Circumcision deaths in 2013: reports from Eastern Cape & Mpumalanga provincial Departments of Health

Meeting report

Circumcision deaths and initiatives taken to prevent them in 2013 summer
Eastern Cape Initiation Report
A report was presented outlining the steps taken by the Eastern Cape to prevent deaths resulting from traditional initiation ceremonies, noting that this had been a major area of focus of the Eastern Cape provincial government. The Eastern Cape Department of Health (ECDoH) as well as it House of Traditional Leaders (HTL), provincial Department of Education (DoE) and South African Police Service (SAPS) were spearheading the implementation of the Initiation Monitoring and Intervention Strategy to ensure the safe passage of initiates from boyhood to manhood. A multi-sectoral initiation monitoring team was established, with the Overall Response Team of MECs, and key leadership in various sectors was led by Nkosi Ngangomhlaba.

It was noted that the Technical Coordinating Multi-Sector Team consisted of the HTL, National and provincial Departments of Health, NGOs, Department of Social Development, SAPS and CODEFSA, an NGO working with Eastern Cape. The Multi-Sectoral Monitoring Team consisted of HTL, the Departments of Social Development, SAPS, Health, Educaiton and NGOs. Traditional leaders led the Initiation Forums and Monitoring teams.

Pre-Initiation build up activities towards the Summer Initiation Workshop for key strategic departments included the HTLs, Departments of Local Government and Traditional Affairs, Health, Education , Social Development, CODEFSA and SALS. Traditional Councils were reached by HTL Executive teams, an Imbumba Yamakhosikazi Akomkhulu, and other stakeholders such as schools, churches, community Imbizos and community radio campaigns were also promoting safe initiation.

Preparation for the Summer 2013 season included the training of traditional surgeons and nurses, monitoring teams that standardised the operational procedures and equipment needed during the monitoring of the initiation schools, the Summer Initiation Launch event and the deployment of the Provincial Technical Monitoring Teams to districts. Further preparation included provision of surgical supplies to all the monitoring teams, provision of clinical personnel to all monitoring teams in the province, deployment of doctors to the OR Tambo Municipal District, preparation and ensuring the readiness of health facilities to admit and manage initiation complications, and establishment of rescue centres facilitated by CODEFSA and supported by male nurses from the Provincial Department of Health.

Health facility readiness included the identification of five main referral hospitals in OR Tambo and Alfred Nzo. These hospitals were St Patrick hospital for Alfred Nzo district, St Elizabeth hospital for Quakeni Sub-District supported by Holy Cross and Bambisana Hospitals, St. Barnabas hospital for Nyandeni Sub District supported by Canzibe and Silimela hospitals, St. Lucy’s hospital for Mhlontlo supported by Malizo Mpehle and Nessie Night hospitals and Mthatha General for KSD Sub-district supported by NMAH.

The statistics indicated that there were 12 310 legal initiation schools and 42 396 legal initiates, compared to 334 illegal initiation schools and 707 illegal initiates. There were 311 hospital admissions. There were 9 amputations of the penis and 43 deaths. The majority of initiate deaths were caused by septicaemia, which accounted for 19 deaths, dehydration that caused 13 deaths, accidents causing 6 deaths, “other” resulting in five deaths, four deaths related to gangrene and three with kidney problems, and two deaths resulting from assaults.

A summer season review workshop was held on 14 January 2014 to critically review the 2013 December/January initiation season and to prepare a comprehensive report that would present recommendations of what programmes of  action should be considered in the future.

A number of challenges were reported. Not every district or local area had established Initiation Forums while traditional circumcision schools were not easily accessible to monitoring teams as they were situated on mountainous terrain.  Initiation schools could not be reached on time as they were scattered throughout the province and often not easily identified. Sepsis had been observed as the most common occurrence in most initiation schools. Partial circumcision still occurred in the Nyandeni and Mhlontlo areas. Initiates fled when they saw monitoring teams for fear of discrimination, while some refused to be taken to hospital. Illegally established initiation schools were still a persistent challenge in the OR Tambo and Alfred Nzo districts. Parents were reported to be against medical treatment of their children with antiseptic ointments and bandages. Discrimination against initiates who sought medical help occurred both by peers and communities. It was observed that underage circumcision was occurring in the Pondoland area. There was no legislation guiding circumcision in the province. Furthermore there was a lack of commitment from municipalities and other government departments. Lastly, there was a high rate of substance abuse by initiates.

Recommendations included the immediate development of national and provincial initiation legislation, institutionalisation of initiation management practice, standardisation of the Initiation Monitoring Teams and Local Forums with clear Terms of Reference, the development and implementation of broader integrated five year strategic plans and year-long programmes of actions and adequate budget allocations for the initiation programme.  Furthermore, centralisation of initiation schools was needed, as was enhanced involvement of traditional leaders at the local level . There was a need to improve the technical training for traditional nurses and surgeons, and a need to ensure vigorous police intervention to secure convictions. Parents and communities needed to be better informed, with parents taking responsibility for their children. There was a need for active involvement and contribution by local municipalities. Finally, psychosocial support for victims of penile injury and peers of deceased initiates was required.

The five year plan for the next season included the review of the current legislative framework, the centralisation of the initiation schools in designated areas, the establishment of local initiation forums with training and provision of the Terms of Reference clearly defined. Furthermore training of male nurses and surgeons had to occur. A database would be established. Vigorous outreach programmes, community mobilisations, Imbizos, community engagement and youth consultation programmes were required. Boys needed to be registered for the initiation through the local traditional council. A workshop for women was required to reinforce their role. A nerve centre should be established to coordinate the monitoring activities during the season, and rescue centres should be established.

Resources required for this period included adequate budget, human resources, doctors and male nurses, food packs, stipends for forum members, transport, communication tools, medical supplies, accommodation for the monitoring team and protective clothing.

Mpumalanga Department of Health Briefing
Mr Josh Motlhamme, District Manager, Mpumalanga Provincial Department of Health, explained the purpose of the presentation and apologised for not being able to submit the report to the Committee in writing on time.

Mr Elphas Nkosi, Senior Manager, Mpumalanga Department of Health, said that he would outline the deaths during the 2013 season, and set out the strategies that this province had put in place. In Mpumalanga, there had been an unprecedented number of complications resulting from circumcisions in 2009 at traditional circumcision sites. The Provincial Department of Health (PDoH) responded by establishing the Ingoma and a team for medical and surveillance support to the Ingomas. There were 138 traditional leaders authorised by his Majesty.  57 traditional surgeons were trained by the forum and 30 148 initiates were covered by the Ingoma forum. There were 31 deaths. The PDoH engaged with stakeholders to establish how they could create an environment in which all the relevant stakeholders played their role. Stakeholders included the PDoH, Department of Cooperative Governance and Traditional Affairs, the South African Police Service, general practitioners, social development workers and local municipalities. The strategies put in place were intended to strengthen planning, prior to the departure of the initiates, monitor the initiation schools, dedicate more health professionals to upscale support to the traditional leaders on health related issues and to get the legislation of the Ingoma regulated. The stakeholders also looked at how to mitigate against the loss of life during the initiation, and mentioned that focus should be placed on the promulgation of the Ingoma Bill, which was being prepared in Mpumalanga.

The main objective of this Bill was to regulate the holding of the Ingoma, because it was realised that certain people were opportunistic, taking advantage of the situation for personal gains, at the expense of the lives of the initiates. These people were not authorized, had no experience and had no rights or authority provided by the traditional leadership to conduct an Ingoma. The promulgation of the Bill would, it was suggested, address these issues. The Ingoma Bill also provided for prohibition of forced attendance of the Ingoma. All initiates were to attend the Ingoma voluntarily. There had been cases where young boys had been abducted and they could not get back home, with parents having to “buy them back”. The Ingoma Bill also sought to provide methods for implementation and monitoring of health and hygienic standards and to prevent the unnecessary loss of life that would undermine the cultural and traditional practices.

The roles of the various stakeholders were also looked into. The Department of Health came to an agreement that it needed to ensure the availability of resources. This was especially important in terms of the training of the traditional surgeons, to show them where to cut, how to cut and how much of the skin needed to be cut so that ultimately the initiates did not have to return for corrective surgery. That Department also took it upon itself to conduct health screening of all registered initiates and treat all minor ailments detected prior to traditional circumcision. The PDoH was aware that in South Africa there were a number of people with chronic conditions requiring advanced screening and revision of treatment before they went for circumcision. The PDoH would also identify high risk cases, classifying them as unfit to undergo traditional circumcision and advise them of the fact that until they completed their treatment they could not be circumcised.

PDoH would also provide the necessary commodities for the period of the Ingoma such as surgical gloves, blades and other related material that might be required for the Ingoma. Those initiates on chronic medication would be given enough supply for the period. In the past, the Ingoma had always been a no-go area, so that initiates were unable to get their chronic medication. Health professionals and private practitioners who had undergone initiation themselves would be deployed to assist during the Ingoma at all sites, as it was accepted that, traditionally, only certainly people were allowed to attend the Ingoma.

Emergency Services would be on standby to assist, so that if any casualty needed to be transported to the hospital, this could be done immediately. Medical tents would be erected on major sites for the management of major and minor adverse events, and teams would assess initiates for quick referral to the hospital. The team would ensure that there would be transport available for health professionals to support all the Ingoma sites, in line with pre-planned demarcation or clustering, with each one having a cluster to manage.

The Department would further provide forensic pathology services so that in the case where there might be initiate deaths, the cause of death could be identified, and a forensic report made available to support any referral to the National Prosecuting Authority. Furthermore, there would be a database developed, for all traditional initiation schools in the province. The purpose of the Ingoma Forum was to provide a platform for male discussion and dialogue talks, to share ideas regarding male initiation, to harmonise ideas between the tribal and health authorities to ensure a safe initiation process. So far, the steps taken covered the identification and coordination of stakeholders, their roles, needs and expectations. The Forum further ensured that all Ingoma holders were authorised by the House of Traditional Leadership.

The initiates themselves had a role to play, as they were partners in the whole process. Those who were considered to be minors would have to obtain signed consent from the parent/guardian. In the absence of the consent form being produced, it would be said that permission was not granted and without it no initiation could occur. The initiates must also produce this consent form for the general health screening, which was to take place at least two months before the initiation began, for this should be sufficient notice should any initiates suffer from minor ailments and require treatment. All initiates through the Ingoma Forum are expected to use health facilities and forms would be developed to monitor this process. Reports must be presented to management, without any delay, on any adverse event.

The person who wanted to hold an Ingoma must first obtain approval for such from the king or queen of the traditional community or the MEC for Cooperative Governance and Traditional Affairs. That person must also obtain approval for the use of the private land from the owner or the municipality, because another major issue had been the invasion of private land without consent.

He noted, in conclusion, that the PDoH was aware that South Africa embraced cultural diversity, and sought to create an enabling and conducive environment for safer traditional practices.

Discussion
The Chairperson said that it would have been useful, had the Eastern Cape Department of Health been present to deliver the briefing. She said it was unfortunate that the Limpopo Province did not send through its presentation.

Mr G Mokgoro (ANC, Northern Cape) stated that the presentation gave the impression that some concerted effort had been made to bring this issue under control. He acknowledged that the issue had been taken seriously by Mpumalanga and thanked it for its efforts, which surpassed those of the Eastern Cape despite the fact that this department had a bigger problem. Noting his appreciation for how the PDoH had set out and was dealing with the issues, he noted that there were no statistics provided on the deaths in the last season.

Mr D Worth (DA Free State) thanked the PDoH but shared Mr Mokgoro’s desire to be presented with actual figures. He noted that, for the last six years, the Eastern Cape PDoH had set out the figures, showing hospital admissions and deaths, number of amputations, legal initiates and illegal initiates as well as the number of people who had been arrested for illegal initiation. It would be helpful to see how the situation had improved or deteriorated, how many legal initiates there were and how many illegal doctors were performing operations.

The Chairperson was pleased to see the focus on prevention, but remained concerned that the proposed legislation, tabled as far back as 2007, had not yet been passed.  She asked where the process had stalled, where the difficulties were, and specifically, whether there was opposition from the initiation schools. She asked whether the Bill was going through a public participation process. She too mentioned the lack of statistics and emphasised that the Committee needed to know how many initiation schools were legal or illegal, and what the main causes of death were. The Eastern Cape report highlighted that when initiates sought medical attention, these children were rejected on the basis that they were “not man enough” and parents were pressurized to take their children, who required medical assistance, away. This was not an issue covered in the Mpumalanga presentation and she asked if the same pertained there.

Mr G Mokgoro suggested that the Committee grant the Mpumalanga PDoH the opportunity to present a revised report with the necessary statistics and details as recommended today.

Mr Motlhamme thanked the Committee for their feedback and suggested that Mr Musa Thugwana (Condom Logistics Officer Mpumalanga and Chairperson of Ingoma Forum) also be allowed to speak, before Mr Nkosi responded, in order to give more information to the meeting.

Mr Thugwana explained that after consultation, health professionals who had themselves undergone cultural rituals were urged to form a Forum and platform to establish dialogue with the traditional leaders. They faced resistance from some traditional leaders who would not allow medical assistance, but these 25 professionals were able to cover 30 148 initiates in the province. He noted that 142 traditional leaders held the Ingoma during this period. Professionals were allocated to rescue centres that were established at circumcision sites in the wilderness. Another strategy that was successful was to have initiates fill in pre-screening forms. He stated that 70% of the forms were completed and returned. This allowed the PDoH to detect many chronic condition patients amongst the initiates. He suggested that this should become a standard requirement prior to initiation. The Forum was holding meetings with CODEFSA, in order to find solutions to the issues hindering the safe practice of initiation.

Mr Nkosi appreciated the feedback from the committee and mentioned that it would be an improvement should the report set out the relevant statistics to illustrate the progress. He also appreciated the availability of resources from the Department of Health, in the form of a sufficient budget and training to traditional leaders. This province was striving for a zero death rate. He stated that there had been some improvements, particularly in getting stakeholders on board, but there was indeed resistance to the passing the Bill from traditional leaders who felt that this legislation would be encroaching on their territory. The Forum had therefore approached the provincial House of Traditional Leaders to present and clarify the roles around circumcision and that had assisted much. Not all traditional leaders understood the issues yet. The Forum ha also launched an open day to which communities, local councillors, The House of Traditional Leaders and traditional health practitioners were invited so that these issues might be debated. He stated that the PDoH would work to getting the Bill promulgated and enforced. The Department of Health was humbled and honoured to have received a letter requesting support from the King, indicating that even he was concerned with the number of deaths as a result of circumcision.

Mr Motlhamme summarised again that the presenters would present a comprehensive summary of the requested numbers at a later stage.

The Chairperson emphasised that the key objective behind this was to avoid loss of life arising from circumcisions.

The meeting was adjourned.