The Johnson Gets the Cut

THE JOHNSON GETS THE CUT

            As for phallic terminology, my mental age is stuck somewhere in high school or college. I can rattle off many a euphemism for the male organ, for instance. I can make a quick retort to another guy by using language that refers disparagingly to the size of his member. I can even… well, that’s enough. Suffice it to say this is totally inappropriate when discussing sexually transmitted diseases, and especially HIV/AIDS.

            All of this came to mind last week as I escorted fourteen boys (aged 14 – 15) from my school to undergo safe male circumcision (SMC). Circumcision is the last thing that I thought I would be promoting in Peace Corps. Back in the United States, and in Europe, the opinion is very much mixed as to the wisdom of the procedure, and that reflects my own thinking. But we learned in training that things are much different here in Southern Africa.

            A few years back, scientists noticed that in African countries with high rates of circumcision, HIV rates are much lower. Field studies confirmed the correlation, and with that began a massive SMC effort for men and adolescent boys. The stakes are high. HIV infection rates for adults in Botswana stand at over 30%. The main driver is heterosexual sex, and women have a slightly higher prevalence rate than men. SMC reduces the chances of a man getting infected by 60%. If a large majority of men get circumcised, HIV rates should fall dramatically.

            Our role in schools includes training students on the ABCs: Abstinence, Being faithful (i.e. no multiple sexual partners, which increases infection rates geometrically) and Condom use (every time). All of this requires considerable behavioral change and it must be learned. SMC is different, in that its success is not fully dependent upon behavioral change.

            The Botswana government, United States agencies (USAID, CDC and PEPFAR), the World Health Organization and ACHAP (Africa Comprehensive HIV AIDS Partnership a/k/a the Gates Foundation) are all behind a huge campaign to get males to undergo SMC. Peace Corps volunteers are on the front lines of all this, because we are trusted in our villages and we can deliver results.

            Last fall, I organized separate talks by a nurse for Form 1 and Form 2 boys. I then collected consent forms signed by them and their guardian (usually the mother or other female relative). We scheduled appointments for boys to attend a counseling session at the local clinic (with their guardian) followed by the procedure. Many boys signed the form, fewer followed up with the appointments and procedure.

            Last week, things were different. After lunch on Thursday, an ACHAP luxury combi (minibus) picked up 14 interested boys from our school and took each of them to their homes. The nurse accompanying them spoke with their mother/guardian and got the consent forms signed.

            The next day, Friday, after lunch, the ACHAP combi returned to school to pick up the 14 boys. This time, I accompanied them. We headed to a special one-day SMC clinic occurring in a village 15km from Goodhope. Once on the road, I handed each of them a piece of hard candy. The candy had come from the United States in a recent care package mailed to us. I made a point of telling the boys that the “sweets” came from America, and they responded with delight.

            Upon arrival at a vocational-technical college, we were directed to two classrooms that had been set up for the event. In one, a nurse completed forms for each boy and conducted a rapid HIV test, to make sure each one was negative. In the other, the classroom had been outfitted as a field operating room with three gurneys, privacy screens and medical equipment. The team had an assembly line process going. Still, there were other males already waiting ahead of us.

            So the boys and I sat under a tree for about thirty minutes. We were joined by members of the Botswana national track and field team. SMC clinics often get sports figures to show up, to boost the morale of the waiting boys and to provide an aura of “coolness” to the occasion. I talked to the athletes a bit. They were focused on winning a competition over the weekend so as to get to a world championship in Europe in a few months.

 

Sports stars in Botswana frequently promote circumcision

            Some of the boys were distracted, and clearly nervous. One boy showed me that his heart was pounding hard. I tried to reassure them. I asked about where they lived. One boy responded that he stays in Kgoro, and walks about 12km each way to school every day. He leaves home at 5:30 AM to get to school by 7. In the afternoon he leaves school at 5:30 PM and gets home at around 7. Another boy, a bit of a braggart, said rather naively that he possesses a large unit. I responded that if that were the case, perhaps the doctor would need to use a bigger knife. That brought peals of laughter from his schoolmates. Sensing an opening, I wanted to make some salami themed jokes, but then I thought the better of it.

            The boys were called into the classroom/operating room in groups of two or three. They emerged one by one after about a half hour, armed with a can of fruit drink, a half box of cookies and a commemorative blue backpack with the words “Be Smart. Be Clean. Get Circumcised” emblazoned on the back. Each told me that he was fine, and did not feel a thing. They sat near me and wolfed down the food and drink. About ten minutes later, each boy began to feel groggy, an after effect of the pain medication. They wanted to go home and lie down. We sent home the first group of seven in the combi. They needed room to stretch out. Some had unzipped their undersized school uniform pants to relieve a bulge within. Each log was bandaged with gauze and it was then taped upright to the abdomen.

            I was offered the chance to leave with the first group, but I thought it better to stay until the last boy had finished. In America, boys this age would likely have a parent waiting to drive them home after the procedure. Here, these guys come from homes with no cars, maybe even from homes with absent or deceased parents. While it goes unsaid, many of these boys decided on SMC because they want to avoid the fate of a parent or other relative living with HIV or dead from AIDS.

            It was getting late when we pulled out in the ACHAP combi with the second group of seven boys. We drove each of them home, where hopefully they will have someone to welcome them, put them to bed, bathe the incision site the next day, and see that they get to the clinic two days later. By the time we got to the remote village of Kgoro it was 7 PM and the sun was setting. We drove by a cluster of maybe seven students wearing the Lotlamoreng school uniform. They were walking along the gravel road in their final stretch toward home. We dropped the Kgoro boy off at his home, a two-room cinder block shack on the edge of the village.

            I followed up with the boys on Monday morning. Each survived the weekend. All but a few had made it to the local hospital on Sunday for a check-up.  One who did not was the boy from Kgoro: it was too far for him to walk to the hospital in his condition. So he asked for and I gave him a permission slip to leave school and walk the 1 km up the road to the local clinic. He’ll be fine for now, and maybe as a result of this he will have a brighter future.

 

Back at school, this boy proudly wears his "Be Smart. Be Clean. Get Circumcised" backpack

            I am looking forward to the next group of boys who will travel with me to the SMC clinic this coming Friday. I may even develop the courage to tell them a joystick joke.