First off, I'll start by saying that it has been fantastic. Overwhelmingly positive. I didn't expect it to begin on such a high note, but since it has, I am reveling in it. My first few hours there I was escorted around the entire facility and to each department, being introduced to all the faces that are fast becoming familiar. My cheeks hurt from smiling and laughing, but in a genuine way. South Africans are like that, full of jokes and gossip, easy to talk to and easy to laugh with.
The next few hours I was tasked to help out in the massive intake room - where everyone's files are haphazardly kept along shelves, ordered numerically... up to a point. I spent the day sifting through the piles looking for names and numbers, hoping to be able to add important test results to their growing files. All of the pathology was coming from a national lab in Green Point, and most often the tests were for creatinine, various thyroid hormones as well as a few STDs (strangely, syphilis was the most common of these). Some files were bursting with paperwork, the outside folder horribly frayed and dilapidated, a hallmark of years of clinic visits. Occasionally, I felt sad when I found test results for one of the disintegrating files - just another paper to add to a stack, sometimes with just more inconclusive results.
The day went quickly, and I was thoroughly amused with the wonderful people of the file room. Bustling back and forth, occasionally shouting banter across the stacks, they kept the mood light while we sifted and sorted. Heideveld is an interesting mix of people. I had known the township itself to be predominantly colored (lighter skinned, Afrikaans speaking) and had assumed that most of the people working in the clinic would be as well. As it turns out, the Heideveld clinic serves a community that extends far beyond its namesake, drawing in patients from many different townships. While many patients are colored, there seemed to be high numbers of black (darker skinned, usually Xhosa speaking) as well as some foreign (usually Zimbabwean or Tanzanian - darker skinned, Shona or Swahili speaking) patients. Even more surprising was that there were a lot of Xhosa speaking black South Africans working in the clinic as well. Both in the file room, and, specifically, in surgery, where I was stationed the following morning.
Without going into too much detail, my day in surgery was entirely about male genitalia.
I attended perhaps twenty five circumcisions, shadowing the surgeon and asking questions about cutting techniques (often times he would switch between a traditional scalpel and one that cauterizes as it cuts), healing, rates of infection and complication, as well as how he felt about the practice in terms of its efficacy against the spread of HIV.
Because that's the real reason that the South African government has begun its campaign to offer free circumcisions to men over the age of 15. There were studies done (the surgeon mentioned Ghana and Johannesburg specifically, though I'm not sure where else) that demonstrated a reduced risk of transmission if the penis is circumcised versus uncircumcised. All of a sudden, the practice has caught on in Western Cape.
Mandy and I had previously joked about the giant billboard we always passed by Mbeki Road that flagrantly read "Girls Like Guys Who're Circumcised" - apparently it wasn't so much of a joke.
However, there are many subtle cultural nuances to this very simple surgery that were exposed throughout the day, and that I found much more fascinating than the simple fact that I spent six or so hours staring intently at flaccid, often bloody, penis.
For instance, while we were both leaning over one particularly intense suture job, I asked the nurse who was stitching about the boys who had come in. It was quite racially segregated, she explained. Black South Africans often have their own rites and rituals when it comes to circumcision, and around 14 years old, boys are sent off into the bush and meet with an elder man who is experienced in making 'the cut'. The entire experience is about moving from boyhood and becoming a man, and is entwined with several other physical hardships and tests of emotional endurance. In contrast, white South African parents (I think she meant mostly in the Western Cape) generally have their boys circumcised after birth, as would be the normative tradition in the United States.
Ahah, I thought, glancing down, that leaves coloreds. Like usual, the colored population falls in the middle, and while they don't often circumcise boys at birth, they don't have a traditional cultural ritual surrounding the practice either. So, instead, they come to the government clinic after 15 years old and spend a few hours nervously waiting and glancing around, becoming best brus with the guy next to them, and sometimes crying through the cutting.
Generally, the men would come in (after getting their folder from the chaos that is intake) and take a seat in the hallway leading up to the surgical theater. There they would wait to be called, one by one, to answer a few pre-op questions (medical history, current medications, age, etc.) and have their blood test and pulse taken. After returning to sit for a bit longer in the hallway, they would be called back in to a private consultation room with a woman who works specifically with HIV/AIDS awareness. I had the opportunity to chat with her afterwards and was thrilled to find out she had previously worked in a clothing factory and had left her job after receiving basic HIV/AIDS awareness and counseling training, feeling the need to help as many people as she could, unable to rest with the notion that South Africa was suffering this epidemic through lack of awareness and because of stigma.
She would take each patient in for a quick consultation and a finger prick. Each HIV test was a simple white cartridge with a control line as well as two antibody markers. Like many similar tests (for you ladies out there, think pregnancy tests) one line means the test has worked (and if no other line shows up, negative). Two lines means positive.
I asked her the procedure if a test read positive and she explained that if the patient knew already of their status and had a CD4 count available, they were simply booked for a different day with other HIV positive patients (without this being common knowledge of course). If the patient was unaware of their status, they were given initial counselling as well as directed toward weekly support groups, given an appointment at a clinic dispensing ARVs as well as sent for a CD4 count. For those of you unfamiliar with HIV/AIDS progression, your number of CD4 expressing T-cells is directly related to how advanced your condition is. T-cells are an integral component to your immune system and its function, and T-cells expressing CD4 help in that fight; lower numbers of CD4 expressing T-cells means your body is less able to combat infection, leading to the development of AIDS.
After the HIV consultation and blood test, the patient was sent back out into the hallway, awaiting his turn to be called to one of the three rickety beds behind makeshift curtains. The curtains, needless to say, didn't offer much privacy, and walking in to see the patient in front of you mid-cutting certainly didn't put them at ease. Worse, however, was the fact that each patient could hear the others groans, cries or occasionally screams of pain just before it was their turn.
After unceremoniously dropping their pants and seating themselves on the bed, the men were each scrubbed from navel to thigh with betadine and the nurse deftly administered a local anesthetic (ligocaine - perhaps a close patent relative of the well known lidocaine in the USA?) directly to the base of the shaft of the penis. Most of the patients found this excruciating, and were quite vocal about their opinion. When the actual cutting began (when the surgeon rotated to that bed), some only tensed and covered their eyes, while others nearly jumped from the bed, screaming in protest. However, they usually calmed down by the time the surgeon was done cauterizing the errant vessels that were seeping blood across gowned laps and preforming the first ventral stitch. And by the time the nurse had taken over for the last few stitches, they were inquiring about post operative care as if nothing had happened, tears still wet on some of their faces. The nurses chalked most of their antics up to psychological pain and the trauma of having their genitalia cut into, though once I did see them administer an extra 2 ml of ligocaine to a fourteen year old boy in quite a panic. I had asked them about what they used to determine how much ligocaine to give each patient, noting that they hadn't taken anyone's weight before surgery, and they simply answered: age. Ahah, I thought again, now I know why some cry more than others.
Interestingly, South Africans tend to say "it's sore" instead of "it hurts" - making it sound quite strange to the American listener. While we may register sore to mean a dull ache, they seem to associate it with the sharp cutting of the scalpel or the pull of a surgical needle and thread. Needless to say, there was a lot of crying, plenty of praying and even some singing as boys from the age of 14 on to men as old as 69 lost their foreskin, were bandaged up and sent home.
- Rh
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