In Africa, it has been shown that male circumcision substantially reduces the risk of HIV transmission from women to men. Of course, using condoms will reduce the risk even further. The Ministry of Health has set Kakumbi Rural Health Centre a male circumcision target, and Nurse Martin Mwanza intends to meet it.
When I arrived at the health centre, there was a group of sheepish-looking young men, aged 18-21, waiting outside the male inpatient ward. Mr Mwanza was going through the consent form with each of them and getting their signed agreement. He did look the part, wearing pressed surgical scrubs and face mask. I asked him if he needed any help and he gladly accepted my offer.
The operating table was an inpatient bed. It was about 30cm too low and I could see that the surgeon would be very uncomfortable operating at this height. The louvred windows were partly covered by makeshift curtains, which let in some light but prevented curious bystanders from peering in to watch the show. Although this is the beginning of the cool season, the rooms in the health centre are very warm in the middle of the day, and the curtains did keep out any breeze. We were sweating.
Although they had been fully briefed about what would happen during the operation, the lads looked very apprehensive. A few of them were wearing football shirts, usually Manchester United, Chelsea or Arsenal (Liverpool is not so popular here in Zambia). Just to lighten the mood, I cruelly would suggest that the operator was a strong supporter of a rival team, but that this would in no way adversely affect the surgery…I could see from their faces that they were seriously considering this, until I clapped them on the back and started laughing.
I will not bore you with the precise details of the operation, other than to say Mr Mwanza took a great deal of care over each patient and did an excellent job. The local anaesthetic dose was rather higher than we would use in UK, but at least the patients felt no pain. For each operation, there was a specially-made up sterile pack. However, this did not contain instruments (blade, gallipot, toothed forceps, artery forceps, needle holder and scissors). I had to hunt through a large drum of tangled ironmongery to find the right tools. There were about fifty artery forceps, but only three pairs of scissors, one of which broke when we tried to use it. There were ten lads having surgery, so we would have to sterilise the scissors several times during the day.
Mr Mwanza had wisely kept aside a pack of gauze swabs, to avoid the problems I had using makeshift swabs from bandages (see “Mosi oa Tunya”), but there was no paraffin gauze. I found some in a huge plastic carrier bag, stuffed with donated dressings, which were being rationed to the health centre. We used this to prevent the dressings from sticking to the suture line. Instead of using paper micropore tape to secure the dressing, Mr Mwanza used thick, strong zinc oxide strapping. This would certainly ensure that the dressing remained in place, but I would not like to the patient when the dressing was being removed.
As a final flourish, Mr Mwanza manoevred the penis upright, keeping it in position by attaching two wings of strapping on either side, reaching round to the loin. Keeping the penis upright used gravity to reduce the oedema and swelling. “But how will he pee?” I asked. Mr Mwanza showed each lad how to peel the tape off his belly to point his penis downwards to pass urine, and then to pull it up again. Ingenious, really. They got a strip of 10 paracetamol tablets and instructions to return in a few days to have the dressing changed and the wound inspected. They were aware that they would be “off games” for about six weeks, until the wounds had healed and the catgut sutures had fallen out or been absorbed.
I pulled back the cardboard box containing the operation packs, which was keeping the door closed, and the boys greeted their soon-to-be-operated-on colleagues with a show of bravado. Of course, in Africa, male circumcision is often considered a rite of passage on the way to becoming a man. This usually takes place with a group of boys, who go into the bush for a few days to learn the rituals and intimate knowledge of their tribe. It is much more than male-bonding. Now I could see why it was so important for the group to wait outside. It was almost traditional. Much better than being given an appointment to turn up for surgery starved at a certain time.
The day was really hard work. I was exhausted and dehydrated by 12:30 so I went home for lunch. When I came back at 2pm, Mr Mwanza was still struggling on, by himself. I asked him if he had stopped for a break, for a drink and a bite to eat, but he said he hadn’t. He had asked his wife for a cold Coca Cola, but she brought him a can of Coke Zero.
“What’s the use of that?” I asked. “What you need is a caffeine and sugar boost, and this has neither.”
“My wife doesn’t want me to become a type 2 diabetic,” he replied.
We had a good laugh about this, and continued operating through the afternoon. We didn’t manage to do all ten, however. Some young men were very disappointed to be sent away still intact, but Mr Mwanza said he was on night duty the following day, and he would continue to operate in the evening as the workload was very light after 4:30pm when the consultations ceased.
His back was aching from bending forward during the surgery. I asked Daillies if we could move the patients’ lockers underneath the bed frames to raise them up. I also suggested we could put concrete blocks under the legs of the beds to do the same thing. When I returned the following morning, the beds were up on blocks and had a locker supporting each end of the bedframe.
I have seen two young men with recurrent preputial herpes in the last week. I have recommended that they have male circumcision in an attempt to reduce or eliminate outbreaks. We used to think that the herpes virus lodged in the dorsal root ganglia of the spinal cord. Now we know that the virus lives just under the skin where it erupts, so surgery might be a simple solution. I don’t think I will be here long enough to find out if I was right, unfortunately.
The last time I did a circumcision was in 1987, so it was an interesting day which I had not expected to be involved in before coming to Zambia. But I do have a lingering doubt that having been circumcised, the lads will not bother to use condoms in the future.