United Press International - April 12, 2004
Steve Mitchell, United Press International

"Xhosa people are very worried about it because boys have died in recent years" due to severe infection, Zukile Khambi, a Xhosa and an independent tour guide who works with the Eastern Cape Tourism Board, told United Press International.

The Xhosa (pronounced KO-sa) tribe comprises the second largest population in South Africa, after the Zulus, which do not practice circumcision.

There also have been reports of penile amputation, other complications due to infection, and the transmission of HIV, the virus that causes AIDS, in boys who have undergone the traditional ceremony.

One problem has been a lack of sterilization. The circumcisions typically are performed by elders and less frequently by traditional healers, both of whom often lack an understanding of the importance of disinfection.

Elders also are resistant to proposals to transfer circumcision to hospitals or medical facilities, saying it would diminish the value of the ceremony. The deaths and infections have raised so much concern, however, the country's Ministry of Health has set up a special program to work with elders and traditional healers to educate them about modern techniques of sterilization and disinfection.

"Children have died" from infection because the elders did not change the blade in between the boys they circumcised, Lillian Cingo, manager of the Phelophepa train, which delivers healthcare to impoverished and remote communities in South Africa, told reporters during a recent meeting.

In addition, the surgeries often are performed under non-hygienic conditions in areas with little or no sanitation, Cingo said. There also is a concern that failure to change the blades could transmit AIDS, because the disease affects approximately 10 percent of the population.

In the ceremony, which can last anywhere from weeks to several months, the elders teach boys, typically around the age of 18, about manhood and responsibility in a rite that culminates in circumcision. The youths go with little or no food or water, live in a grass hut in a remote area in the bush, far removed from the modern comforts of the cities, and spend much of the time naked or covered only with a blanket.

Traditionally, the boys were given small quantities of a watery porridge that at least provided some nutrition and hydration, Khambi said, and added in recent years there has been a shift to even more severity, with elders forbidding water or food for up to seven days.

"In the old days, experienced elders would oversee the ceremony and carefully observe the boys to make sure they were OK," Khambi said. Now they have inexperienced people in charge, he said, and they are permitting dangerous activities and putting the boys in danger.

Khambi said when one of his sons recently went through the procedure he suspected something was wrong and decided to visit the remote location where the rite was taking place. He found his son and the other boys so dehydrated their lips were dry and cracked and they were unable to stand. He pleaded with the overseeing elder to give them water, but he refused. Khambi took it on his own to purchase and provide the boys with a supply of a Gatorade-type drink and oranges. After about two days, their condition improved, he said.

Such situations are occurring less frequently, however, if at all, because the Health Department has become involved and has started doing routine check-ups on the ceremonies.

"If (health department officials) find very ill boys they will send them to the hospital," Khambi said. In addition, the boys are now required to be given water at least twice a day.

Phelophepa also is conducting programs aimed at improving the situation, Cingo said. The train works with both elders and the traditional healers, teaching them the importance of boiling the surgical equipment, changing blades and using disinfectants. The train officials also explain that failure to follow these steps can transmit disease and cause death.

Phelophepa's efforts seem to be paying off. In the most recent class they offered, 12 traditional surgeons were in attendance and all said they appreciated receiving the information, Cingo said.

Maintaining this receptive attitude is important, she added, because these surgeons and healers are an esteemed part of the community in some regions.

Health officials must be careful to work with them rather than appearing to be diminishing their authority, she said. "We want to empower them, not take away from them," Cingo said.

Getting the information to 12 surgeons carries an additional benefit, she said, in that they will return to their communities and share their newfound knowledge with other traditional surgeons, further reducing chances for infection, death and disease transmission.

Steve Mitchell is UPI's Medical Correspondent. He has been on assignment in South Africa. E-mail sciencemail@upi.com
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