Public Health January/February 2011

The Kindest Cut

Swaziland turns to mass circumcision.
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Leif Parsons

Banele Shabangu is scared because he should be scared. Because a man in a mask is about to stick a needle into the base of his penis. “Are you ready?” the man asks.

“No one could be ready for this.”

“Don’t touch, don’t jump,” says Nurse Justin, the man with the needle. Then he injects Banele with a local anesthetic. Banele shouts. It hurts, but it’s more where it hurts than how much it hurts.

Banele, an 18-year-old in his last year of high school, has come to the clinic in Matsapha, Swaziland, to get circumcised. Like the dozens of teenagers and men packed into the waiting room, he’s doing so because he heard that circumcision offers partial protection against HIV, the virus that is obliterating the future of his country.



Slideshow: Photos from Swaziland's circumcision campaign

But first he needs another injection. “Wait, wait, please,” he says. “I’m sorry for screaming, you’ll forgive me, sir.” He clenches his teeth as the nurse sticks the needle in again.

Just under 20 percent of Swaziland’s 1 million people are HIV positive, an epidemic fueled by poverty, a lack of medical resources, and a male-dominated and promiscuous culture in which polygamy is still common. Look more closely, and the numbers get uglier. Nearly half of women ages 25 to 29 and men 35 to 39 are infected. Since 1998, according to one report, the average life expectancy has dropped from about 61 years to 47. “With the highest prevalence of HIV in a population ever recorded, we have got to do something to intervene,” says Dr. Vusi Magagula, chair of the government’s male-­circumcision task force.

Swaziland has been preparing its men for mass circumcision since 2006. The previous year, a randomized controlled trial in South Africa (later confirmed by studies in Uganda and Kenya) found that circumcised men are as much as 60 percent less likely to contract HIV through heterosexual sex. Scientists do not yet know exactly why, but the study was so convincing that it was stopped after 18 months, because preventing the uncircumcised control group from getting the procedure would have been unethical.

Now a nationwide campaign is under way to circumcise 160,000 HIV-­negative males by the end of this year. That’s the number organizers believe will walk willingly into the operating theater. The government’s task force plans to recruit additional doctors from around the world, train them, and send them throughout the country to perform the surgeries. At the campaign’s peak, the organizers expect to have 35 doctors and 245 nurses. “This will prove to Africa that together we can fight HIV,” says Ayanda Nqeketo, of the ministry of health. “It will be a historic moment.”

To encourage men to have the surgery, outreach teams are traveling to all areas of Swaziland. When I visited the small city of Nhlangano on a hot August day, four agents were pulling aside men and boys in the town center. “Hey, brother, are you circumcised?” they asked. “No? Why not?” A DJ played loud dance music. Every 10 minutes he got on the mike and said, “Circumcision reduces the risk of HIV and other STIs. It’s easy and not painful. Go to the tent and register.”

Many Swazi men want to get circumcised, “but most of them for the wrong reason,” says Bheki Vilane, the national director of Marie Stopes Swazi­land, a non-governmental organization performing circumcisions. He’s voicing the main concern about circumcision as an HIV-prevention strategy: will it make Swazi men even more sexually reckless than they are already? “Some of the men have the misconception that they’ll be 100 percent safe.” To dispel this myth, NGOs are ensuring that every patient goes through counseling before and after the procedure. Each man is told to use condoms, and also given the option to be tested for HIV, which about 85 percent agree to do.

“How’s it going?” asks Dr. Ronald Wandira, once Banele’s anesthetic has kicked in. Wandira, who works for an NGO called Population Services International, will perform the surgery.

Banele is so nervous it hurts to watch him. “Like I am on my way to heaven,” he says, his hands covering his eyes.

It also hurts to watch the procedure. Banele is getting the forceps-guided method. The task force has chosen this as the preferred technique for the campaign (over “sleeve” and “dorsal slit”) because it is thought to require the least amount of surgical skill while still producing good results. Wandira pulls Banele’s foreskin up over the glans of the penis and squeezes it with the forceps. The foreskin is stretched taut so that the doctor can remove the targeted tissue.

“How far now?” Banele asks, almost as soon as the cutting begins.

“You mean how far to heaven?,” Nurse Justin jokes. “Maybe you’re going to hell.”

“Hell was when you injected me,” Banele counters. By the time Nurse Justin and Wandira stop laughing, the cutting is done.

After the surgery, Benele’s penis is wrapped in gauze and taped facing upward under his belly button to prevent swelling. He must wait six weeks before engaging in sexual activity, including masturbation. “How can I make it sleep? If I get horny?” Banele asks.

Ten days after his operation, Banele has returned, showing the clinic to two uncircumcised friends. It’s the first day of a back-to-school circumcision campaign, and the waiting room is packed with teenage boys. Those who can’t fit inside hang out in the parking lot or on the stairs, playing games on their phones and waiting to be called.

Banele says the recovery has been easy, and he’s already back on the soccer pitch with his friends. “They can see that I have no pain. Nothing. I run just like them.”

He’s been trying to persuade the rest of his friends to get circumcised. They want to go, he says, but they are afraid of the knife.

Shaun Raviv is a Fulbright scholar in Swaziland.
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Shaun Raviv is a freelance writer based in Accra, Ghana.

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