Meeting with the Ministry

Perhaps the cause is el Nino. It is supposed to be summer, but the weather is foul. Dirty-grey clouds were scudding over the peaks on either side of the valley road to Mbabane. But this persistent, mizzling rain is not enough to break the drought. We need heavy downpours. Last week, the temperature hit 40C, but yesterday there was snow in Lesotho, another mountainous kingdom a few hundred kilometres to the south west of Swaziland.

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Tyler and I were driving to a meeting with the Ministry, specifically, the Sexual and Reproductive Health Unit of the Ministry of Health. All the stakeholders (how I detest that word!) had been invited, but only two others turned up. UNICEF, WHO, World Bank, Global Fund and several other big players had been invited but were absent. This was the last quarterly planning meeting of the year. The ladies from the Ministry wanted to know what we had been doing and what were our plans for the coming year, to incorporate this into the master plan for the kingdom.

The venue was a delightful lodge, just off the main road, surrounded by forest at the head of the valley. The views would have been stupendous if it wasn’t for the mist and low cloud. We followed the signs pointing to “Ministry of Health” and I sneaked into the seminar room, just five minutes late. I was surprised to see so many participants already seated. Usually meetings don’t begin for at least half an hour after the scheduled start. I whispered to the person sitting next to me and realised that this was the e-Health meeting, not the UNFPA meeting to which I had been summonsed.

I slunk out of the room and walked briskly down the path to a thatched conference room with marquee tent attached. The room was silent when I walked in. Half a dozen people were seated in a horseshoe arrangement around a central table. The video projector was showing a bouncing logo on the screen. All eyes turned away from WhatsApp on their smartphones and onto me as I took my place. “Sorry I’m late, I had to look after someone who had been raped and it took more time than I expected,” I explained. The atmosphere was frosty; I didn’t take off my fleece. “Doctor, please have some coffee while we wait for the other stakeholders.”

The coffee wasn’t the usual bitter, black, sludge which is served at meetings. It was hot enough to allow me to add cold milk, rather than the hot, skinned milk provided. I was thirsty. Two cups of coffee and no more stakeholders later, I was buzzing with caffeine. Beside the beverages, there were three trays of “breakfast” sandwiches, scones and muffins. It was almost 12.30 and I was hungry. The soggy toasted triangular sandwiches might have been palatable at 10am, but not now. The egg mayo and the tuna were the best of a bad batch. The muffin was good. Then I realised that I was the only one eating. This was supposed to have been their breakfast. Lunch was yet to come.

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We kicked off with the lead person from the Ministry telling us that their main priority was reducing maternal mortality. Swaziland had failed to make a dent in this millennium goal. The figure remains stubbornly high at 220 per 100,000 live births. To put this into perspective, Malawi’s figure is over 550 per 100,000; the UK’s figure is 8 per 100,000. Swaziland’s target was 100 per 100,000. Over the past decade Swaziland has participated in African Union initiatives, Declarations, the Maputo Plan of Action and now has “sustainable development goals”. (One really wonders if all these talking shops actually accomplish anything.)

The lady from the Ministry was warming to her theme now. So stakeholders need to share their plans and vision with the Ministry. And for transparency’s sake, their funding. We need to be prepared, “like the French people with their shiny blankets”, referring to the response of the emergency services to the Paris shootings.

The first stakeholder was prepared. He delivered an excellent, thorough presentation. But it didn’t mention the Ministry of Health once. And it concentrated on girls, 62,000 adolescent girls who are the most vulnerable group for HIV infection.

“So why are you not targeting boys, as well?” asked the Ministerial spokesperson.

“Because the data shows that the incidence of HIV in this age group of girls is highest. In males, the incidence of new HIV infections is highest in the 25-35 age group. The biggest driver of HIV in Swaziland is intergenerational sex – older men infecting younger women. Sugar daddies.”

“But what about sugar mammies? Older women targeting young boys for sex?” asked another lady from the Ministry.

Silence. Some participants nodded their heads, but I couldn’t believe what I was hearing. Sugar mammies? Who would choose to have sex with adolescent boys? I was gobsmacked.

“And of course those girls who have been infected will go on to have sex with boys their own age in time. We must have gender equality in programmes.”

Then it was my turn. I spoke about our work in the field of gender based violence and how we were keen to adopt the new Ministerial guidelines. I also mentioned our attempts to introduce cervical screening but this was hampered by lack of capacity at Government hospitals for women found to have suspicious lesions. I think I got off lightly because I didn’t use PowerPoint.

“Mothers to Mothers” was next up. This is an excellent organisation where HIV positive women provide support and guidance for women found to have been infected with the virus when they attend antenatal clinic. They work in the community and help to contact women who have dropped out of treatment programmes, whose children have not been fully immunised, those who no longer attend for antenatal care, etc.

M2M is funded by the President’s Emergency Plan for AIDS Relief (PEPFAR) and works in 57 large health facilities in Swaziland. One of these sites is our MSF clinic in Matsapha. Indeed, our clinic distorts some of the data because it is so good (for example, getting men involved in antenatal care and couples HIV testing). But because the clinic is not 100% Ministry of Health, the funding for our three M2M workers is being withdrawn next month. I protested about this, but was told that there was nothing I could do, the decision was final. I really don’t know if MSF will pay the M2M staff salaries.

This is not the first time M2M staff have been withdrawn from health facilities. They were removed from our local general hospital because they were getting carried away at a health promotion session, extolling the virtues of oral sex while using a condom, to an audience composed of mothers and children. And another health facility had delegated the giving of infant immunisations to unqualified M2M workers, “while the midwives sit on their….benches”.

Sometimes I get a little paranoid that whenever MSF does something exceptional and good, it arouses some reactionary criticism. The Australians call it “tall poppy syndrome”. Perhaps it is just jealousy that we have some additional funding and the courage try out new ways of doing things.

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We took a short break in the hope that other stakeholders might turn up for lunch. I spoke to a delightful retired Zambian obstetrician/gynaecologist who was employed by the UN to support the Ministry of Health. Being of a similar age, we reminisced about working in Africa 35 years ago.

“That was when there was some hope,” the special adviser said. “Clinical specialists were training, there was less private practice, and WHO hadn’t started banging on about ‘Health for All by the Year 2000’, the Alma Ata Declaration.”

“The WHO convinced African governments to prioritise the training of Public Health doctors. All they do is sit around tables and have meetings. But people still get sick and need skilled physicians and surgeons. Public Health doctors haven’t reduced illness. They just talk about it. There are no specialists in government hospitals anymore to train medical students and junior doctors.”

It was rather like a scene from the TV series “Grumpy Old Men”, looking back at the good old days through rose-tinted spectacles.

When no one else turned up to present their activities and future plans, the participants left. I didn’t realise that they were going off for lunch and they avoided my request for anyone who might be travelling east to give me a lift. I was left on my own, so I telephoned the clinic and asked if a driver was free to pick me up. It had started to rain heavily and low cloud was obscuring the view down the valley. I felt a bit peckish and went back to the breakfast sandwiches, which, by this time, were well on the road to entropic doom. Even worse than British Rail.

As I was picking out the best of the butties, one of the cleaning ladies came into the room without me noticing. She tapped me on the shoulder and told me off for eating “breakfast bread”. She directed me to the dining room, up the hill but I wanted to keep my eyes on the car park for the MSF car. Instead of going for lunch, I sneaked back into the e-Health workshop. This was much more fun. Another retired professor (this time of health informatics) recognised me as I took my seat and asked me to tell the Public Health doctors around the table about my experience initiating treatment in patients with HIV.

“First, I fill out the Chronic Care File, making sure all the boxes are completed as this will be audited. Then I write a summary in the patient’s exercise book, which they keep. They also have a smaller notebook, specifically for HIV treatment, in which I write the same information. Then I write out the prescription for HIV drugs. And finally, I fill in the pharmaco-vigilance form. I spend 15 minutes writing and just 5 minutes talking to and examining the patient. I get through two ballpoint pens a week. I wish I could just write it once on a computer.”

I glanced at the door. The driver had arrived. The kind cleaning lady appeared again and ushered him in for a cup of tea, a scone and a muffin. There was plenty of time to drive the 30km back to the clinic before knocking off time.

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