The Cultural versus the Clinical

A couple weeks ago, Sabrina and I had a tour of the SACTWU Worker Health Program in Salt River, which is the largest program of its kind in South Africa, providing its workers with disease prevention resources, treatment, and support. Originally, it acted as a response to the HIV/AIDS epidemic, but it has branched out into dealing with other STIs and tuberculosis. We accompanied Khaliefa and Xolisile to a health briefing at a small factory during the workers’ lunch break and we handed out two different informational pamphlets; one on tuberculosis, the other on medical male circumcision. After the briefing, we realized that while the former type of pamphlet was completely gone, we still had many copies of the latter.

SACTWU Worker Health has launched a large campaign for medical male circumcision, advocating for its role in significantly reducing the spread of STIs. They have clinics set up in their offices on select days, and mobile vans that go into townships and rural areas in order to make it easier for the young men there to get circumcised. At first glance, the initiative seemed like a no-brainer. Given that the procedure is free for SACTWU workers and their dependents, I couldn’t understand why families would choose not to take advantage of it.

Several days later, the union paid for the two of us to take a guided tour of certain locations in Cape Town and select townships in the surrounding Cape Flats. Colleen, our tour guide, did an excellent job explaining the history of the areas we went through, and the roles that apartheid, government aid, and community played in shaping the present-day townships. On the ride back, she initiated a discussion on circumcision practices within the Xhosa tribe, to which most of the native Africans in the Western Cape region belong. It was then I remembered that in several African tribes, circumcision is a rite of passage that is usually accompanied by a grand ceremony.

For Xhosas, this practice, known as Ulwaluko, is extremely confidential, but there are several things outsiders do know. In short, when a boy is ready to become a man and earn the respect in the tribe associated with being a man, he must go up to the top of a mountain for several weeks, where he is accompanied by a cohort of his peers who have made the same choice. This cohort falls under the supervision of an elder within the tribe who is tasked with looking after the boys, and making sure they are fine. During the days on the mountain, the young men’s heads are shaved, and they are given very little to drink. The circumcisions are performed by a traditional surgeon using a traditional spear. This instrument is rarely disinfected from boy to boy. Many complications and mutilations can occur in this process as well; at least 853 initiates have died in this process since 1995, and many more have undergone penile amputations. In recent years, there has been an increase in deaths recorded. Certain stories have made the news, but others have gone unheard.

However, this ceremony is about much more than simply the act of circumcision. On the mountain, elder males in the tribe take time to teach the young men what they see as fundamentals of manhood. Every boy reaches a point where he wants to know what it is to be a man, and seeing that many of these boys grow up without a father at home, this event can often be quite pivotal.

“The principles that lie at the very core of the ritual are respect for self (including self control and integrity), respect for family (not to bring shame to them), and respect for community (to protect them from harm).”

I became intrigued by this process that holds such great cultural value, but is simultaneously characterized by its health and safety risk. In efforts to learn more, I accompanied Rachel and Jenna, who are working at Sonke Gender Justice, to a graduation ceremony in Khayelitsha for a group of eight 16-20 year old boys who had participated in a program on sexual and reproductive health and rights. We had the privilege of having an open and lively discussion with the young men and several young women from the community as well. However, when I brought up the topic of circumcision, silence fell over the group—which I actually expected. The boys eventually opened up slightly, being careful not to divulge any specifics, but essentially said that they had to follow their culture. To get the procedure done medically, or not at all, was wrong to them. They cited an example of a middle-aged man in the Eastern Cape who had not gone to the mountain, and even today, he is not recognized as a man within the tribe. At events, he must sit with the boys, and he is not allowed to marry. Czerina, their mentor, encourages these youth regularly to challenge the norms of their culture. For anyone, this is much easier said than done.

I also talked to a co-worker about his experience with Ulwaluko. He also refrained from giving me specifics, but he let me know he was health conscious, and made sure to get complete physical examinations done before going to the mountain. He assured me that there is a lot of personal responsibility involved staying healthy during the period.

This past week, when Sab and I flew to Durban to conduct some interviews, we were given the opportunity to tour the SACTWU Worker Health offices in another part of the country. Durban is in the province of Kwa-Zulu Natal (KZN), and instead of the Xhosas, the Zulu tribe is dominant in this area. When we walked into the facility, a male medical circumcision clinic was underway, and dozens of boys were present, eager to get this procedure done.

Zulus have a similar rite-of-passage ceremony to Xhosas, but as a community, they have responded to the public health initiative much more positively. One of our co-workers attributes it to the warrior history of the Zulus. The old king realized he couldn’t have all his men on the mountain for months at a time when he needed them for war, so he shortened the ritual dramatically. The Zulu king recently decreed that all babies born within the tribe are to be circumcised at birth, which I think is a bold move. Over the next few years, it will be interesting to compare the sexual health within and between these tribes and see what is revealed.

When looking at the success of the medical male circumcision campaign in KwaZulu-Natal, and its apparent lack of traction in the Western Cape, I am reminded that there are so many underlying aspects to consider when creating a public policy or a public health initiative. These aspects, if not properly considered, can render even the best ideas useless.

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