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.