King Mswati III International Airport

P1000738Swaziland’s first international airport was quite close to the clinic in Matsapha. A new airport was built in an isolated spot called Sikhuphe, coming into service last year. It was named King Mswati III International, in honour of the present ruling monarch.

The new airport is very impressive. The white concrete and glass building rises out of the dusty scrubland like a mirage. I’m not sure why this remote spot was chosen for the new airport. It is a long way from the main population hub of Manzinin-Matsapha-Mbabane. It would probably be quicker and cheaper to drive to Jo’burg from Mbabane than driving to KM III IA, and taking a scheduled flight. It may be inconvenient to get to, but it is probably the only international airport which doesn’t charge for parking.

P1030184

The exterior walls flanking the main building are painted with Swazi emblems, shields and cattle. The surrounding grass lawns resemble green baize. Massive glass doors slide open automatically as you approach the entrance hall. It is really pleasant inside, bright and airy. The special glass keeps the building cool by reflecting the heat. Sadly, a couple of the huge panes of glass are broken. I pondered how this could have happened and came up with the idea that pebbles might have been hurled out by rotatory grass mowers.

On the interior walls there are massive billboards advertising Swaziland’s treasures. There is a tiny medical centre (just in case you arrive from Asia with MERS) and a small bar-restaurant. One door is marked with the symbol of a teacup and a sign “Staff Only” – pretty self-explanatory.

Although it may be technically correct to call it “international”, the only city you can fly to directly from Swaziland is Jo’burg. Mozambique’s capital, Maputo, is just three hours away by road, so not surprisingly, there is no demand for an air connection. Harare and Durban may be a profitable routes in the future. But the three large parking spaces for aircraft in front of the terminal are empty for 99% of the time. South African Airlink has a few flights a day, using small 20-seater jets flying the one hour hop across the border. There is one runway, but it is very long. Perhaps the planners foresaw larger jets or military planes landing at the airport in the future.

P1030569

This might be an “urban myth” but I heard that when the new airport first opened, a plane from Jo’burg arrived but needed refuelling. The waiting passengers boarded the plane only to hear the pilot saying that there was no avgas at the new airport. There was still a fuel depot at the Matsapha airport. No one could contact the driver of a tanker to transport fuel to Sikhuphe. The captain took off, having decided he probably had enough avgas vapour to get from Sikhuphe to Matsapha, where he could refuel. The people on board must have been praying furiously and the flight was successful. How did “put aviation fuel in the new storage tanks” get missed off the checklist for opening the new airport?

There’s nowt so queer as folk

“You have risen me up from the dead!” said the delighted gogo. I hadn’t a clue how I had done this. I try to do my best for my patients, but I don’t do miracles. She saw from the look on my face that I was perplexed. “You cured my sugar, docotela,” she said. “Don’t you remember?”

This lady is not the one referred to in the text.
This lady is not the one referred to in the text.

Well, I had diagnosed and treated her diabetes after she’d been unwell for months. But now I had to get over the message that diabetes was for life, and would always need treatment. It is true that some people can change their lifestyle so radically that they can become non-diabetic (take a bow, father), but this is rare. Some Swazis find the concept of needing to take medication continuously for a chronic disease rather strange. Doctors are powerful, their “muti” (drugs) should be able to defeat the disease. Once the hypertension or the diabetes is controlled, they think the job’s done and there is no need to continue taking medication, especially when they feel well.

A few days ago, a young lady, who was carrying a baby on her back, gave me a beaming smile when she encountered me in the clinic corridor. “Your special muti has made me a new person. I feel great on the new tablets,” she effused. This isn’t normal Swazi behaviour. People often avoid eye contact with their “betters” and would not normally approach their doctor in such an outgoing, disrespectful way. I smelled a rat. Could this woman be one of the fifty or so patients whose medication I had switched from NVP to EFV? Is this the beginning of euphoria leading to mania?

P1020698I might well be suspicious. Yesterday, I saw a woman in clinic who had become acutely disturbed a week after starting EFV. She had stopped sleeping, was pacing around all night, could not stop talking and accusing her neighbours of plotting against her. She had even trashed her room (“She has become a vandal, doc!”). She escaped from the clinic, pursued by her relatives, whom she called “demons”. I ran after them and caught up with her when she sat down in the driveway of a housing estate after being denied access by security guards. She was lustily singing hymns and rolling her eyes. She told me I could not treat her because I was in a different century. I offered her some medication, but she dashed the 10mg haloperidol and diazepam out of my hand.

I left her with the security guards and went back to the clinic. We informed the police who were empowered to take her to the National Psychiatric Hospital. They didn’t have a vehicle available, so we sent our ambulance to pick up the constables and transport them to the patient.

‘All the world is queer save thee and me, and even thou art a little queer.’ Robert Owen

A man in his 40s came to consult me about his failing memory. I fell into the trap immediately. “How long has this been troubling you?” I asked. “I don’t know. I can’t remember,” he replied. He reached into his plastic bag and pulled out a sheaf of loose medical records. I saw an A4 pale green card, only used here by the National Psychiatric Hospital. “Can I have a look at this?” I asked. It showed that he was taking a small dose of carbamazepine, which is the standard treatment for bipolar affective disorder ( what used to be known as manic depression).

“Do you go to see Dr Violet, the consultant psychiatrist?” I asked. He couldn’t remember, even though he had been given a prescription just four weeks ago. He said he was running out of tablets, so I gave him another prescription, wrote on his psych records and asked him if he would remember to take the medication. “I hope so,” he replied.

No relation to the person described in the text
No relation to the person described in the text

“My faith healer has told me that my baby’s umbilical cord is too thin, so I must have an operative delivery,” said the anxious young lady in front of me.

“How did he diagnose this? Does he have an ultrasound scanner?” I asked.

“No scanner, he just put his hands on my bump,” she replied.

“Why have you come to me? Why didn’t your healer refer you directly to the hospital for the delivery?”

“I don’t know. He told me to come to you. But you must send me soon, to stop my baby from dying,” she said.

I examined her. She was 17 and about 32 weeks into her first pregnancy, abandoned by her boyfriend and berated by her mother. I couldn’t find anything wrong with her pregnancy, so I sent her to our psychosocial counsellor at the antenatal clinic. Unfortunately, no one could persuade her that the baby was growing normally. I gave in and referred her for an ultrasound scan.

A week later, accompanied by her mother, she came back to clinic with the result. It was fine: cord seen, normal diameter, normal pregnancy. Her mother sat beside her with her arms folded under her ample bosom. She started to answer all the questions I directed at her daughter, so I had to find a way of shutting her up. “Ok, ma, tell me what you think about the situation,” I said.

This unleashed a non-stop diatribe – she should never have taken up with that useless boy, she knew about contraception but didn’t use it, now she’s pregnant, HIV positive and going to be a single mother. Her chances of having a career are over, she’s going to be a professional baby mother from now on. This pregnancy has always been ill-fated. She has vomited for most of it, despite using western and traditional medicine (drinking lemon juice and water then eating orange peel). Probably been vomiting her HIV medication, too.

I felt I had to intervene. This poor lass had had a rough time, I said that she needed some support.

“That’s why we took her to the Zionist pastor, who specialises in helping pregnant women. He has got a big reputation. He helps everyone.”

“Is he the one that uses Nigerian ‘holy water’? ” I asked.

“No, we went to him as well, but it didn’t work.”

“Right, you have had your say, ma. Now I want to hear from your daughter.”

She was in tears, of course. A frightened girl whose dreams of romance had been dashed. I tried my best to salvage some of the good bits. The baby was normal. The HIV medication would greatly reduce the risks of the baby being infected. There was still the chance she could continue her education and pursue a career, with help from her family. She dried her eyes and said she would come back and see me in two weeks.

This lady doesn't need any treatment.
This lady doesn’t need any treatment.

The nurse seeing outpatients had gone for her hour-long lunch break and the queue was stretching down the corridor, so I stepped in. My first patient was a large lady weighing well over 100kg. Someone that Alexander McCall Smith (author of The No. 1 Ladies Detective Agency) would describe as “traditionally built”. We discussed her headaches and sides pain for a while, then I noticed her legs. The right leg was distinctly fatter than the left. “I have pain in my left leg, it can’t walk properly, it feels weak. Look, it doesn’t look strong,” she said. As she was so large, I examined her while she was sitting down. I told her I thought that it was the right leg which had the problem, but she insisted I was wrong. With a lot of heaving, I managed to get her up onto the examination couch. I was sure the problem was an old deep vein thrombosis in her right leg.
P1030566
I called in a senior nurse to help me. Perhaps I was losing something in translation. He chatted to her for a while and told me that indeed she had been to hospital when this first happened. The doctors had told her that there was a blockage in the veins. But this was so long ago that she had forgotten which leg had been affected. Her thinking was that a large fat leg must be stronger than a thinner leg.

On the front of her medical records book it said that her religion was Zionist. This Christian sect draws its inspiration from the Old Testament. As part of the service, the congregation en masse walks round and round a central post in an anti-clockwise direction. I had a sudden brainwave. If she has a weaker left leg, it would suit her when walking anti-clockwise around the pole at church. I couldn’t resist asking her if she circumambulated at church. She said she was too tired to do that, she just sat and watched from her pew.

Last Week’s News

It’s been a quiet week in Swaziland. An arsonist firebombed a house so efficiently that he set himself on fire and had to be admitted to hospital with burns to his “private parts”. Perhaps he should be referred to as an “arse-onfire-ist”.

A police officer became a cowboy for an hour, as he herded some cattle away from the main road between Manzini and Mbabane. A full colour advertisement promoted looking after your cows in a responsible manner, but one old lady got into trouble with the law because her cows strayed onto a road. She was told to sell the cows and put the money into the bank. She refused saying that banks would misappropriate her money.

P1040289

The World Health Organisation has named Swaziland as having the second highest obesity rate in Africa. I bet you can’t guess which country took the number one spot. Answer at the end of the post.

Sex always features strongly in the paper. A serial rapist was caught in a forested area near the border with South Africa. He caught women who were collecting firewood. His chat up line was that they were at risk of being gang raped, but alternatively they could submit to his advances. He is on remand.

Another chap was fined 2,000 Rand because he forcibly kissed his sister-in-law. The magistrate asked him why he only had one girlfriend. If he liked kissing so much, he should get another girlfriend closer to his home. After all, there was no law in the Bible or in the kingdom about how many girlfriends a man could have. He could have ten if he liked.

Another article was headed “180 school boys drop out after impregnating girls”. At first I thought that these lads had left school in order to help bring up their offspring, but this was not mentioned at all. The 634 school girls who became pregnant and dropped out did not get the headline. The author says that “shaking our heads and wondering what went wrong” is not enough.

Finally, there is a series of warning cartoons, advising against taking selfies in dangerous situations. Well, one chap fell down a ravine last month when he was using WhatsApp on his mobile phone, and not looking where he was headed.

The fattest country in Africa is…Seychelles.

We all make mistakes

Her gnarled hands lay in her lap, looking painful. The knuckles were swollen, the fingers distorted and the palm muscles which controlled her thumbs were wasted. I made a diagnosis of long standing, “burnt out” rheumatoid arthritis. No fancy finger joint replacement for her, too late for physiotherapy, all I could do was to prescribe painkillers.

At the end of the consultation, I noticed a basket by her side, filled with shopping. “If your hands are so bad, how can you carry this heavy shopping?” I asked. She looked puzzled as she hoisted the bag onto her head. As they say in Zambia, “You can tell the real worth of a woman by how much she can carry on her head.”

This is not the lady concerned. But the shopping bag looks pretty.
This is not the lady concerned. But the shopping bag looks pretty.

I was called to see a young woman in our special room which we use to treat survivors of sexual and gender based violence. I’d seen her about ten days previously, just after she had been raped. We routinely give survivors a blast of prophylactic antibiotics to counter sexually transmitted infections, but despite this, it looked like she had a pelvic infection. I glanced through the notes I had made when I saw her. I’d prescribed cefixime, azithromycin and metronidazole, all in high doses. But unfortunately a few minutes after I had left her, she had vomited and no one felt confident about repeating the treatment.

I gave her an injection of ceftriaxone and a week’s course of oral doxycycline with metronidazole, rather than using single massive doses. At follow up a week later, she felt fine and had no symptoms, so hopefully no permanent damage had been done.

We obviously want to get the drugs into the patient as quickly as possible. I used to give more intramuscular injections, but young people were prone to faint and it put them off coming back for further treatment. I switched to high dose oral medication, which I could see the patient taking, but this can cause them to vomit. This is especially problematic when they also have to take post-exposure prophylaxis against HIV. Lower doses for longer periods of time could work, but we are concerned that the patient may not take the full course when unsupervised.

I did think of prescribing an anti-emetic (metoclopramide) before the patients took the drugs, but this can cause dystonia and occulo-gyric crises, especially in young females. As Rohinton Mistry would say, it’s a fine balance. In future, I will just try to tailor the treatment to the individual patient.

One thing which irritates me a great deal is being interrupted during consultations. When I am trying to harness all my dwindling neurones to deal with a patient’s complex problems, I don’t want to be distracted mid-synapse to sort out another problem. It’s like changing horses in midstream. For some reason, this often happens when I am with a survivor of sexual violence. A couple of weeks ago, I actually locked the door to Room 72 (from the slogan “Treat before 72 hours”) to keep everyone else out. I wanted some quality time with the patient. Unfortunately, the lock jammed and we were stuck in the room for nearly an hour.

This is the lock on a friend's apartment in Maputo, Mozambique. Not the lock on the door of Room 72.
This is the lock on a friend’s apartment in Maputo, Mozambique. Not the lock on the door of Room 72.

Ironically, the logistician/handy man was busy dealing with money and couldn’t be interrupted to rescue us. The nurse was getting angry because the delay meant she was missing her lunch break. She even asked someone on the outside to pass some food to her through the bars on the windows. Eventually, once the handy man had the correct tools, he was able to prise the door open. I hope my credit card still works.

“I’m dying from ulcers,” the young woman said. My assessment was that she had gastritis and I prescribed some omeprazole. I told her that her symptoms would resolve within a week. She asked me for a “sick sheet” – a medical certificate sanctioning time off. When I handed her the note, she was furious. “Just one day off! I need a week,” she hissed. “Take one tablet now and another in the morning, you should be okay to work tomorrow,” I said. She flounced out, but before the next patient could sit down, she gave me a prolonged, narrow-eyed, malicious stare from outside the door. “Ah, doctor,” said my translator, “She gave you the evil eye.” “I’m only too glad she didn’t throw a punch,” I replied.

The middle-aged man looked miserable. “I feel dizzy all the time,” he said. “I think it is because I have high-high (hypertension).” Unlikely, especially when his pressure was 106/58. I told him it was probably a side effect of medication. He explained that he had gone to a hospital outpatient clinic six months ago, complaining of headache and was told he had hypertension. The doctor had prescribed one drug, then another and finally three drugs to get this under control.

I looked at the paper from the hospital clinic. His BP had been only mildly raised at 155/100 when the diagnosis had been made, one the basis of just one reading. I talked to him about lifestyle changes, reducing salt in his diet and losing a bit of weight. And then I asked him if he wanted to try coming off the medication. I told him we should monitor his pressure regularly but if it remained under 140/90, I would be happy for him to remain drug-free.

He was delighted but my GP sixth sense could tell that something was still bothering him. “Are you stressed?” I asked him. Things were not going well at home. “Let me guess,” I ventured, “Are you having problems maintaining an erection? This is a common side effect of anti-hypertensive drugs.” He told me his wife thought he didn’t love her anymore. “Is she with you?” “Yes, she’s waiting outside.” I brought her into the consulting room and explained what I thought had happened. She still looked concerned until I told her that we would be stopping the medication and I expected that “things will be back to normal in a week or so.” Her face broke out into a broad smile and she reached out to shake my hand. I only hope I’m right.

P1040476

Swaziland Craft Beer Festival

What a blast! Jazz, Country and Western, solo singer with guitar playing great music through the afternoon. My favourites were Billy Ray Cyrus’ Achy Breaky Heart and Creedence Clearwater Revival’s Bad Moon Rising. Cowboy hats were de rigeur.

Tasty filet steak and chips, with butternut squash and green beans from  Malandela’s restaurant. The locals got quite frisky as the afternoon wore on.

Petra de Haas (TB Lab Adviser), Paola Uribe (Lab Tech) and I had a great time.

Substitution

The pharmacists at Central Medical Stores in Mbabane must have been surprised last month when they looked at the expiry date on their stocks of the anti-HIV drug, nevirapine (NVP). It was May 2015. They put in an emergency order, but the supplier had “production problems”. Swaziland was in danger of running out, so existing stocks had to be rationed.

Our solution was to restrict repeat prescriptions to a week’s treatment until the stock rupture was corrected. When patients came to pick up their medication, we offered to substitute another drug, efavirenz (EFV) for the NVP. Good plan, eh? Well, it isn’t easy to convince someone, whose HIV has been effectively suppressed, to change their treatment, the same treatment which we have promoted as being essential to their health.

I had to explain the situation to the patients, what measures we had taken to conserve stocks, the advantages and disadvantages of changing their treatment regimen. If they agreed, I had to alter their chronic care file, their treatment record, their clinic book and to write out a new prescription. This could take between 15-30 minutes. Last week, we substituted EFV for NVP for 42 patients. That’s a lot of extra work.

This photograph bears no relation to the subject of this blog. It is quite cold in the mornings in July. So Santa Claus socks are appropriate.
This photograph bears no relation to the subject of this blog. It is quite cold in the mornings in July. So Santa Claus socks are appropriate.

Most people agreed to the substitution, “if that’s what you think is best, doctor.” With some patients, the process was less straightforward. One man was a night guard. He was unhappy about the substitution because he had taken EFV when he first started treatment. The standard advice is to take this drug at night because it causes drowsiness. He got caught sleeping on the job and was nearly sacked. His regime was changed from EFV to NVP some years ago; now I was proposing to change it back.

I suggested taking the drug before he would normally go to sleep, in his case, 9am. “So what do I do when I have days off work?” he asked. I told him that it was best to take the drug at the same time each day.

“But then I will be drowsy during daytime on my days off,” he said. I asked a colleague for some advice on this issue, and she said, “Too difficult. Leave him on his current regime.” However, when I told him that we thought it best not to change his medication, he was upset. “This new drug sounds better than my old one. And my job’s rubbish. I’m fed up working nights. When I find a new job working in the daytime, will you switch me over then?” The best possible solution, I thought.

This man has nothing to do with this post, but he has a lovely face
This man has nothing to do with this post, but he has a lovely face

Another patient was deaf but could use sign language. I had just read a magazine article on signing in Swaziland, so I thought I could try my hand (sorry). I managed N-V-P and E-F-V, but little else. I struggled to get him to understand that the new drug, EFV, should be taken once daily, not twice daily like NVP. He confused this with the once daily drug co-trimoxazole. After a fraught 15 minutes getting nowhere, I decided to leave him on his current regime and wrote on his chronic care file, his treatment card and patient held record the reasons why he was not suitable for substitution. At this point, he opened his bag and showed me the past three months’ worth of NVP combination treatment which he had not taken.

One of our pharmacy assistants is proficient in sign language. She quizzed him about why he had not taken the drugs as prescribed. He explained, “Co-trimoxazole suits me best as I only have to take one pill a day.”

“But that tablet is not suppressing your HIV! It’s an antibiotic.”

Realising that once daily dosing was the most important thing for him about taking medication, I went through my spiel again, this time with the pharmacy assistant, promoting once daily EFV.

Later in the week, I saw a young lady who was very interested in what I had to say about the side effects of EFV. I told her about sleepiness, dizziness, mood changes, strange dreams and hallucinations. “Oh, I already have special dreams. I get messages from God in my dreams,” she explained. “Will I be able to communicate better with God on the new pill, doctor?” I told her that dreams were not reality and hopefully, she would not be bothered by the side effects of EFV.

“But I am training to be a pastor. I want to prophesize and see visions. It will help me in my future work.” I told her that I thought that she should not switch drugs because her mental state might deteriorate. She insisted on my making the substitution.

“What you refer to as hallucinations, I call being in closer touch with God. If you give me this medication, you are doing God’s work.” I prescribed a month’s treatment and will review her, personally.

One patient whose medication was switched from NVP to EFV developed mania within a couple of weeks. He wanted his care to be transferred to a remote rural clinic, where he grew up. He said he needed to look after his thriving business raising chickens. Reasonable enough, I thought. “How many chickens do you have?” I asked. “Four,” he replied. “And some are not laying.” I persuaded him to stay under our care while we sorted out his medication.

This whole process reminds me of my work as a GP in Leicester, switching people from one form of a drug to another to save a few pence, then switching them back again as the manufacturers changed their prices. It was one of the things which drove me crazy about working in the NHS. And now I am doing it here in Swaziland. Only another 200 patients to go.

Allo Allo

The aloe plant in our garden threw up a stalk and these branches of flowers have opened up, attracting birds and bees. I haven’t managed to photograph a bird sipping nectar from the flowers yet, but my camera can be operated by wifi from my smart phone. So I could set up the shot, and hide indoors, then trigger the camera without disturbing the birds.