rifles walked in. The atmosphere immediately became tense.
One of the soldiers asked, "Where are you from?"
We quickly replied, "We're from China, here to conduct training for the Zambian Ministry of Health."
To our surprise, the officer responded with a smile, "What a coincidence, I'm also from China. I graduated from the Shijiazhuang Mechanized Infantry Academy."
The tension broke, and everyone burst into laughter. Professor Li took the opportunity to briefly introduce the Shang Ring to him, and after we exited the elevator, we captured this photo.
While in Zambia, I also visited some local hospitals. Even at the University Teaching Hospital in the capital, Lusaka, the environment still looked like Chinese hospitals from the 1990s—old facilities, but very clean and orderly.
When hearing that I was from the Shang Ring factory, the doctors in charge of the training were excited. They eagerly took photos with me and shared how the Shang Ring had significantly improved their surgical efficiency and how satisfied their patients were with the procedure.
At that moment, I suddenly understood why my father was obsessed with improving this surgery, and why Professor Li and the experts in the clinical team spent so much time verifying the safety of the Shang Ring.
The surgical method using the Shang Ring has continued to evolve over the years. In 2019, Dr. You Hai from Kunming Children's Hospital developed a no-flip technique for the Shang Ring, which has since received prequalification and can now be used for infants and newborns. This significant advancement was recently documented in a paper published in The Lancet.
Despite the growing recognition of the Shang Ring, it's crucial to understand that expanding the public procurement market is an extremely long and challenging process.
As an innovative device, the Shang Ring faced unique challenges when Snnda first applied for prequalification. There wasn't a specific category available for it. Even after obtaining prequalification, the absence of a "circumcision instrument" category in the procurement catalogs of various institutions left the Shang Ring in an awkward position—eligible for procurement but not listed in any catalogs.
This situation was perplexing for our team, forcing us to reach out to different organizations to address the issue. However, adding a new category to procurement catalogs is an extraordinarily complex task, and despite our persistent efforts, we made little progress.
Just when we were on the brink of despair, in 2019, we finally received our first order from the public procurement market. It had taken nearly 12 years since we first believed that the Shang Ring could enter the public procurement market.
A saying perfectly summarizes these years of experience: "It's not because we saw hope that we persisted, but because we persisted, we had hope."
Over the past 16 years, whether it was project officers from the Gates Foundation, Professor Philip S. Li and the experts from the multicenter clinical team, or us as the manufacturers—if any one of us had given up along the way, the Shang Ring would never have made it to Africa. So, I want to say "thank you" to all the people who have chosen Shang Ring.
So far, eight African countries have integrated the Shang Ring into their national VMMC programs. This grassroots invention from China has already enabled nearly 700,000 Africans to safely undergo circumcision.
Our next goal is to ensure that all 14 priority countries for HIV prevention in Eastern and Southern Africa have access to the Shang Ring. With increased production, we can further reduce unit costs, enabling Snnda to offer the device at an even more affordable price to the countries and people who need it.
Thank you!
The Bill Gates talk in Stanford in 2012
 | A guest post by
|