The most unkindest cut

It is my last week in Zithulele and I am entrusted again with the charge of the Male ward. My work entails a daily ward round accompanied by a senior nurse, which occupies either the whole morning or afternoon, and clinic, either outpatients or HIV, filling the remainder of the day.

There are around 26 inpatients and their conditions cover the complete range of medicine with some orthopaedics and a sprinkling of general surgery. The range of complexity and severity is huge from young otherwise fit men with a fracture through to the majority who have advanced medical conditions, commonly infectious but also severe chronic cardiac and respiratory disease. Around a half of the patients have HIV; it may not always be the reason for their admission although it commonly is, particularly as TB accounts for another significant and mainly overlapping diagnostic group.

This week I have two teenage boys in my charge who have injuries from attempted self circumcision. I have looked after one previous case of a botched circumcision which required catheter drainage from directly out of the bladder while the healing, or rather scarring, process took its course. These two boys are sat out once a week on a bench in a side room with their handiwork exposed for medical inspection. In one of them the end of the penis is pink and healthy looking. He must have pulled the foreskin forwards away from the penis, but too far, and then cut off the loose skin neatly with something sharp and clean. He has a neat ring shaped area of skin about 3cm wide missing from below the end of the penis. This in fact looks promising as the foreskin itself is still intact and some skilled surgery could pull the loose skin back to cover the raw looking gap and meet the rest of the epidermis on the shaft of the penis. He is able to pass water normally.

The second boy is not so lucky. His attempt has become infected and the end of his penis is now gangrenous. He has already been through the hands of the urology team at Mthatha who managed to compound the damage further. He now has a catheter protruding from the base of his penis on the underside. He has about 4 cm of penile stump which looks like it might survive but the terminal half is black and shrunken and is going to self amputate sooner or later.

The origin of the practice of circumcision is lost in the mists of time. Its historical antiquity is well established and it goes back over 1000 years. Why humans should decide in the absence of any precedent in the rest of the animal kingdom to mutilate their genitalia in this way is perplexing. It is certainly good evidence of our distinguishing capability of making tools. Its role as a mark to differentiate one tribe from another, or the sexually mature from the immature within a tribe is widely recognised.

In recent years circumcision has attracted a great deal of attention. The ritual practice of female circumcision which occurs mainly in Africa and the Middle East is perceived as mutilating, oppressive of the female gender and intrinsically dangerous. Perhaps because male circumcision is so widely practised in the West – around one third of the males in the world are circumcised – male circumcision is accepted as a norm and has strong religious and cultural associations. The appearance of HIV has reignited the debate with clear evidence showing a 38-66% reduction of virus acquisition by a circumcised as against an uncircumcised man. As such the practice is being publicised and encouraged. The ‘Right to Care’ charity in Jo’burg will counsel a new male client about it on first registration and if the message is warmly received the patient will be asked to sign consent forms for an HIV test and to be circumcised and both will be done at that first visit. As a day case procedure in aseptic conditions it is safe and takes a matter of minutes.

Circumcision is a rite of passage for Xhosa males. Boys who have reached sexual maturity go off to a circumcision school (an umkwetha), spending a period of time, sometimes out in the wilds, and returning minus a few square inches of flesh.
One boy in my outpatient clinic was visibly excited that he was now old enough to be circumcised and we went through how he should manage his diabetes during his time away in the forest.

Circumcision is performed independently of the health care system here. There is no licensing or regulation of umkwetha and they are commercially run so that a cheaper school may attract more clients. It is not inexpensive and cost is as important a driver of where the boys go as any skill or reputation of the school ‘surgeons’.

Unless you have been brought up with it, the social pressure to be circumcised is difficult to understand or to overestimate, as are many ‘cultural’ issues here, and elsewhere. Both my patients had caring and worried parents who had told them of the danger of circumcision and had refused to let them go to an umkwetha. For both, accepting this would have led to intolerable peer pressure. I am guessing that the taunts of cowardice, sexual immaturity and being babyishly obedient to their parents would have been amongst the abuse they would have had to endure. Kids are cruel; here no less than anywhere else. To learn to swim here boys are taken by their slightly elder peers to the river and thrown in and pelted with stones until they swim to safety.

Two unfortunate individuals then; one of whom may be salvageable, but there is the skill of the Mthatha surgeons to survive yet, and one whose life is blighted forever and who for the rest of it will be left with a penile stump and having to urinate through the base of it while seated.

The statistics say that circumcision is very safe and that the complications of bleeding and infection occur in 1% or less of patients. These are global figures from sites where health statistics are reliable. The morbidity and mortality in the Eastern Cape and KwaZulu Natal far exceeds this because of the unlicensed cowboy setups who do it. December is circumcision season. In the outpatients this week five boys have been seen, all of whom are from the same umkwetha. Four are going to lose their penis. The statistics here are anecdotal but the informed estimates are that hundreds of septic complications, including septicaemia, are seen throughout this region during this time and that the number of deaths is in the tens; somewhere between ten and a hundred culturally accepted, nay encouraged and pressurised, cases of manslaughter every year, not to mention hundreds of painful complications with long term deformities and functional abnormalities. The psychological trauma can only be guessed at.

It is ironic that the month preceding this is ‘Movember’ where males, to show their solidarity with mens’ health issues grow a moustache. It is even slightly competitive in a jokey way as to who can grow the best one in that time. Social pressure and harmless male testosterone fuelled boasting at the mildest end of the spectrum. At the other end – deformity, dysfunction, humiliation, sepsis and even death are the common end results of the same hormone related sexual sparring.

It is difficult to know how to finish this posting. There will never be any widespread protest from the victims of this carnage, at least not in the foreseeable future. It would take a huge level of courage to make public the sort of anatomical mayhem that they live with. Things ‘cultural’ are in many ways sacrosanct and massive political vote losers to oppose or campaign against, so the chances of action at governmental level (even if there was a government in place which was not the exemplar of flabby, self-interested, corrupt, indecisive incompetence) are zero. International health bodies are similarly touchy about intervening in anything which has a ‘cultural’ epithet or justification.

From the play Schlageter by Hanns Johst, performed for Hitler, comes the quote misattributed to Hermann Goering “Wenn ich Kultur hore..entsichere ich meinen Browning!” [Whenever I hear of culture.. I release the safety catch of my Browning!]
On this one occasion and in this unique context I can almost empathise with the sentiment.

Perhaps the least one could aim for would be some sort of regulatory oversight of the umkwetha. The governmental failure to control other aspects of the Health care system here however does not inspire optimism for this approach (see ‘Strikes’, ‘Strike Two’ ‘New Depths’). This area of Southern Africa is stiff with churches, missions and evangelical ministers. Could they not preach that it is time for humans to progress from Genesis 17;14 to 1 Corinthians 7;19

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