By David Njagi
Many countries are short of resources to meet the high demand for male medical circumcision. (Photo Courtesy Edward Echwalu)Tharaka-Nithi, Kenya — A chorus of ululations pierces the dawn at Pius Nyaga's homestead in eastern Kenya, marking the end of a brief ritual near the family cowshed. Nyaga's son, Antony Mwiti, has just completed the rite of passage into manhood - the traditional way.
An elder quickly wraps Mwiti in a white sheet as another leads him to the freshly built seclusion shed, where he will nurse his circumcision wound for the next few weeks. There he will also learn some of the cultural secrets reserved for fresh initiates.
In previous years, only those who have themselves faced "the knife" the traditional way would be allowed to visit an initiate. But today Mwiti's father has hired a clinical nurse to attend to the teenager, who will join high school in nearby Kiereni village once his wounds heal.
"It has become necessary for parents to reach out to modern medicine during these rites, even if we still value the cultural way," Nyaga says. "The reality of HIV and Aids, as well as the possibility of the wound worsening due to an unhygienic operation, is the reason for this."
New research says male medical circumcision reduces HIV infection by up to 60 percent during heterosexual intercourse. This fact is likely to give medically supported traditional circumcision a significant boost.
Coming from a region that has steadfastly guarded the traditional male circumcision ritual, it is remarkable that Nyaga would dare to blend traditional practices with modern medicine. In pre-colonial times, if Nyaga had allowed an outsider to tend his son's wounds he would not have earned a place as an elder. And his son would have been denied the chance to become a custodian of clan doctrines.
But in his 64 years of living near the foothills of Mt. Kenya, Nyaga has felt the pain of mothers who have lost sons to fatal infections after the use of crude tools during circumcision rituals. Nyaga says he also believes a growing number of young men have contracted HIV from the unsterilized knives and razor blades used on youths who are circumcised at the same time. Health officials say these cases are seldom reported due to stigma and restrictive cultural bonds. HIV prevalence among circumcised men is estimated at 2.6 percent in eastern Kenya, according to the 2007 Kenya Aids Indicator Survey (KAIS).
The head of strategy at the National Aids Control Council (NACC), Regina Ombam, says the government does not have programs targeting traditional male circumcision, nor has much data been collected related to the practice.
"But, we are encouraging communities to make use of the government-led male medical circumcision option, which is showing great progress in reducing HIV infections," says Ombam.
The NACC does not link HIV infections exclusively to traditional male circumcision, but some reports suggests that HIV is spread through this rite of passage in some parts of Kenya. Health advocates hope that if the National Aids and STD Control Programme (NASCOP) task force conducts research on traditional male circumcision, the possible link with HIV could become clearer.
Even more troubling, according to a World Health Organisation (WHO) report, is the practice in some African communities where young men are encouraged to have sex shortly after circumcision, a time when the wound is not fully healed. The WHO is also concerned that other groups circumcise an initiate-in-waiting after he has had sex for the first time, a situation that could have already exposed them to a range of sexually transmitted infections (STIs), including HIV.
Elders in some African societies believe that group circumcision rites are important for creating strong bonds among age mates in preparation for future duties, such as ensuring the community's security.
"Cultural practices such as mass circumcisions with one cutting instrument for all participating boys are common," says Domenic Micheni Ngaruni, the clinical nurse practicing in Tharaka Nithi county and who is attending to Nyaga's son. "It is a source of pride for the boy to be circumcised with the same knife as his peers."
Ngaruni, who has seen some of the tools tucked in dirty goatskin pouches, explains that the traditional circumcisers perform as many rites as possible due to the prestige that goes with the practice. This is why Gitari Magorwe is in a hurry to leave Nyaga's home after successfully initiating his son into manhood. He wipes the bloody knife with a banana leaf, but surprisingly, also pulls a bottle of antiseptic from his pocket, which he sprays on the tools.
Magorwe says he learned this practice from an official of the USAID-funded Aids, Population and Health Integrated Assistance (APHIA II) Project, which has been working with traditional circumcisers to make the practice safer.
"There was a time when I almost lost the confidence of the elders after a boy I had operated on took four months to heal," says Magorwe. "But it is the threat of HIV that is making people like us listen to health officers."
Amos Murerwa of the APHIA II project in eastern Kenya says traditional circumcisers also receive training on how to reduce the adverse effects of circumcision, which WHO says can lead to severe bleeding, permanent damage to the penis, persistent swelling, erectile dysfunction and even death.
"We also reach out to community elders to educate them about the harmful effects of female genital cutting and gender violence," says Murerwa. He says they encourage the elders to pass on these values of respect to the youths.
With time, it is possible for traditional circumcision to be medically guided and to reach relatively safe levels, officials say.
Kenya aims to circumcise more than one million men by 2013 in medical facilities. The country's male circumcision campaign is the most successful in eastern and southern Africa, officials say, but health facilities struggle to keep up with the demand.
"Circumcision of boys is very expensive in public hospitals, and that is why some communities prefer the traditional way," says Nderitu Njoka, chairman of Maendeleo Ya Wanaume, or "Development of Men", a group that lobbies for men's rights in Kenya. "The government of Kenya should subsidise it to make the process free of charge."