Outreach

The photographs accompanying this post are on my Facebook page – http://www.facebook.com/ian.cross.969

The weather on Saturday morning in the Kingdom of Swaziland was as bad as it ever gets. Mist and fine, drizzling rain, aptly described by my mother as “mizzling”. Like Scotland in summer, where it is termed “dreich”.

I didn’t find it particularly cold, but the Swazis thought it was perishing. The outreach nurse said, “It is so cold, the patients won’t be up. They’ll be in bed with the windows and doors closed, with no ventilation. The TB germs will be trapped in their rooms.” I was accompanying the nurse on the injection run – visiting seven patients suffering from drug resistant TB. During the intensive phase of their treatment, these patients need a daily injection. They are too unwell to make the long journey to the clinic (or they may still have active TB), so we inject them at their homes.

As a GP in Leicester, I always enjoyed home visits, so I was looking forward to seeing Swazi patients in their own homes. It gives me background knowledge which helps me to understand my patients better. And I am naturally curious – nosey, some might say.

It was also an opportunity to see more of Swaziland. I am familiar with the main urban areas. I have walked in the countryside and game parks. But I haven’t visited the villages or the parts of the town where the tarmac gives way to rutted tracks. The grinding poverty of these areas shouldn’t have been a shock, but it was. I must be getting soft.

The first house we visited was on the side of a hill in the middle of nowhere. The track was deeply rutted and I wondered whether even a four wheel drive vehicle could manage it during the rains. Despite the cold, the windows and door were open. Our patient was up and about, doing her washing. She seemed genuinely glad to see us and welcomed me into the single room of her dwelling. A plaque on the wall read, “I wish my enemies a long life so they can witness my successes.”

The next patient was still abed when we arrived. He was not quite as house-proud as the first. Cooking pots and bottles were piled against the wall. Tracey Emin would have been impressed with the state of his bed. The patient saw me looking at his television set. “It doesn’t work,” he said. “It needs a satellite,” said the nurse. “Oo-oh.” As we walked back down the track to the LandCruiser, I asked the nurse about what social support was available for drug resistant TB patients. He said that we are trying to provide support, but it was difficult. “So what does that patient do all day?” I asked. “Nothing, he just stays at home.” It must be depressing, just waiting for the treatment to be effective.

It started mizzling again as we drove to a desolate settlement on the outskirts of Matsapha. The patient was unwell, lying in bed with her baby, shivering with the fever, not the cold weather. I listened to her chest and it sounded terrible. But after several years of being ravaged by tuberculosis, her chest probably sounds terrible on a good day. I made a presumptive diagnosis of secondary chest infection and arranged for her to have some antibiotics. But my thoughts were with the infant, sleeping next to her mother. The child had been checked and seemed to be doing well, but I fear for her future.

The next patient lived in the countryside. She had made it clear that she didn’t want her neighbours seeing the MSF vehicle pull up outside her house every day. TB still carries a stigma in Swaziland. We parked the LandCruiser at the far end of a newly-ploughed field and trudged to her shack. The patient was sitting with her husband sheltering under a lean-to, warming herself by an open fire. The nurse took her indoors to give her the injection, while I chatted to her husband. “What are you planning to grow in the field?” I asked him. “Beans, maybe. But there is no money in this, there are no opportunities here. We are living from hand to mouth,” he replied.

We drove back to a village, manoeuvring the ‘Cruiser down narrow lanes to a small compound. Our patient was lying in bed, this time with her mother. After we had exchanged pleasantries, she rolled onto her side and pulled down the bedclothes to reveal her buttock. I turned to look at the decor in her one-room hut. There was a poster advertising different styles of wig, modelled by glamorous young women. The poster illustrated a lifestyle which was light years away from the experience of this young woman. I asked the nurse about her. “If the sun comes out, she will sit outside to get warm. Then she will go back inside, she is very weak.”

The next patient lived about 10km away, but the track was so difficult, it took half an hour to reach her home. I felt like an honoured guest when the nurse introduced me to her. I looked at a photograph of the patient’s family, propped up on a table. “That’s my daughter, that’s my sister, and my mother is there, in front.” “Where are you?” I asked. She pointed to someone in the background, slightly blurred from hurrying out of shot. She looked like tubercular, ghostly figure, shunning the limelight, moving from her family. Was the stigma of TB so great that she was ashamed of being in the photograph?

Unsurprisingly, the conversation led onto my family. Was I looking for a wife? No, I’m happy living here as a bachelor, I told her. I was ineligible. The ladies outside the house laughed at this strange response. Extended families are very important for the social fabric here in Swaziland. I wondered how I would cope, if I were diagnosed with a serious illness, without my family around me. An uncomfortable thought.

Tuberculosis is a grim disease. Having drug resistant TB means months of unpleasant treatment while feeling weak and lethargic. The patients dourly accept their fate. The only alternative is to give up. We have had patients who stop taking their medication, secretly hiding their pills and effectively committing passive suicide. Some of the patients appeared to be clinically depressed, while others faced their ordeal with dour stoicism and a smile for the nurse.

Swaziland is a low income country, but all these patients were very poor. None of them was able to work. Their days seemed empty and repetitive. Their lives were on hold, just waiting, hoping, to recover. Les damnés de la terre. But one thing is for sure. Without MSF, their lives would be much worse.

Back in Harness

I received a warm welcome back at Matsapha Comprehensive Health Clinic last Monday when I returned to work after some leave in UK. I was the only doctor in the clinic, so I certainly had my work cut out. I was exhausted at the end of the day. Unfortunately, the internet connection in our house in Manzini has been downgraded and I cannot upload photographs and text to the blog. I am typing this at work, feeling a bit guilty. Hopefully I will find a way to continue blogging.

But I am back!

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.

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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.

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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.
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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.

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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.

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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.