Mathilda looked over her ill-fitting spectacles and smirked a little as she slid a folded piece of paper across my consulting room desk. The result of her fasting blood glucose test was abnormally high. I copied the figure down in her medical notebook using a red ballpoint pen, with theatrical emphasis. She folded her arms over her ample stomach and pulled her shawl across her shoulders, preparing to do battle.

I always try to start a consultation on a positive note. Her blood pressure had finally been reined in to an almost acceptable level using the maximum permitted dose every one of the four anti-hypertensive drugs we have available in our pharmacy.

“Well done, Mathilda. This is the best blood pressure you have recorded in over a year,” I said. 

“Thank you, docotela, but my sugar…” she replied.

“I’m afraid this is higher than it has been for some time. At this level I would expect you would be feeling thirsty and passing lots of urine. Are you sure that you have been taking the medication as prescribed?” I asked her.

She insisted that she had been a compliant patient, pointing to the improved control of her hypertension as corroborative evidence. But she added that she was unduly thirsty and her “personal itch” had been troublesome recently.

“So what do you think has caused the increase in your blood glucose? Has anyone you know died recently?” I asked.  Funerals are times of feasting and it would be considered impolite if you did not eat your fill at the wake.

“No, docotela, I am addicted to sugar,” Mathilda replied. She told me that she tried to cut down on sweet foods and stopped adding sugar to her tea but after a few days of being “good”, she reverted to her old ways. “I love sugar. Life without sweetness is dull.”

Swaziland’s entire economy is based on sugar production. The local Coca Cola factory produces the sweet liquor which forms the concentrated base for Coke. It is Swaziland’s principal export and is transported all over south eastern Africa. It is almost unpatriotic to be anti-sugar.

We furtively discussed artificial sweeteners. “But don’t they cause cancer, docotela?” I told her that as far as I knew, the modern sugar substitutes were not carcinogenic. I suggested trying Canderel, but my translator intervened and said that there was a whole section of shelving in Pick and Pay devoted to sweeteners. Canderel was expensive because you had to buy it at the chemist. They chatted about this for a few minutes in siSwati.

Just when I thought we were making progress, Mathilda told me she hated giving herself twice daily injections and wanted to stop insulin. My heart sank. The injections were too painful, she told me. I checked her injection technique, examined her usual injection sites, made sure that she wasn’t using the same needle for a month, but couldn’t discover what had gone wrong.

“Can I go back to oral treatments for my diabetes?” she asked me. I knew I had to be careful how I handled this. If I was too rigid and clinical, she might just give up and take her diabetes elsewhere. I explained that diabetes was a lifelong condition, you had to take responsibility for looking after your own health.

“How about a compromise?” I suggested. “If you stick to a strict diet and lose some weight, we can try withdrawing the insulin and putting you on the maximum amount of oral diabetes treatment. But you must realise that poor control of your sugar increases the risk of complications, such as nerve and blood vessel damage.” I thought about telling her that every week, our local hospital amputates ten gangrenous feet because of diabetes, but held back, waiting for her response.

“But docotela, I love my sugar, I’m addicted,” she said.

Swazis like narrative comparisons, parables if you like, to illustrate a point. I talked about balance and choice. I stretched out my arms with the palms facing upwards. “On this hand, you can eat sugar occasionally because you have the insulin injections to help your body deal with it; on the other hand, you don’t have the pain of injections, but your sugar intake is severely restricted and you have to take massive doses of oral anti-diabetics.” I moved my arms up and down, emulating a weighing scale.

Mathilda looked at me over her glasses, put her elbows against the sides of her chest and opened up her hands in a supinated expression of exasperation.

I think I was on Plan D by now, so I suggested just taking one injection per day of long-acting insulin, rather than twice daily mixed insulin.

“Why didn’t you tell me about this before?” she asked.

“Well, it doesn’t provide as good control as two injections. But it is better than no insulin at all,” I answered.

She replied sotto voce, “I am only taking one injection a day anyway, docotela.”

Ah. That was why her sugar levels had gone through the roof after being reasonably well controlled for the past year. We compromised on a single evening injection of long acting insulin and I started writing out a summary of the consultation and the prescription.

My translator seemed more exasperated than I was. When Mathilda launched into a list of other complaints, such as “sides pain” and headaches, the translator marched to the door and rattled the handle. “You’ve had nearly thirty minutes,” she growled. “Bring this up at your next consultation in October.”

The gogo eased herself out of the chair and left the room, thanking me profusely for looking after her, and glowered at the translator. I breathed a sigh of relief. Sometimes it is useful having a “hit man” to do my dirty work in the consultation room.

Before the next patient came in, I tried to explain to my translator that time spent now in really getting to the bottom of patients’ problems and trying to fix them was time well spent, not wasted. She sneered at my naivety, “They will suck you dry, these people. Give them an inch and they will expect a mile next time.”  My “hit woman” seems to have compassion fatigue.


Afternote: Midway through the next consultation, the pharmacist knocked on the door and told me that the long acting insulin was out of stock.


By Dr Alfred Prunesquallor

Maverick doctor with 40 years experience, I reduced my NHS commitment in 2013. I am now enjoying being free lance, working where I am needed overseas. Now I am working in the UK helping with the current coronavirus pandemic.

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