September 5, 2013
KAMPALA, UGANDA – When the teenage twin sons of Nangobo Alex Wapepena told their father that they were ready to become men, Wapepena says he knew the time had come for their traditional circumcision ceremony.
The ceremony, known as “imbalu,” is a significant rite of passage for the Bamasaaba, Wapepena’s tribe. With historical roots throughout Uganda, circumcision is also at the center of a Ministry of Health campaign to reduce HIV and AIDS.
But the campaign, which promotes medical circumcision as a means to combat HIV and AIDS, ignores these meaningful traditions, Wapepena says. The campaign focuses only on the physical, and not the cultural, aspects of circumcision.
“The actual circumcision and procession are only small parts of a complex ritual, which involves almost the whole community,” he says.
His twins spent six months preparing for imbalu, he says. During this time, Wapepena and other male relatives counseled them on the meaning of manhood within the Bamasaaba.
Precise rituals accompany the practice of imbalu, he says. During his own circumcision ceremony, he underwent the tradition of “lirima,” in which boys endure four months of pain to prepare them for circumcision. For example, ropes cut off circulation in the boys’ wrists during a 10-day pilgrimage through town. In another part of the tradition, community members ridicule the boys to test their tempers and characters.
Wapepena has not contracted HIV in his lifetime because he went through imbalu and has embodied its essence and principles of responsible manhood in his lifestyle, he says.
“See me,” he says. “Do I look sick? I am not sick. I am a truly circumcised man. The ancestors protect me to this day from sickness because I honored them with imbalu.”
His sons have also remained HIV-negative since their imbalu ceremony in December 2012, Wapepena says.
Circumcision is an important part of both modern and traditional Ugandan culture. But some Ugandan men and health care professionals say that traditional circumcision rituals carry risks of HIV transmission. To reduce the spread of infection, the Ministry of Health is conducting a campaign that circumcises men safely, which officials say complements – not replaces – cultural traditions.
The HIV prevalence rate was 7.3 percent in Uganda as of 2011, according to the Uganda AIDS Commission.
Uganda’s Ministry of Health launched a safe male circumcision campaign in January 2010 to combat HIV and AIDS. The motivation for the campaign was a series of studies that the World Health Organization and the Joint United Nations Programme on HIV/AIDS conducted in 2007 that indicated that circumcised men had lower rates of HIV infection.
Circumcision holds a significant place in many Ugandan cultures.
“Interestingly, the beginning of circumcision has deep roots in ancient public health strategies,” says Eria Olowo Onyango, a lecturer in the Department of Sociology and Anthropology at Makerere University. “It was mainly encouraged to promote hygiene in communities where water was scarce and bathing, irregular.”
The imbalu circumcision ritual among the Bamasaaba involves a season of mentorship on positive aspects of manhood, he says. The actual circumcision is only a small part of the process.
Still, it is a crucial part, community members say.
If young men are resistant to circumcision, elders should forcefully circumcise them, says Jackie Nyamata, a member of the Bagisu community group within the Bamasaaba nation. She counts herself lucky that she married a circumcised man from her community.
“If I had married a Mugisu man and he was not circumcised, I would report him to the elders and have him forcefully circumcised,” she says. “It just is not right for him not to be circumcised. The dirt alone that accumulates beneath the foreskin even after just one day without bathing – imagine that!”
If young men reject circumcision, then community members should go so far as to drug them with a local root that has properties that infuse men with an overwhelming longing to undergo circumcision, she says.
But others say that traditional circumcision practices foster the spread of disease rather than prevent it.
An overexcited crowd may force circumcision on unwilling men, says Samuel Wanyama, a health and community affairs counselor in the Manafwa district of eastern Uganda.
“Usually, the crowd gets overjoyed and does crazy things like forcefully circumcise those who are not circumcised or even sexually assault revelers,” he says. “This is where the traditional circumcision starts to go wrong. Suddenly, these people forget about AIDS, culture and morals when they engage themselves in mass sexual orgies.”
Orgies were once a normal part of circumcision ceremonies, as tradition holds that the first sexual encounter is a rite of passage into manhood, says Michael Wawuyo, an actor and makeup and set designer from eastern Uganda. There were orgies at Wawuyo’s traditional circumcision ceremony 40 years ago but not at his two sons’ ceremony 10 years ago.
Further, overeager young men may engage in sexual activity after circumcision before their wounds have healed, says Dr. Alex Opio, the assistant commissioner of the health sector at the National Disease Control Department in the Ministry of Health. This increases their risk of contracting or transmitting an infection.
The Ministry of Health’s campaign aims to combine the traditional ritual with modern medical practices to prevent HIV transmission.
The campaign takes advantage of existing circumcision practices in Ugandan culture, according to its “Safe Male Circumcision Policy,” which outlines the goals of the campaign. Its stated goal is “to contribute to the reduction of HIV and other sexually transmitted infections through safe male circumcision services.”
Dr. Wamubi Juma, an orthopedic medical officer at Kibuli Muslim Hospital in Kampala, Uganda’s capital, underwent the Ministry of Health’s medical circumcision training in 2010. He circumcised about 115 adult men in January 2013 alone, he says.
Many men opt for medical circumcisions in hospitals rather than traditional circumcisions because they think they are safer, Juma says.
“When I ask them why they have chosen not to undergo the traditional ceremony, they say that they do not like how it is culturally done,” he says. “The same knife circumcises all males for the case of the mass circumcisions on the assumption that all these lads are infection-free.”
Men also opt for medical circumcisions over traditional circumcisions so they can benefit from anesthesia, he says. The hospital procedure enables them to heal faster than a traditional method, too.
But other men, such as Wapepena, say modern medical practices ignore the cultural ritual surrounding circumcision. In response, health professionals say that the Ministry of Health’s campaign complements and increases the safety of traditional practices, not replaces them.
Wanyama, who underwent the campaign’s training, attempts to merge aspects of traditional ceremony with safe medical practices, he says.
“My office tries to ensure that the traditional circumcision is done in hygienic conditions with sterilized knives,” he says.
The Ministry of Health’s goal is not to abolish or to discourage rituals such as imbalu, but to stress the need for safer practices in the face of the spread of HIV and AIDS, Opio says.
“We are not trying to compete with culture,” he says. “Rather, we are working to augment it since health is a national holistic effort.”
That is why the campaign goes by the title ‘Safe Male Circumcision,’ which is a change from its previous title of ‘Safe Medical Male Circumcision,’ he says.
Juma defends the practice of medical circumcision against men who say that the government’s campaign will erode their traditional practices.
“Safety is not the death of a culture but the revival of it,” he says.
There is no accurate count of the number of men who have participated in the campaign, now in its third year, Opio says. But the government is working to gather funds to monitor and to evaluate the campaign’s success.
“Whether or not the campaign is achieving its intended goals remains to be evaluated,” he says. “But we are motivated by the scientific research that proves that circumcision is noted to be significant in mitigating the spread of HIV in communities where its prevalence is high.”
The number of men who undergo circumcision has remained stable before and after the launch of the campaign, says Dr. Matovu Badru, a medical officer and head of clinicians at Kibuli Muslim Hospital. On average, the hospital’s staff circumcises eight people to 10 people a day. Juma says the number of men he circumcises per month has also remained the same.
As long as HIV and AIDS present a public health challenge to Uganda, the government will promote the campaign alongside other prevention strategies, Opio says.
Still, it is important that men recognize that circumcision – whether traditional or medical – is not a foolproof guard against HIV and AIDS, Juma says. He has seen many men die of HIV and AIDS regardless of whether they were circumcised.
“Character – not circumcision – will make you a man,” he says. “They must choose to redeem their immoral and unsafe sexual behaviors and take responsibility for their actions.”