Gogos

A large, smiling lady sat down in the patient’s chair and handed me her medical records notebook. Her first name was “Happy”. What an appropriate name for such a jocular, friendly lady, I thought.

“Madam, how did your parents know that you were going to be so happy when they named you?” I asked.

“They didn’t,” she replied. “They named me Happy because they were happy to have a baby.”

Turned out well, then.

“Now let’s talk about reducing your risk of developing high-high (hypertension) and sugar (diabetes),” I said, spoiling the mood.

This lady has the same name as my maternal grandmother, Dorah. She has the same look of grim determination, too. I asked if I could take her photo and she agreed. I took the second photo after telling her about her namesake. Her face lit up and she asked if I would show her photo to my grandmother. I told her she was long dead (how old did she think I was?) but instead I showed her a picture of my mother, who will be 90 this year. She was delighted. She is 87. I didn’t ask, but I bet she knitted that cardie.

Family relationships are very important to older people in Swaziland (and the rest of the world). The old order of respected elderly parents being cared for by dutiful children has been disrupted by the massive mortality from HIV/AIDS over the period 1990-2010. A swathe of future carers were cut down, leaving their elderly parents in poverty. I see a lot of depression in the elderly, too. One elderly gent looked so miserable after telling me about his physical problems that I told him he looked very sad. He burst into tears and needed a bit of time. My translator was not impressed. “In Swaziland, it is taboo for a woman to see a man cry.” I apologised but said it is part of the job to see patients in desperate situations, and sometimes they break down. “What does the taboo mean?” I asked her. “I will get bad luck,” she replied.

P1010413Much of the work of general practice in UK is preventing disease from happening, and once it has happened, preventing it getting worse. Here, I see disease which has been neglected and untreated for years. Elderly ladies don’t usually like showing off their knees, but in the consultation room, all is revealed. I have seen some truly massive knees, lumpy with additional bone from osteoarthritis, which must cause agony. I tell them I can’t fix it, but I can help with the pain and they are grateful. There is no joint replacement surgery here.

This is an example of what we used to call Housemaid’s Knee, or prepatellar bursitis. I told her that she should not kneel down for long periods, “But take a cushion with you to church”.

Another lady was referred to me by a nurse because of a fungal infection between her toes which was not healing. When I looked at her feet, she had a huge bunion which had forced her big toe out of line, and twisted it under the second toe. Instead of the gap between the toes being vertical, this cleft was horizontal, so sweat was pooling, being retained and providing perfect culture material for bacteria and fungi. Doctors have to be resourceful when working with a limited array of treatments. I used some antibiotic eye ointment and an oral treatment we usually reserve for people with advanced HIV suffering from fungal oesophagitis to treat her.

Most elderly people have problems with their vision, but hardly any wear spectacles, which are just too expensive. Every six months or so, a team from UK comes to Swaziland to refract patients and give out second hand spectacles with the correct prescription. This lady has a white dot (an early cataract) in the centre of her lens which prevents her from seeing properly.

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Mothers always dress their children in their Sunday best when they bring them to the clinic for vaccinations. Now I have been here for two months, I can see patients coming back to see me wearing their best outfits, too. It is a real privilege being respected by patients.

Ἰατρέ, θεράπευσον σεαυτόν

“Good grief, Ian, you look terrible. You’ll be frightening the patients!” said my supervisor.

Just to be helpful, my translator chipped in, “Yes, they think they will catch something from you. I blame this cold on you.”

I don’t spend a lot of time looking in the mirror. When I shave in the morning, the mirror is misted up with condensation following my shower. I didn’t notice a problem. But after work today, I reluctantly took a peak in the hallway mirror at home. My face and neck are pocked with a dozen angry red mosquito bites.

P1010421

I seem to react in a strange way to mosquito saliva. At first the bites cause itchy red lumps often with a pale central area. Then after a day or so I get a tiny tense blister, surrounded by a halo of livid inflammation. Scratching the bites at this stage leads to a prolonged healing process, with oozing sticky plasma which sticks the surrounding hairs together with golden glue. I now have two ulcerating areas about a centimetre across on my inner right thigh. My body is putting up a fight. The lymph nodes in my groin are enlarged and each ulcer sits atop a 4cm disc of induration, which is really tender. Walking is uncomfortable.
The bites on my face, neck and scalp are at the early stage. I must leave these alone or I will be consulting with my head in a paper bag at the end of the month.

P1010398

So how did I get bitten so much? Well, I have been ill with “man flu” for a week. But this is man flu with knobs on. I get drenching night sweats, waking up freezing cold. I feel hot in the early evening and go to bed with a fan aimed at my body. I use a sheet, which I fling off when I get hotter. When I wake up wet through, I get under the sheet and light duvet while my teeth chatter for a few minutes. When I overheat, I kick off the covers, until the next sweat. I reckoned that having a fan directed on me would waft away any hungry female mosquitoes. But I realised last night that they were biting my face when I turned my back to the fan.

I would prefer to sleep under a net, but no one else does. The rooms have gadgets filled with insect repellent which plug into an electricity socket. The liquid is vapourised by heat. I started using this when I first arrived, but the vapour irritated my eyes. It needs replacing every 45 days, but I neglected to do so.

Just to make matters worse, my big toe has a paronychia. I have a tiny bit of numbness in the left foot following a prolapsed disc at L4-5 in 2012. A few days ago, I cut my toenails and inadvertently must have ripped the outer edge of the big toe nail, which disrupts the seal with the skin. Now I have a massive whitlow which is making it difficult to get a shoe on. Everything here gets infected very quickly. Initially, I thought it looked like a staphylococcal infection, but no creamy yellow pus developed and the inflammation spread down my toe despite taking cloxacillin. So it is more likely to be streptococcal. I’ve switched to some co-amoxiclav which is going out of date soon. It still feels very boggy.

P1010428

It is strange being ill overseas. Just like in UK, greeting colleagues with, “How are you?” we expect the reply, “Fine, how are you?” But if I say I am not fine, my colleagues, both local and expat, don’t really know what to say. If I just mumble that I’m okay, the more perceptive nurses may pause in thought, wondering what to say next. Earlier this week, the nurses working in outpatients had realised I was poorly and tried to take on more of the clinical work, to make it easier for me. At the end of one tough day, one even asked me if I was going home to UK.

I have been reluctant to take a day off work, because that’s the kind of person I am. Today, we were missing several nurses and a doctor, so it would have been unfair to the 300 plus patients attending the clinic if I had taken a sickie as well.

I have been pretty exhausted after work so I have been going to bed at 7pm and sleeping till 6am to try to recharge my batteries. I did very little at the weekend, and spent all day Sunday resting.

I normally have a healthy appetite, but I don’t really fancy food much. When I had my physical examination for MSF just after a particularly indulgent Christmas, I weighed a podgy 88kg. Now I am just a shade under 80kg. I have lost a mixture of fat and muscle. Partly it is because the food here is plain and unexciting. And I don’t need to eat much in the heat. Being unwell, I don’t feel hungry but I try to eat what I can.

As the most experienced general clinician in the programme, I am happy to take on the role of GP for the expats (they can see other doctors privately using medical insurance if they choose). My two medical colleagues here are drug resistant tuberculosis specialists. I certainly hope I don’t need their help! I should be able to sort myself out with common (clinical) sense, time and rest.

At least I am not as spotty as this lady (we have a mini outbreak of chickenpox at present).

P1010394

Ἰατρέ, θεράπευσον σεαυτόν translates as “Physician, heal thyself” from Luke 4:23

Shopping

Perhaps it is because I am in touch with my feminine side, I rather like shopping. I particularly enjoy rummaging through African markets. In Bradt’s Travel Guide to Swaziland, the market in Manzini features in the “Swaziland in Colour” section. I just had to take a look. Saturday morning at 8am, I set off to explore.

The very centre of the market is a two storey structure. Underneath, there is a wholesale market with vendors selling cartons of fruit, sacks of onions and potatoes. On top, there is a tourist market with trinkets, carvings, beadwork, traditional clothing, jewellery, paintings and batiks. Surrounding this building is a ramshackle arrangement of wooden stalls and some shops selling absolutely anything, but not much of it you’d want to buy. Out on the street there are more stalls, squeezing pedestrians onto a narrow sliver of pavement. Across the road, there is a new modern market area, with concrete tables and corrugated iron roofing. It looked sad, depressing and empty. Most shoppers were patronising the shanty stalls in the old market. Finally, there is a massive warehouse supermarket called “Boxer”, at which you can pick up any items you failed to find in the market.

Manzini Market

Manzini Market

I like quirky. I’m not interested in rows of similar detergents or cereals. My eye is drawn to the unusual. “What on earth are those?” I stopped in front of a couple of stalls on the street selling clay-coloured spheres, the size of cricket balls. Using sign language and pidgin English, I worked out that they were balls of ochre, which have a very special purpose. After a man has chosen a bride, he takes her home and the following day, he covers her in ochre. Meaning: “This one’s taken,” I suppose.

Ochre balls and powder

Ochre balls and powder

The juxtaposition of steel wool and toilet paper on one stall was interesting. Probably no hidden agenda here, but it reminded me of an advertisement for glyceryl trinitrate ointment, used in treating anal fissures, which featured a toilet roll made from barbed wire.

Brillo and Andrex, all your bathroom needs

Brillo and Andrex, all your bathroom needs

Next door, a lady was selling a skirt made of black and white lengths of plastic attached to a belt. She demonstrated how it swished to draw attention to a lady’s posterior. I am too miserly to afford WordPress Premium, so I cannot upload the video. Shame.

Swish

Swish

I walked inside the shanty town market, attracted by a familiar noise: the sound of coconut being grated. The tool for doing this is virtually the same all over the world. I still have one in my garage at home from the Solomon Islands. It consists of a solid plank of wood, upon which you sit, attached to a sturdy metal pipe, which has a serrated tip. It is used to remove the white flesh from inside half a coconut, rotating the shell a few degrees after a few scrapes. Again, apologies for the lack of video.

The row of shops in the market resemble a set of lockup garages. The first half dozen were occupied by tailors and seamstresses, knocking out fashionable tops in bright African cloth. Further along the row, the shops became more traditional. One shop was selling drums and goatskin bracelets. For a moment, I thought they might be handcuffs. After all, “Fifty Shades of Grey” is currently showing in the multiplex cinema at the Gables Shopping Centre in Ezulwini (which translates as Valley of Heaven, but in colonial times it was known as “Happy Valley”). The adjacent shop had tunics for sale made out of hairy goatskin. I am not sure if PETA would be happy with this, even though the goats were killed for their meat, not just their skins.

P1010155

Finally I got to the traditional healers. On display in front, there were dried puffer fish, sea urchins, cowries, starfish and shark jaws. The healer makes medicine by pounding these in a pestle and mortar to make a powder. In the back of the shop, there were shelves storing different pieces of wood and bark. The patient adds bits of tree to boiling water in order to extract the active ingredients. Another healer had sacks of roots, seed pods and twigs from medicinal plants on sale, some of which had already been crushed to a powder.

Traditional medicines

Traditional medicines

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The healers were happy for me to take photographs of their shops, but neither of them wanted to appear in the pictures. One offered to sell me something to give me “power”, “traditional Viagra”. I told him I didn’t need any, besides, I didn’t have a girlfriend.

“Oh, I can fix that. You must bathe in this special liquid and you will have girls flocking to you,” he replied. “Then, you will need power. I can give you both products for a special price.” Hmm, extract of Lynx?

“I am going to the second marula festival this afternoon,” I said. “I was propositioned five times at the last festival. I don’t think I’ll need your muti, Sangoma.”

“I’m not a Sangoma, throwing divining bones. I have proper traditional medicine.”

As I shook my head and turned to leave, he called after me, “Do you have any tablets for me, dokotela?”

“But you are a healer. Why do you need Western medicine?”

“Power is power, doc, wherever it comes from,” he said, hedging his bets.

Ideal for those who shop at Aldi, where they charge for plastic bags

Ideal for those who shop at Aldi, where they charge for plastic bags

My eye was drawn to a blaze of colour. Three ladies were weaving coloured plastic strips into shopping bags. “You can fold them for packing, only 50 Rand,” said the first lady. Sheila would not have been able to resist buying at least a couple for £3 each.

“I am impressed, but I’m working here for a year,” I told her. “I’ll buy some next January.”
“But I am hungry. I have not eaten breakfast. Please buy one of my baskets,” she pleaded, rubbing her ample stomach.

“I’ve got my rucksack until then, madam. Sorry.”

My next stop was the wholesale market. Almost all the produce on sale originated in South Africa. Tomatoes, peaches, plums, apples, grapes, tangerines and oranges, all looking delicious. Perhaps the beetroot, potatoes and onions had been grown in Swaziland. I was tempted, but the vendors were selling in bulk; I couldn’t even carry it back home, never mind eat it.

In the market parking area, men were selling loose apples “orf the back of lorry”. They offered me a taster. It was really good and I bought 10kg for 30 Rand (less than £2). They packed my rucksack full, so I couldn’t zip it shut. Not being packed carefully in cardboard boxes, the apples were not first class, and didn’t have those annoying plastic “Cape” stickers, but I was happy with a bargain.

"Sell off the back of a lorry"

“Sell off the back of a lorry”

Upstairs, there were no customers in the craft market. As a result, the prices were keen, but the only item which tickled my fancy was a metre-long, wooden jumbo jet with a broken tailfin and a family of warthogs painted on the fuselage. I thought about buying a batik, signed by Homo, for my newly wedded gay friends, but it wasn’t up to the high standard of art work decorating their 30th floor apartment in Chicago.

In the dilapidated stalls around the wholesale market, there were buckets full of sweet potato, taro, groundnuts and chillies. I left without making any purchases and crossed the road to see if the newly built market had more variety of foods. It didn’t.

The Boxer supermarket was playing loud dance music, so I couldn’t resist jiving around the aisles pushing a trolley to the funky beat. First I had to check in my rucksack, asking the clerk not to bruise the apples. I wanted to buy some bananas. In UK, most of the bananas we eat are one variety, Cavendish. But in Africa, there is more variety, in size, shape, colour and taste. Boxer had bananas on sale, but all their stocks had been sold.

I followed my nose to the butchery department. Something didn’t smell fresh. Just behind the glass counters selling ox spleen, chicken necks and intestines, butchers were hacking at meat with gay abandon and large cleavers. It was enough to turn one vegan.

Chicken intestines, chicken necks, ox spleen and liver

Chicken intestines, chicken necks, ox spleen and liver

The pharmacy shelves in Swaziland are interesting. They are quite open about advertising dubious products claiming to improve sexual performance and libido, both male and female. It looks more scientific than the traditional medicine in the market, but I didn’t see customers queuing up to buy it.

Get your mojo back with Makhonya

Get your mojo back with Makhonya

After buying some bread, it was time to leave. I had plans to go to the last Bugano (Marula) festival at Hlane Royal Residence in a few hours, and I wasn’t looking forward to a long hot walk up the hill with 10kg of apples on my back.

Little boy in traditional dress

Little boy in traditional dress

PS Confession: My guilty secret is buying fresh chips on Sunday morning at Pick’n’Pay, the “Waitrose of Southern Africa”. They even give you spicy seasoning with your salt and vinegar. The trouble is that the chips get cold and soggy quickly. Obviously, it is best to eat them while you shop and to disregard the strange look the lady on the till gives you when you show her the barcode on an empty bag.

General Practice, but not as you’d know it

A day in the life of Matsapha Comprehensive Health Care Clinic.

The day didn’t start well. The King’s motorcade drove through Manzini at 7am, the start of rush hour, causing traffic chaos. We were late being picked up by the driver, and it took longer than usual to get to the clinic.

The last patient I had seen yesterday was a man with a genital ulcer. I suspected syphilis, but typically the chancre is painless and this wasn’t. I’d asked him to return for a blood test to confirm my suspicions. As I walked into the clinic, I saw him sitting outside my consulting room, clutching a piece of paper. Positive RPR.

I thought I would give him an injection of benzathine penicillin before my teaching session, so he could get off to work. The treatment, benzathine penicillin, is tricky stuff to deal with. I normally add local anaesthetic to the powder, to numb the pain after the injection. The suspension is renowned for clogging up the needle, so I used the widest bore available. I took him into the consultation room, closed the louvres and locked the door. He dropped his pants and I aimed for treble 18 (assuming his buttock was a dartboard).

After injecting about 1 millilitre, the needle blocked and I began to sweat. I felt sure I could force it through with a bit of brute force. Something had to give. The spray from the end of the syringe covered my face, shirt, trousers, the floor, the patient and couch. I looked up at the patient, he looked down at me and we both burst out laughing. I apologised and he said, “Don’t worry, no problem.” Some things nurses do a lot better than doctors.

I went into the conference room and our new nurse took one look at me and realised what had happened. “You look like you’re covered in glitter,” she said.

“Does it look awful? Should I wash it off?” I asked.

“No, it looks rather nice,” she said. I didn’t know whether to believe her, but there was no time. I lurched into an interactive seminar on hypertension.

“What exactly is blood pressure?” I asked the massed nurses.

Silence.

“OK, what is it about the words ‘blood’ and ‘pressure’ that you don’t understand?”

It was going to be a rough session, I thought. Until I got their attention by asking how high the blood would squirt if you chopped someone’s head off? Not in a Jihadi John ISIS-style beheading. More a hypothetical horizontal slice. Yes, the blood would easily hit the ceiling.

Fifty minutes later, buzzing with adrenaline following the teaching session, I went back to the consultation room, determined to redeem myself. First up was an elderly lady (remember “gogo”?) who had recently had a below knee amputation. She had been released from hospital after a prolonged stay. In a scenario very familiar to British GPs, she had no discharge notes, no medication details and no follow up arranged.

She was in a wheelchair, but our portakabin consultation rooms are raised about 40cm above ground level. We have heavy metal ramps which are dragged into position to permit access for disabled patients. Against my advice, the carer insisted on pushing, not pulling, the wheelchair up the ramp. The small front wheels on the chair can whiz around through 360 degrees and one slipped off the side of the ramp. The chair slumped sideways. The patient had to be rescued by two other patients, who hauled her chair into the consultation room.

An interesting start to the day: what did she want me to sort out? Her poorly controlled hypertension? Her rampant diabetes? The deteriorating circulation in her remaining foot? Her depressed mood? No, she just wanted the dressing changing on her stump.

I am in charge of the Sexual and Gender Based Violence unit. This means I get called, as an emergency, away from my outpatient duties, to attend to survivors of rape/sexual assault. We have a good relationship with the local police who bring the survivors to the clinic for assessment and management of psychological and physical problems. Today the police brought in two girls, both under 16.

I try to do my job, compassionately and efficiently, making sure the girls get the best treatment. But the horror experienced by the girls is infectious. It leaches into my brain. I can’t parcel it away like I do when dealing with other tragic events. I find it difficult to comprehend how someone could do this to a child. And even more difficult to write about.

Our new nurse suggested we get a nice box of tissues for the survivors, instead of offering a few feet of thin paper roll, which is normally used to dry hands. I dismissed this at first as pandering to our western sensibilities, but on reflection I think it is a great idea. The only time I ever see a “survivor” smile is when we give them a dignity kit. This contains some toiletries (soap, toothbrush and toothpaste), a towel and new underwear. I am sure they would appreciate some soft, scented tissues to dry their tears.

Back at the outpatients department, I saw two small boys in the queue. They looked subdued and quiet, so I knew something serious was wrong. The first had fallen and scraped his knee. Instead of cleaning the wound, applying some antiseptic cream and covering it with a dressing, it had been neglected for a few days. It stank and was dripping pus. His knee was so swollen that he could not bend it more than 20 degrees. I needed to rule out a septic arthritis by sticking a needle into the joint and trying to aspirate pus. This was clear, so he went to the nurse for “wound toilet”.

The next boy had a tense swelling of the lower leg, with a shiny, thin patch of skin next to his shinbone. I lifted him onto the couch and told him that I needed to let the poison out of his leg so it would get better. It would hurt, but just for a short time. He looked up at his mum for reassurance. She nodded her head in my direction, signalling to get on with it. There was so much pus from deep inside the leg that I was worried he might develop osteomyelitis, so after dressing his leg I asked his mother to make sure I saw him when he came back for a dressing change.

The next few patients were referrals from the nurse. Old ladies with hypertension which was not under control, two patients who had recently had strokes, and a patient with a strange genital rash. This has the impressive Latin name “molluscum contagiosum”. I can diagnose it, I can even spell it, but the treatment is more medieval than Latin. Better to let it vanish by itself over the next year or so (luckily the person concerned was HIV negative).

After a quick cup of redbush tea, I returned to the fray. I was called to see a patient with suspected tuberculosis. Yesterday, I had examined her and on percussing her chest, I thought both bases were dull. Something solid was underneath. Could be liver on the right but not on the left. Maybe fluid, maybe consolidation. I’d ordered a chest radiograph to make sure. It showed a left pleural effusion, almost certainly caused by tuberculosis.

Another young girl had multiple, discrete, firm lumps in her neck. I knew she was having anti-retroviral treatment but was this just HIV lymphadenopathy, or could it be tuberculosis or even cancer? I asked one of our experienced nurses to try to get her to produce some sputum to look for TB. Another hospital manages her HIV, so I wrote her doctor a short note.

Patients often come to our clinic when they feel that they haven’t been treated properly elsewhere. A pregnant lady living with HIV came for a second opinion yesterday. She had lost almost a quarter of her body weight over four months, her breathing was very rapid, she looked pale and frail. She told me she had been put on oxygen by her local health provider, but was sent away after a chest Xray was apparently normal. Her temperature was normal when she arrived, but she felt hot to me. My fancy ear thermometer showed she was febrile at 39C. I listened to her lungs and convinced myself there were some signs at the right base.

Should we send her back to hospital or try to sort her out at the clinic? The consensus was to run some tests and give her treatment for pneumonia. I saw her today to review her. The antibiotic treatment seemed to have worked. Her temperature was down, her breathing was easier and she felt much better. Just when I was preening myself at having sorted out her problem, the geneXpert TB test result came back positive. She had tuberculosis after all. This should not have responded to the antibiotic I had prescribed. There is a lot of art in medicine, which doesn’t appear in the textbooks.

Back in outpatients, I saw a man who was diagnosed with HIV last year. He had developed an abscess on his abdomen which was not healing. A biopsy showed it was cancerous, a lymphoma. He had come to ask questions and seek advice about what to do next. Swaziland has only limited capabilities to treat cancer. He would need chemotherapy in South Africa (if he could find funding).

A teenager with “asthma” was next. He had been given treatment by nebuliser, but when I listened to his chest it was bubbling with secretions. If he was suffering from asthma, his chest should have been quiet or wheezy. Slowly I pieced together the clinical picture. Born with HIV. Tuberculosis in childhood which had badly damaged the airways in both lungs so he now had bronchiectasis. To explain this, I compared his lungs to a tree. The main trunk is the windpipe and the branches get progressively thinner and more leafy. This is where the oxygen is exchanged. The main branches in his lungs had been pollarded, producing thick stumpy branches. He seemed to have been following the analogy well upto this point, but now he looked puzzled. I realised that they don’t pollard trees in Swaziland.

I saw a couple of patients who had defaulted from anti-retroviral treatment and needed to be “reinitiated” on medication. This involves lots of paperwork, but it is easy once you get the hang of it.

Finally, a young woman came to my consulting room looking like death warmed up. The nurse who had seen her thought she might have meningitis, but in fact she had the worst migraine I have seen for a long time.

I returned to my shared house feeling rather shell-shocked. The adrenaline high keeps you going when the pressure is on, but now I was back at home, I felt exhausted. At work, I had been weighing up patients’ symptoms, evaluating clinical signs and making important decisions all day. At home, I couldn’t even decide what to have for supper.

Patients

The young man needed to be physically examined. He stripped off his shirt to demonstrate various abrasions, lacerations and bruises as proof of his having been assaulted. The problem for me was that these injuries did not appear to have been sustained at the same time. Some appeared to be recent, within a few days, and others looked more than a week old. I began to document all the skin lesions.

“When did this happen to you?” I asked, pointing to a long, thin scar over his heart.

“Can’t remember,” he replied.

“And what about this wound here?”

“Oh, I got that playing football,” he said.

Very unlikely, I thought. But sometimes, I can’t resist saying the first thing that comes into my head.

“Have you been playing against Barcelona?”

“Why?”

“It looks like Luis Suárez has bitten you.”

Human Bite

Human Bite

Another patient had been badly injured in a horrific accident many years ago. He had lost an eye and one arm. Soon afterwards, he went stone deaf. I communicated with him by writing questions on a piece of paper, to which he would reply in speech.

Sometimes, my spontaneous comments can be rather crass.

“Is it possible to use sign language when you only have one arm?” I wrote on the paper.

He smiled back at me and said, “I manage ok.”

Patients are often keen to show you what’s wrong. One chap said he had a boil between his buttocks. Before I could ask him any more questions, he turned his back to me, dropped his pants and bent forward. “Don’t shoot!” I said, “You’ve got piles.” He laughed so much at this that he turned around and shook my hand. Or maybe he was relieved he didn’t have a pilonidal or ischiorectal abscess.

A schoolgirl came to see with skinned knees. The abrasions were surrounded by a dark ring. “What’s this?” I asked. “Oh, it’s boot polish. My friend told me it would heal better if I applied it.” I remember seeing a Karen child in Mawkerthai whose scalds had been treated with toothpaste. Perhaps patients see treatments as being black or white?

Boot polished knee

Boot polished knee

Occasionally, consultations can be quite surreal.

“Sawubona, good morning, how can I help you?” I asked a patient yesterday.

“I have a rash on my knees,” she said.

“I can’t see any rash here.”

“It only happens when it is hot,” she replied.

“Can you come back and see me when it’s warmer, please?”

“I’ve got another problem. I have abdominal pains.”

“Tell me more about your pains.”

“They are worse when I am having a period.”

“Are you in pain now?”

“No, I am not having a period now.”

“So it is likely that you are having period pains, then?”

“I don’t know, doctor. But can I have a sick sheet?”

Spiky baseball cap

Spiky baseball cap

One patient had a magnificent baseball cap, one half of which was covered in conical spikes. But one spike was missing. I had been consulting for almost six hours flat out without a break, so my mind was starting to wander. Was the missing spike the clue I needed to make the diagnosis? Had she sat on the hat, leaving a spike attached to her? Had she eaten it? Were the spikes a device to protect her from radio waves, but only on the right side of her brain? It was obviously time for me to have a cup of (rooibos/redbush) tea, regardless of the queue of patients outside my door.

In the clinic, I have taken an interest in non-communicable diseases, such as diabetes and hypertension. The first few hours of my working day for the past couple of weeks have been devoted to seeing elderly ladies (average age about 70) with wonderful names like Nellie, Mavis, Elsie and Dorcas. Although they may just be attending for a blood pressure check or a fasting blood glucose measurement, it is inevitable that they have another half dozen significant medical problems. Most have signs of cardiovascular disease, high cholesterol, poor dental care, cataracts, deafness, osteoporosis, osteoarthritis in the knees and ankles, urinary problems, prostate enlargement in men and incontinence in women. It is just like consulting as a GP in UK. But it is rather novel here in Swaziland, where most medical problems are infections. Most of these conditions do not even merit a mention in the official Swazi medical treatment handbook.

My translator told me this morning that three of the old ladies had remarked to her in siSwati how pleased they were to have seen a doctor who took an interest in sorting out their multiple problems. “And when a Swazi person says ‘ngiyabonga (thank you)’, they really mean it, doctor.”

There was a record of atrial fibrillation in one lady’s medical notes, so while we were talking, I put a hand on her wrist to feel her pulse for a minute or two. I’m not sure what this old lady thought I was doing, but she put her hand on top of mine and smiled at me.

Old ladies are called “gogos” in Swaziland. I am seeing so many of them that perhaps my new nickname is going to be Dr Gogo.

Walk for hunger seems a strange slogan

Walk for hunger seems a strange slogan

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.

http://www.bbc.com/news/health-19463105

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.