An edict by the king of the Zulus to bring back circumcision for thousands of teenage boys is causing alarm in South Africa, amid record numbers of deaths from the traditional manhood ritual.

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On Tuesday, at a meeting called in Durban by the government of KwaZulu-Natal, traditional leaders in the province will outline how they wish to implement King Goodwill Zwelithini's decision to reintroduce circumcision 200 years after it was scrapped by King Shaka. But health officials working with South Africa's second largest tribe, the Xhosa – who never gave up the practice – say the move could put thousands of lives at risk.

"We have had a disastrous year, with 80 deaths, including two suicides," said Sizwe Kupela, a Xhosa who is health spokesman for the Eastern Cape. Each year, 50,000 Xhosa boys descend on the vast province to undergo the secretive ritual – including circumcision by a "traditional surgeon" and one month's seclusion in nakedness. "We see horrific cases of rotting penises, septicaemia and inadvertent castrations," he said. "Others die from dehydration and hypothermia. HIV is spread because the same knife is used on large groups of boys. My personal view is that if the Zulus go back to circumcision, they must do it the western way, in hospital.''

Last Saturday, wrapped in a blanket, 19-year-old Andile Ngcolomba ended his month in seclusion by walking off the aloe-covered slopes of Peddie into his mother's impoverished village in Qamini Location.

He remembered very little about the visit he received in his mountain shelter on 7 December from the traditional surgeon: "He arrives covered in clay and animal pelts. He is so ugly you don't want to look at him. I never even saw the knife. You just black out. When you wake up, it is done, and there is some powder there to help the healing.

"I did not sleep for seven nights for the pain. To help the pain and healing, they gave me dagga [marijuana] to smoke and I was not allowed to drink water or have salt in my food for a week after the cutting.''­

During his time "on the mountain", Ngcolomba and other initiates in adjacent shelters received visits every other day from an ikangata (teacher), Mazinyanwana Mkhongi. The teacher, in his 70s, said: "My role is to check that the wound is healing and to explain the duties and responsibilities of a man. He must be able to survive in the wild, fight, but also resolve conflicts.''

Ngcolomba, who lives with his mother and elder sister in the Cape township of Khayelitsha, had gained a warrior name, Nasayi, and been briefed by his teacher on the terrible dangers of the witches of Peddie, said to be among the most fearsome anywhere.

After enduring the process, he was more convinced than ever of its virtues: "To us Xhosas, circumcision is what makes you a man. All my friends are doing it. Without it you are inkwenkwe – a boy – and you are not allowed to mix with men. Hospital circumcision does not count. You are not a man unless you have survived what I went through. No man can be a leader without it. To me, now, President Jacob Zuma is a boy because he is an uncircumcised Zulu."

Former presidents Nelson Mandela and Thabo Mbeki and Archbishop Desmond Tutu are all circumcised Xhosas. Whenever prominent South African figures misbehave, Xhosa title-tattle centres on whether they have been ­circumcised.

Xhosas frequently denigrate Julius Malema – the outspoken leader of the African National Congress Youth League – because he is an uncircumcised Zulu. In 2008, ANC politician Fikile Mbalula succumbed to peer pressure and, aged 37, entered an initiation school. He later became deputy minister of police.

King Zwelithini claims to be reintroducing circumcision for Zulu boys because there is evidence that the practice sharply reduces HIV transmission. However, with a Zulu president in power, it is likely that the king is equally motivated by a desire to bolster his nation.

Critics of initiation say traditional leaders have failed to update their teachings from the times when the ritual was put in place to select and grade warriors. Despite undergoing government training courses, teachers largely do not address burning South African concerns such as HIV prevention or sexual violence.

The tradition also places a tremendous financial burden on poor families. Goats, blankets and bottles of Viceroy brandy and Smirnoff vodka must be bought. After initiation, a young man must be bought a suit and cap and must throw away his entire wardrobe, including underwear, shoes, school uniform and school bag from his boyhood. Even his mobile phone must go.

During Ngcolomba's seclusion, he was not allowed to see women. His aunt, Nobhukulu, cooked him two meals a day on her hearth and they were taken to him by local boys. Only on emerging from seclusion were women's concerns briefly addressed. Ngcolomba sat in a hut to which his aunts were invited, to present him with gifts and impart views such as "please do not spend all your time in the shebeen".

Aids campaigner Vuyiseka Dubula, secretary general of the Treatment Action Campaign, is concerned that the Zulu king's decision to reintroduce circumcision could put thousands more lives in danger. But she said it was not too late for King Zwelithini to use his decree to mark a revolutionary step forward for both Zulu and Xhosa men.

"Most new incidences of HIV are among women," said Dubula, secretary general of the Treatment Action ­Campaign. "Initiation should be about education, including respecting women. I am a Xhosa woman and I know the initiates are taught how to use their power, not how to control it. If this could be changed, while not alienating the traditional leaders, we could see a new generation of men emerge, circumcised and more responsible.''

Sizwe Kupela was less optimistic. "I have a two-year-old son and I will never allow him to go through what I endured," he said. "I am talking to his mother about a hospital circumcision now. My personal view is that the king needs to order Zulu infants to be circumcised under sterile conditions. If the king wants to reduce HIV, it is no good waiting until boys are 18 and already sexually active."

A member of the KwaZulu-Natal health department, speaking on condition of anonymity, said the department hoped to convince Zulu traditional leaders of the virtues of medical circumcision over the Xhosa approach.
Circumcision and health
A key factor in the decision by King Goodwill Zwelithini to bring back circumcision has been the disproportionate impact of HIV on the Zulu people. "Bacteria can linger under the foreskin and the resulting infections can make glands more susceptible to the transmission of HIV," says Tim Oliver, an emeritus professor at Queen Mary University, London. "Statistics indicate that circumcision has helped to halt the spread of HIV in southern Africa."

Other health benefits linked to circumcision include reduced rates for penile, cervical and possibly prostate cancer. In people of Jewish and Arab origin, who traditionally circumcise their boys and young men, rates of the first two diseases are generally very low.

However, the connection between circumcision and disease prevention is not straightforward. "Studies that have compared disease rates in circumcised and uncircumcised men have not fully teased out the possible roles of other variables," adds Oliver. "Instead of circumcising, it may be just as effective to provide good sexual education and make sure fresh water is available to communities so good hygiene can be practised."

Certainly the risks of circumcision as practised by people such as the Xhosa are substantial and include the danger of developing septicaemia and other infections. In his autobiography, Nelson Mandela says his circumcision, part of his coming-of-age ceremony, left him feeling "as if fire was shooting" through his veins. "Today with modern local anaesthetic this need not be the case," says Oliver. "It worries me that the Zulu king intends this to be a test of courage."

Thus the question facing Africa is whether more circumcision is needed, or whether the same investment – spent on improving access to running water and on education at puberty about foreskin and general sexual hygiene – would provide a greater all-round health gain.