Field Trip to the National Tuberculosis Hospital

After two days in “school”, I desperately needed to get out of the classroom. The final straw was being told off for answering a question without putting up my hand. I was looking forward to the field trip to the National Tuberculosis Hospital at Moneni. We were split into four groups so we could interview a patient and present a case report at the plenary.

The next morning, I was rather late getting down to breakfast at Esibayeni Lodge. There were no vacant places at the delegates’ tables so I sat at the table of a white man who was eating his breakfast while reading his iPad. I said good morning to him and he raised his eyes over the iPad. “Goy-tag”, he replied, returning to his full Afrikaans breakfast. That’s just like a full English, but with extra hanks of boerewors (a vinegary sausage).

“I must have a photograph of this bloke,” I thought. I got out my phone to take a furtive snap while pretending to surf the interweb. I was stopped in my tracks by a loud gunshot. This was followed by the sound of a bolt being pulled back and an empty cartridge being ejected from the breech. I know this stuff; my father had guns.

“Jeez,” I said, “What the hell was that?”

My dining companion apologised and told me that he was playing the role of a sniper on an internet game.

“But surely that is so loud it would give away your position. I thought snipers depended on being silent and invisible.”

“It is loud because it is a 50 cal,” he explained. “The target won’t hear you because this gun can kill from two klicks away.”

Fifty calibre sounded big. But two kilometres? “Have you fired one in real life?” I asked.

“Nah, but I’ve shot a 30 cal when I was in the military,” he replied.

I feigned interest while he rattled on about target circles and minutes of accuracy, all of which flew over my nodding head.

Trying to lighten up the conversation, I asked, “So have you seen the Clint Eastwood movie, “American Sniper”, then?”

“Nah, not that interested in films,” he replied, and went back to his game. Obviously I wasn’t the “right stuff”.

And I had thought he was just checking his email.

I finished eating and went out to wait for the transport to take us to the TB hospital. I was expecting a bus, but we had to squash into pickup trucks for the twenty minute journey to Moneni.

Open 24 Hours?

Open 24 Hours?

Do you know of any hospitals which are NOT open 24 hours?

The hospital is surrounded by a fence topped with razor wire. There are guards stationed at the only entrance, with a striped barber’s pole hanging across the road. As a senior official of the National Tuberculosis Treatment programme was driving our vehicle, we were waved through without being stopped. I was not sure if the security was to keep people out or to keep highly-infectious patients in.

The hospital was built on the side of a hill, with beautiful views over the town of Manzini. It took a decade to build and opened just over five years ago. If I walk to the bottom of the street where I live, I can see the hospital over the valley. A couple of weeks ago, I was out bird watching on a Sunday and noticed a group of people dressed in white, parading outside the hospital. I thought they might be nurses out on strike, but through the binoculars, I could see they were all dressed in church uniforms. I realised that they were conducting a service outside the hospital ward, for the patients’ benefit.

The National TB Hospital, Moneni

The National TB Hospital, Moneni

Our group walked down the concrete causeway, past the outpatients block, the laboratory and an operating theatre. As a medical student in the 1970s I had heard of patients having surgery to remove diseased parts of lungs, or having ribs remove to deflate lungs (thoracoplasty), to treat their TB. “What kind of procedures do they do in the theatre?” I asked a delegate who also worked at the hospital. “They can do anything there, but they do nothing,” she said.

We walked along a long corridor towards the wards. At the laundry storeroom, we were issued with a wraparound overall and a green 3M surgical respirator. I thought that these masks had performed poorly in the “fit test” study at MSF so they were no longer in use. Still, they were better than nothing.

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In 2012, the Swazi Observer, a local newspaper, had criticised some nurses working at the hospital for wearing their masks over their spectacles. Obviously the masks would then not form a tight seal over the face, and this would not prevent them from inhaling TB germs. I understand that “fancy hairdos” were also cited as stopping masks from fitting tightly.

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We passed a solarium, with floor-to-ceiling windows so the patients could sunbathe as part of their anti-TB therapy. At the turn of the 20th century, rich Europeans suffering from TB travelled to Switzerland, where they were hospitalised in sanitoria in the Alps to get “heliotherapy”. Sunshine increases the amount of vitamin D being made in the skin, and we now know that this vitamin helps the immune system kill TB germs.

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Sister’s office had a wonderful view over the town, spread out among the hills. She had an old La-Z-boy reclining armchair in one corner. I wondered if it had a special refrigerated compartment for beer, like Joey and Chandler’s chairs, featured in an episode of Friends. We made small talk then moved to the nursing office where the patients’ files were kept. The ward nurses were ensconced here, safely apart from the infectious inmates.

An Egyptian doctor working in the hospital introduced himself and suggested several “interesting patients” whom we should see. When he realised I was a doctor, he brightened up and asked my advice about a patient who had a medical problem not directly related to tuberculosis. The patient had a very low platelet count and had bled, but unfortunately the blood from the National Transfusion Service was incompatible with the patient’s. He had tried “washing” the blood, but it still wouldn’t cross match. He was at a loss as to what to do next. I told him I’d get some advice from a blood transfusion expert (Christine) and advise him on the best way forward. I got the impression that he felt his job was solely to treat tuberculosis.

A nurse in my group was keen on seeing a patient with eye problems, downstairs in the male ward. This was bright and airy, but none of the louvred windows were open, so there was no ventilation. There were just four beds in each bay. I didn’t see any hospital nursing staff. There was no decoration on the walls and it looked grim. We went searching for the patient, but his bed was empty. Then someone noticed he was hiding underneath. “What was he doing under the bed?” I asked. “He was frightened of us,” said the nurse. I racked my brains, what anti-tuberculous drug has psychological side effects? Cycloserine, but he wasn’t taking it. I suppose that when people suffering from MDR-TB have to spend months as inpatients, having injections which cause tinnitus and deafness, it must have a detrimental effect on their mental state.

The patient cheered up when he realised we just wanted to talk to him. He had been taking ethambutol, a drug which affects colour vision. How could we test this? I had a brainwave. I could download the Ishihara Colour Charts from the internet onto my smart phone. Ishihara plates are those circles of pastel-coloured dots which may, or may not, form numbers.

Pleased with myself, I showed him the plates but he correctly identified all the numbers. Then one of the group said, “He only has the problem with one eye, doc.” So I repeated the test with his good eye covered. Lo and behold, he had red-green colour blindness. But just in one eye.

It is possible to use more sensitive tools, such as the Lanthony Desaturated test, which looks a bit like a socket set with slightly different pastel colours. The patient arranges the colours in order. This can demonstrate deterioration of colour vision at a much earlier stage. But I didn’t expect the ward to have one of these.

While the nurses pored over his notes, I wanted to know why he was still in hospital. His sputum was no longer infectious. He just needed daily injections for a few months. Surely this could be arranged in the community? Once a GP, always a GP.

The problem was that his home is too far from the nearest health centre where he could have his daily injection. But it was just £1.20 kombi fare away. I wondered how much it cost to keep him in the ward. While the nurses recorded the history for the case presentation, I went upstairs to see another patient.

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This lady was very thin and her TB treatment looked like it was failing. She was also suffering from HIV. The nurses seemed to want to collect all the information from the hospital notes in order to present her case history. I wanted to speak to her and examine her, but this was not the task we had been set. I chatted to her nevertheless, offering her some comfort. I wonder when “compassionate care” will feature in the Swaziland Health Service?

It was lunch time. The other groups had already left to return to the lodge. We walked to the car park in the sunshine to wait for transport. I was just beginning to dread having to listen to the case histories back in the classroom, when I was saved by the bell, well, by the ringtone. The MSF medical team leader summoned me by mobile phone. I was needed back at the office and would have to leave the workshop. I can’t say I wasn’t relieved.

Drug Resistant Tuberculosis Workshop

The thing I hate about workshops is that they shop work.” Dr Immo, German Technical Assistance, 1982 Mansa Konko, The Gambia.

As soon as I found out that MSF had lined me up for a job in Swaziland, I knew I needed to refresh my knowledge of tuberculosis (TB) and HIV. This is because Swaziland has the highest prevalence of both diseases in the world. And quite a few Swazis have both HIV and TB. Not only that, but the rate of drug resistant TB is incredibly high.

My home town, Leicester, has one of the highest rates of TB in the UK. Dr David Bell, Consultant in Infectious Diseases, specialises in TB. He kindly agreed to have a chat with me about the management of drug resistant TB (DR-TB). At that time, out of the million people living in the hospital’s catchment area, just two were being treated for DR-TB. In comparison, the MSF clinic at Matsapha currently is treating 86 patients, with a catchment area of 35,000.

As I had failed to get more practical experience before starting work in Swaziland, I jumped at the chance of attending a workshop on tuberculosis run by the Swazi Ministry of Health. The event was held at Esibayeni Lodge, just a few kilometres from the clinic.

Artwork at the Lodge

Artwork at the Lodge

I arrived at 8am when the workshop was scheduled to start, but the room was completely empty. I checked into my room, unpacked my rucksack (mainly filled with electrical chargers for phones, tablet and laptop) and went back to the workshop. By now it was 8:20am and there were a few participants sitting around chatting. I sat next to a glamorous lady and introduced myself to her. “I know you, Dr Ian, I work at Matsapha with you,” she replied. In my defence, she was dressed up to the nines and had a fantastic new hairdo, shot with gold threads, so no wonder I didn’t recognise her. She had no trouble recognising me; I was the only white person in the group.

Gradually, the room filled up with delegates. At 8:45am the chairman officially opened the workshop with some remarks about “housekeeping”. I was expecting the usual guff about there being no planned testing of fire alarms and the location of the toilets. Instead, the chairman asked for volunteers for a pastor to lead the prayers and a timekeeper, to let the speakers know when their time was up.

Early start

Early start

“Now, about ground rules. What ground rules are there?” he asked.

There was silence for a few seconds before someone chirped up, “Switch off mobile phones.”

Another person said, “Everyone must be active participants.”

Finally, some wag said, “No thinking with eyes closed.”

I thought that if we all kept to the ground rules, this was going to be more interesting than most of the workshops I have attended in UK.

There were twenty plus delegates, mostly nurses, sitting at tables around three sides of the room, with the projector, laptop and lecturer occupying the fourth side. Every table had a saucer of sweets wrapped in crinkly cellophane. These didn’t last long, and I noticed some people moving to vacant seats, perhaps to get a better view of the screen. Or better access to an untouched saucer of sweets.

It wouldn’t be a proper workshop without at least one lecturer getting into difficulties with link between projector and laptop, but generally the IT went very smoothly. PowerPoint rules in Swaziland.

One nurse made a plea for the whole workshop to be conducted in siSwati, the local language, but thankfully for me and Dr Yves (recently arrived from Democratic Republic of Congo), English prevailed with the compromise that if people could not find the right words, they could revert to siSwati to express themselves fully.

We all completed a pre-test to assess our knowledge prior to the workshop but to avoid embarrassment, we were told that we could put any name on the top, as long as we used the same name for the post-test at the end of the workshop. Then came the introduction, the epidemiology, the basic biology and natural history of tuberculosis. By this time, the delegates were getting fidgety. The timekeeper had a hopeless job trying to get us to the mid-morning tea break on time, as we had started 45 minutes late. The organiser told us to get a move on as the dining room staff wanted to get the room ready for lunch.

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The tea break was interesting. The waitresses offered us toasted sandwiches and biscuits. For drinks, there was a hot water geyser, some tea bags and several shades of brown powder in glass jars. Unfortunately, the labels had come off but I reckon one was Milo, another Ovaltine, one resembled Nescafe instant coffee but I was mystified by the last jar. I tried it, but it didn’t smell or taste of anything, so I added a spoonful of instant coffee granules. Quite a few of the delegates obviously had not had breakfast, so they helped themselves to generous amounts of sandwiches. I normally prefer tea, but with just one milk jug by the geyser, you had to add hot water, teabag and milk all together.

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We struggled on to lunch a few hours later. This was a buffet where most people took a sample of everything which was on offer. Mutton stew, chicken, fish, rice, salad, pap and veg. I didn’t eat much. A mental image of sputum being whipped up like eggs into an omelette (kindly provided by the speaker from the laboratory) put me off a bit.

Not surprisingly, the group’s performance after lunch was more solid than stellar. One lecturer tried to combat our postprandial lassitude with some stretching exercises. Another lecturer managed to get us interested in infection control by the force of her personality alone. When she started discussing the problems of using face masks (the technical term is “N95 surgical respirators”), one nurse complained that wearing them ruined her makeup.

As in the UK, some lecturers have the gift of enthusing their audience, grabbing their attention and making the subject matter seem simple and logical. Other lecturers have probably never been taught how to teach. At times, I felt like I was back in primary school. One lecturer would speak very slowly, often reading out the content of the PowerPoint slide, word by laborious word.

Another used the “complete my sentence” technique: “Mycobacterium tuberculosis is an acid and alcohol WHAT?”

Repetition figured strongly, too. Occasionally the lecturer would have trouble expressing exactly what he/she wanted to say in English, and reverted to rapid siSwati.

One lecturer’s phone rang during his lecture, so he asked us to discuss the term “culture” for a few minutes among ourselves, while he popped out to complete the call.

But all the lecturers were eager to get their message across, and make sure we had kept up. “Are you still with me?” “Are we all together on this?” I was amused by a lecturer who added the phrase “innit?” at the end of statements. When he reverted to siSwati, he used the phrase “yamoueh?” – which I think translates as “innit?”.

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On the second day, we started with a prayer in siSwati, followed by a rousing chorus of “We shall overcome.” The next item was a recap of the previous day’s lectures. I am sure that this is a good way to cement facts into one’s memory banks, but we were all a bit dull and unresponsive. One nurse took it on herself to embarrass us all by reeling off all the salient points. The lecturer caught her sneaking a peek at her notes and wittily asked, “Why don’t you keep on reading up to the end?”

During the more clinical lectures, some of the nurses seemed to switch off. I caught one thinking with his eyes closed. Several had their heads bowed, not napping, just keeping up to date with their pals on WhatsApp and Facebook. The timekeeper rapped her glass of water with a pen to indicate the lecturer’s time was up. He ignored her, but it jolted a few participants back to consciousness. She gave up after that.

To be continued: The Field Trip to the National Tuberculosis Hospital.

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Buganu Festival

Every February, Swazi people gather fallen marula fruit (“emaganu“) to make an alcoholic drink called “buganu“. Marula fruit are the size of large crab apples. As they ripen, they turn from green to creamy yellow. To make the brew, women wash the fruit, peel off the skin and squeeze out the juice (“kuhlabela“). After adding half as much water as juice and sugar, the liquid is left to ferment in a vat. The longer it ferments, the more alcoholic it becomes. The leaders of women’s groups (“lutsango” means women’s regiment) present the bugano to the Queen Mother, Her Majesty the Indlovukazi (the great she-elephant) at the royal residence in Ebuhleni. The following day, the King arrives and, after the royals have had a drink, it is party time for their subjects.

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Yesterday, along the roadside in Manzini, there were groups of women dressed in identical uniform, trying to hitch a ride to Ebuhleni. They wear black skirts, with a colourful top tied over one shoulder with an epaulette of goat hair on the other. They sport a fetching hairnet and wear bands of dried seeds around their ankles when dancing. They carry a small staff, sometimes a wooden spoon or a metal strainer spoon.

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This is a festival for the women, as they are the ones who prepare the booze and dance for the King. Men do attend, but not as a group (“emabutfo” means men’s regiment). They wear a similar wrap, tied over their shoulder, but have an animal hide attached to a belt round their waist. The men carry a knobkerry. Lots of other men wear normal clothes and join in the drinking.

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I went to the ceremony yesterday and it was a blast. Policemen were stationed along the route to Ebuhleni. “Just in case there are terrorists trying to ambush our King”, explained my driver. Several times we were overtaken by a group of four black BMW SUVs, lights a-flashing, travelling at dangerously high speed. One of these carried one of the King’s 14 wives and her children, flanked others containing police bodyguards.

Ebuhleni is a small town in the northern province of Hhohho. There is a supermarket, a petrol station and not much else. But outside the town there is the royal residence, with kraal and parade ground, where the festival was being held. The driver dropped me off and immediately I felt totally out of place, surrounded by thousands of women dressed in their colourful regalia.

I chatted to some ebullient ladies who might not have observed the custom to wait until the King had drunk the first draught of marula beer before partaking themselves. They were all wearing a necklace with two squares of beadwork attached. This was the emblem of the Royal Swaziland Police. “Don’t worry, we won’t arrest you,” they laughed. Interestingly, all the ladies in this group maintained they were unmarried. They all had smart phones and wanted me to pose for photographs. I didn’t give them my full name so hopefully I won’t be trending on Twitter or have my smiling face tagged in uploads to Facebook this weekend.

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Luckily, I was rescued by an interviewer from Swaziland TV Channel S. He was bare-chested, wearing a goatskin attached to a Dolce & Gabbana belt. He began recording an interview with me using a Sony camcorder, asking what I was doing here, what did I think was going on, did we have this kind of ceremony in UK. After a minute or so, a drunken man decided it was his turn for 15 seconds of fame. He clapped an arm round my shoulder and contributed to the interview in a slurred voice.

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I made my excuses and walked up the hill, into the royal encampment. The lutsango were massing by a cattle kraal and I saw a photo opportunity coming on. I was stopped in my tracks by another inebriated man who said that it was “women’s business” and I should not go any further. I crossed the road to talk to him about this tabu and he then told me I should not have crossed the King’s path. I was not correctly dressed. It seemed I couldn’t do a thing right. He harangued me for a while until a handsome gentleman in traditional dress motioned him to stop. This was the local MP. Thank you, Mr Sikhumbuzo Apton Ndlovu, Honourable Member of the House of Assembly (Timphisini Inkhundia). I also met one of the local chiefs, who sported red feathers in his hair.

The King’s entourage arrived, but the side windows of all the cars were darkened, so I couldn’t see him. I did see a group of five white folks (Brazilian, Swiss and British) so I went over for a chat. Apart from us and the Ambassador for the European Union, I saw no other whites at the ceremony. Just as I was making conversation, a half-naked dusty old man started pulling at my shirt asking for money. I wondered who he was until I recognised him as a man passed out under a tree whom I had photographed. The white folks moved away while I dealt with the situation. Eventually I detached his grip, mumbled my excuses and left to get in position to photograph the lutsangos dancing en route to the parade ground.

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I managed to get into the parade ground but, not being an honoured guest, I couldn’t get close to the King or the shaded area for dignitaries. I had to pass through a metal detector doorway, but it can’t have been working because I was carrying my camera and no flashing lights went off. I couldn’t get close to the dancers either, so I took some photos of the spectators.

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A man working for The Swazi Observer newspaper (motto “Revived, Reliable and Read”) was giving away free copies so I took one and read about last year’s ceremony. Rather cheekily, the paper featured a picture of members of the Royal Family listening attentively to the King’s speech, next to another picture of white diplomats looking less riveted (one was shown playing with his smart phone).

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Barbecue with goat and chickens in reserve behind her

Barbecue with goat and chickens in reserve behind her

As their alcohol consumption increased, the ladies were becoming more bold and friendly. I was invited into the back of a Kombi for a bit of slap and tickle by two rather forward young ladies. In my innocence, I didn’t even think a cash transaction could be involved. Another man offered me his girlfriend, who was wearing a miniskirt with a fringe of plastic cords which swished when she sashayed. Again, I declined.

A group of men and women beckoned me over and challenged me to guess what SPTC (they were all wearing the logo) stood for. “Ehrr, Swaziland Post & Telecommunications?” I ventured. The prize for this successful answer was the hand in marriage of a middle-aged lady who appeared not to understand a word of English. I kept on smiling and refusing in the most polite way possible. Altogether I had five proposals of marriage during the afternoon.

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What a contrast to the tailgate parties we have outside Twickenham before Six Nations matches!

As the light faded, I wandered past ladies selling little cardboard plates of cold chips, plastic shrink wrapped apples, fluorescent orange plastic bags containing frozen drink (any reader old enough to remember Jublees?), animal skins, beadwork jewellery and sweets. No one was selling marula beer; everyone had brought their own. It wasn’t even seven o’clock and already one poor lady was slumped against a wall, breasts akimbo, chin lolling onto her chest.

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I reached the town and needed a drink. What better than a bottle of marula-flavoured fizzy water? I wanted to cross the road at a zebra crossing because I have heard of pedestrians being fined on the spot for jaywalking. A cop was conducting traffic when a police car drove up and handed him a beverage (surely not buganu?). He took a break from directing traffic and sat on a concrete block at the side of the road. I chose my moment well, and crossed with a mass of locals.

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A reliable source told me that some time ago, a man accused of drink driving had successfully been reprieved because earlier he had been drinking marula beer with the King. As a result there was a rumour that no driver would be breathalysed by the police on the main road for the day of the festival. This contrasts with an advertising campaign in the newspaper: “Where do you want to sleep tonight? In your bed, in a prison bed or in a grave bed. Don’t drink and drive.”

I leaned against the hot wall of a concrete bus shelter, drinking sweet fizzy water, waiting for my ride home. I reflected on the afternoon. Was this mass alcoholic binge just an officially sanctioned way to allow women to let off steam, to break rigid social rules, just once a year? I understand that a prodigious amount of sexual activity goes on throughout the evening. The driver said that he would never allow his wife to come to one of these events because “she might get a taste for it.” After the festival, the normal social order is restored, no questions asked about what happened at Buganu.

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In my free newspaper there was a joke:

At their 50th wedding anniversary, an old man asked his wife about their youngest child.
“My dear, there is something that I must ask you. It has always bothered me that our tenth child never quite looked like the rest of our children. Tell me the truth, I must know. Did he have a different father?”
The wife hesitated and finally said, “Yes, he did.”
The old man was shaken, and with a tear in his eye he asked, “Who was the father?”
The wife mustered up her courage and replied, “You.”

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Back in the saddle

I like a challenge. Life is more fun when there are new skills to learn and master.

My role in Matsapha Clinic is a bit like being a GP. Half the work relates to people suffering from HIV and tuberculosis, the rest is like general practice, but hyped up on steroids. I see more serious illness here in a day than I would in a month in Leicester. A few weeks ago, we initiated twelve people on anti-HIV drugs in a single day. It is projected that by the time I leave here, our clinic will be caring for over 5,000 people living with HIV/AIDS, the vast majority of them on effective treatment. By comparison, Leicestershire (population 1,000,000) has about 700.

Today I saw half a dozen people suffering from tuberculosis which was resistant to one or more first line drugs. When this happens, you have no option but to put together an arcane concoction of antibiotic drugs like injectable kanamycin, ethionamide, clofazamine, levofloxacin, cycloserine and good old amoxicillin/clavulanic acid (Augmentin). Side effects of the drugs are grim and the treatment is prolonged – 15 to 20 months. An enormous amount of effort goes into supporting and encouraging the patient to comply with the regime. Last year, I spent some time with a consultant at Leicester Royal Infirmary, to get some insight into the treatment of multidrug resistant TB (MDR-TB). At any one time, there are one or two patients with MDR-TB on their books; Matsapha 86 patients with MDR-TB. And 80% of these patients also have HIV.

We wear special masks called “N95 surgical respirators” to avoid being infected. You need to have a special mask fitting, to ensure that the seal is tight around your face. I find the masks claustrophobic. They muffle your speech so it is difficult to have a conversation with the patient. They hide so much of your face that patients cannot see your facial expression, which impedes communication. My interpreter teases me about using my eyebrows a lot to convey meaning.

Even when it is cold, we have the clinic windows and door open to promote good airflow. We have even had an electric fire on in the consultation room when it is particularly chilly. There is even a twirly silver spiral chimney in the ceiling to whisk away any particles containing TB in the air.

All patients are screened for TB by a cough officer. If you have a cough, night sweats, weight loss, close contact with TB or other symptoms suggestive of TB, you move over to a parallel set of clinic rooms, just for TB. There is even a well-ventilated sputum production room (see the photograph below of the building with bricks missing). Patients with TB sensitive to the first line drugs attend one block; others with drug resistant TB attend another.

After 25 years of ordering chest Xrays and relying on a specialist’s written report, I am now having to learn how to read the films myself. It is easy when someone has barndoor obvious TB, but the inflammatory changes seen on the radiograph rely on the patient having an immune system to attack the TB germs. Many of our patients with TB are co-infected with HIV, and often they don’t mount an immune response, so the film doesn’t show the classic signs. People can be dying with TB and have a normal chest Xray.

I have been studying TB by reading the national guidelines, but luckily the Ministry of Health is running a workshop for doctors and nurses, which I will be attending to improve my skills. More on this in subsequent blogs.

HIV is something I am more familiar with, having diagnosed the first case in North Devon in 1985 when I was working as a medical senior house officer. I worked in the sexual health clinic (genito-urinary medicine – GUM) in Leicester Royal Infirmary from 1989 to 2013 and my general practice surgery had about 65 patients living with HIV when I resigned. To sharpen my skills, I sat in on some GUM clinics in Leicester prior to coming to Swaziland. All the patients I saw were stable and well-controlled on modern anti-HIV drugs. In contrast, the clinic at Matsapha has quite a few very sick patients living with HIV, even though there are adequate supplies of basic medication. It reminds me of the early 1990’s when there was no effective treatment to suppress HIV, and patients were ill with a wide variety of opportunistic infections*. Unfortunately, we don’t have easy access to expensive investigations or very expensive treatments for the most unusual infections.

As in UK, when patients are stable and their disease controlled, it is relatively easy to manage HIV. But when they become unwell with odd symptoms and signs, I find it very taxing.

In my first week I saw couple of patients living with HIV who had such deep jaundice that the whites of their eyes were almost green with bilirubin. One had acute hepatitis (for which we have no treatment available) and the other was suffering from an adverse reaction to their anti-HIV medication. The problem was, which of the four drugs she was taking had caused the jaundice?

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I saw another patient who complained of being clumsy and having difficulty walking, getting worse over the past three months. She could not cook or dress her children because her coordination was so poor. I reckon that she has problems in the cerebellum at the back of her brain, but this doesn’t fit the usual way most opportunistic infections attack the brain. Her symptoms are not typical of a brain tumour. I have prescribed some vitamins in case there is some nutritional deficiency, but I am struggling to make a diagnosis. This is where I am lucky to be working with a bunch of experienced physicians, whose brains I can tap. I’m hoping to start up a case meeting once or twice a week from 8-9am, before the clinic gets busy, for us to discuss patients with difficult problems. And I am indebted to the group of friends and colleagues in the UK who are always happy to offer an opinion by email. You know who you are. Take a bow.

* Opportunistic infections are infections with bacteria, fungi, yeasts, protozoa, viruses etc which would be easily defeated by an intact immune system. These infections can cause havok when the immune system is damaged and depleted.

Bridal Heaven

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I suppose in a country where the King has married fourteen wives, I should have expected that weddings are very popular. But I didn’t realise that they would be such big business. Strolling around Manzini at the weekend, I saw half a dozen bridal shops.

The shop window mannequins are glorious, displaying wonderful dresses, amazing hats, natty three-piece suits. Deeper inside the shops there is more matrimonial paraphernalia: table settings, candelabras, ornaments and fancy chairs.

I can’t wait to attend a wedding or two while I am here.

Sunday morning

While working in rural Zambia, I used to enjoy the sight of families walking along the roadside to church on Sunday mornings. Everyone dressed in their best clothes, father in a dark suit several sizes too big, mother holding a large umbrella as a sunshade, and the children often carrying their prayer books and bibles on their heads. I am now working in urban Swaziland, so this Sunday I decided to take a walk around the churches in Manzini town centre.

Three members of the Zion Church, Matsapha. The pastor is on the right. The man in the  middle is a senior. The are all wearing dog collars.

Three members of the Zion Church, Matsapha. The pastor is on the right. The man in the middle is a senior. The are all wearing dog collars.

Just like in Zambia, Christianity takes many forms in Swaziland. There must be over a dozen different denominations. The first churchgoers I met were a trio of officials in the Zion Church. They were dressed in very fetching turquoise vestments (lab coats) with extravagant white epaulettes. Even thought they had just finished their service, the pastor offered to go back for second helpings if I would praise the Lord with him. I declined, “Church of England, you understand.” And he did.

When I brought out my camera and asked about taking a picture, they became concerned about their appearance. They dug out their dog collars and threaded them under their shirt collars. One man had to get a white apron from his pickup truck. They posed in full sunlight and looking through the viewfinder, all I could see was three featureless black faces. I didn’t feel I could ask them to move into the shade, so I dialled in a couple of stops of extra exposure to counter the back light. All I got was one picture. It would have to do. At least you can see their features.

The Assumption depicted on the wall of the Roman Catholic church.

The Assumption depicted on the wall of the Roman Catholic church.

As I wandered further down Nkoseluhlaza Street, I could hear strains of gospel music coming from several locations. I thought one gathering was taking place under a marquee in a car park, but the alleyway was blocked by two heavily built men in suits. I have never seen “bouncers” at church before. I thought they might be charging for admission, so I walked on.

As I walked under a hotel balcony, I could hear an amplified dialogue between preacher and congregation. I didn’t understand what uplifting words he was saying, but they brought the response “Amen”, in unison, not close-harmony. As I was thinking of climbing the steps to the balcony, a pretty young girl asked me if I wanted to attend her church. It was very tempting, but I didn’t want to spend the next two hours worshipping.

Just across the road from a newly-built mosque is the Roman Catholic cathedral. It has a stolid campanile arising from the car park. Above the front doors, there is a massive mosaic frieze of the Virgin Mary. Perhaps a bit excessive, verging on Collyridianism, if you ask me.

The service was in full swing to a packed house. It was standing-room only at the back and a team of ushers was slotting late-comers into the rare empty places in the pews. An usher beckoned to be but I declined to join in, for the third time. Instead, I walked over to chat to a lady eating cake in the shade of the cloister.

Mabel Middleton, who claims to be related to the Duchess of Cambridge.

Mabel Middleton, who claims to be related to the Duchess of Cambridge.

She asked me what I was doing in Swaziland, so I explained that I was an British doctor working in a clinic. “Ahha,” she said, “I am from British stock. In fact, I am related to your future queen.” It took me a few seconds to realise that she was talking about the Duchess of Cambridge, not Camilla.

“My name is Mabel Middleton,” she said.

“Are you a close relative?” I asked.

She said she was, related by a tenuous link between her father’s cousin’s cousin and Kate’s family.

“So you didn’t get an invite to the wedding, then?”

She scowled back at me and asked me about my religion. As she was Catholic, I didn’t use my usual Church of England reply. I said I was a humanist. I believed in helping people and not doing harm.

“So help me, then. Give me 20 Rand.” I told her that I was helping people by treating them in the clinic, not by giving them money.

“You are Satan!” she said. Like an investigative reporter for the now defunct “News of the World”, I made my excuses and left.

Three girls in matching dresses and shoes, posing after leaving the Roman Catholic church.

Three girls in matching dresses and shoes, posing after leaving the Roman Catholic church.

I spent the next half an hour waiting to take photographs of people leaving church at “chucking out time.” The only promising picture I took was of three teenage girls in matching fuchsia dresses. I think they were choristers from the Roman Catholic cathedral I had just left. I asked if I could take their picture and they looked taken aback.

“Why us?”

“Because you look great in your matching outfits!”

While they giggled, I took a quick photograph.

It’s been decidedly chilly in clinic this week

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Perhaps you’ve heard the expression: “Four seasons in one day”? Yesterday, the weather forecast for Manzini was 22C and snow! The photograph above shows an electric bar heater in the immunisation room. I hope the nurses didn’t leave it there; you can see the infant weighing scale just above it. It’s good to keep babies warm, but we don’t want cooked kids.

The weather was crisp this morning; the sky was cloudless and caerulean blue. By lunchtime, it was unpleasantly hot. The sky clouded over and by 2pm it had become very humid. The thunder and lightning started at about 3pm, with a drenching downpour that rattled the clinic roof. The storm cut short the flow of patients into the clinic, so we were able to finish just before 5pm. It was dull and cloudy on the journey home before the storm started up again at 6:30pm. As I am writing this at 9pm, thunder is still grumbling in the hills and the temperature has plummeted.

The cold weather seems to bring some strange patients. While I was consulting with a nurse yesterday, a female patient in her 20s told us that she was suffering from a headache. We listened as she described her symptoms, but these were vague and her story was inconsistent. She realised that we were not taking the bait, so she told us that she had an offensive vaginal discharge. We took a sexual history and the nurse decided an examination was necessary. She asked the patient to remove her panties. The nurse then looked at the gusset of the patient’s knickers, which were as clean as a whistle, showing no stains or discharge. As a result, the nurse decided she didn’t need to do a vaginal examination.

The patient got dressed and nurse looked into deeply into her eyes, as if to ask, “What do you have to say now?” After a long pause, the patient coughed. She wasn’t feeling ill. In fact, she had spent most of the morning walking around the factories in Matsapha seeking work. When she saw a group of people walking up the hill to the MSF clinic, she decided to follow them, wrongly thinking they would lead her to another employment opportunity. She soon realised that she had walked into a health centre, so she thought, “I might as well get some medicine while I’m here.” As you do.

We weren’t vindictive. We just took the opportunity to suggest she may want to have an HIV test and offered some health advice. But not a job.