Incwala

Incwala – the First Fruits

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The ceremony begins when King summons young bachelors to collect a sacred bush called lusekwane. They have to march 50km to the site, where they lop off  branches under the light of the full moon, which this year was at Christmas.

The next day, elders weave the freshly-cut branches between the poles of the King’s hut.

On day three, the lads collect a red-leafed shrub called imbondvo, which is added to the mix. The sacred bull is allowed to escape from the kraal; the boys have to capture it and bring it back to the enclosure.

The main events are staged on day four. All men dress up in traditional warrior outfits, with sticks instead of spears. Women wear their lihiyas, and maidens go bare-breasted. Inside the sacred enclosure, everyone dances and they carry out sacred rituals, such as throwing the sacred gourd, the liselwa, into a crowd of young men, one of whom catches it on his shield.

The King retires on the fifth day in seclusion. Royal policemen, called bemanti, patrol the village during daylight, making sure no one does anything taboo, such as having sex, shaking hands, singing, dancing, sitting on chairs or mats. Even having a good scratch is prohibited.

On the final day, the King’s regiments collect firewood to make a bonfire in the kraal. Objects from 2015 are burned in the conflagration, symbolising the end of the old and start of the new. There is more singing and dancing, until rain puts out the fire. But the weather forecast says no more rain until the weekend, so it is going to be a long party.

We attended on the main day, which was a public holiday. Even the supermarkets were forced to shut down (a few years ago, one was heavily fined for remaining open on such an important day). Our driver told us that the ceremony started at 9am. Having lived here for almost a year, I realised that this was very optimistic, so we arrived at 10.30. The senior policeman in charge of the road block at the Palace Gates was one of my patients. He greeted me by name and waved us through into the VIP area. However, it seems we were not important enough and a more senior official dispatched us back to the public car park about half a kilometre from the kraal.

We wandered about, watching people eat hard pap and barbecued meat from styrofoam containers, trying to get some shade and taking some photographs of men in warrior garb. By 12:30 we were getting hungry and someone told us the dancing would not start until at least 3pm. So we went home and I rustled up cheesy scrambled eggs on toast for our group. We had the remains of Ann’s plum cake a la mode for dessert and got back to Ludzidzini by 3:30pm. Still nothing happening.

At 4pm people started going through security, a metal detecting arch. I don’t think it was switched on, but it looked good. We were told we could bring in no cameras, phones, watches or anything metal (apart from keys). Inside the parade ground, another official told me that I had to take off my shoes. A paramedic walked past me wearing boots. “What about him? I’m a docotela, too!” I said. “He is on duty,” said the minder. Saying,”I’m on duty 24/7, too. Just ask Jeremy Hunt!” didn’t cut any ice. We took the shoes back to the perimeter fence and left them outside with Ann, Yuan and Sellah.

I met another patient as we entered the Royal Kraal, the enclosure where the dancing and rituals were to take place. I was just getting started, feeling the rhythm, shuffling my feet, when another official told me that we could not stay, for some unspecified reason. I thought the better of asking him, “Is it because I is white?” Obviously not, as my companion, Andrew, is a black Kenyan. We were dispatched to the outer perimeter. Perhaps we had not made enough effort with our wardrobe.

The ladies were allowed in and ushered to one side, where they were shown the dance moves. I wandered around, taking photographs in the public area outside the Kraal. One self appointed arbiter of custom law decided to report me to two policewomen for taking pictures inside, but I was innocent.

The silver-helmeted soldiers of the Royal Guards paraded outside the Kraal waiting in the heat to be inspected by the King and a flurry of courtiers, all dressed in warrior garb. Although the King was 200 metres away, a soldier dressed in camouflage scanned the crowd at the perimeter. He looked like a steward at a Premier League match, watching for any disturbance among the fans. Only he was carrying an automatic weapon.

By now it was 5:30pm and everyone was hot and thirsty. The soldiers marched past, swinging just their left arms as their right arms kept their rifles bolt upright. We followed them to the paddock where our car was parked and drove home.

This was not a friendly festival, like the Reed Dance (umhlanga). I felt an undercurrent of hostility from some of the traditionally-dressed men. But it was good to have seen a whole year of cultural events.

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2015 in review

The WordPress.com stats helper monkeys prepared a 2015 annual report for this blog.

Here’s an excerpt:

The concert hall at the Sydney Opera House holds 2,700 people. This blog was viewed about 16,000 times in 2015. If it were a concert at Sydney Opera House, it would take about 6 sold-out performances for that many people to see it.

Click here to see the complete report.

Clinical Notes

 

The readers of my blog have asked me to write more about my work, rather than my walks. As always, I have altered the details to preserve patient confidentiality.

There are few things more dramatic than a patient being brought to the clinic in a state of collapse. The relatives flap around anxiously. The nurses quickly abrogate responsibility to the doctor. Having worked in our local hospital, Raleigh Fitkin Memorial Hospital, my Zimbabwean colleague is highly sceptical of these “dying swans”. After a quick examination, she gets straight to the point, “What’s stressing you, eh?” And often they ‘fess up and talk about how awful their husband has been to them, or how their children don’t take care of them.

Two lads came in last week. They didn’t speak much siSwati, never mind English. The sick one was leaning on his friend and collapsed into a chair.

“His legs are numb,” said the friend. Tell me more.

“They are painful. They are weak. He cannot walk.” When did this happen? “Today.”

The history became more convoluted. The young man was able to walk to work, but his toes hurt. He managed to work from 7am to noon before he collapsed and could not get up. His friend managed to get him into a Kombi and brought him to the clinic. His HIV test was non-reactive.

With difficulty he got up onto the couch. “Can you move your legs?” I asked. “No”

“Where does it hurt?” He bent his leg so he could point to the back of his calf. “Aahh!” said my colleague triumphantly, “You said you can’t move it, then you move it. What is stressing you?”

There were no obvious stressors, so I did a full neurological examination and, apart from equivocal plantar responses, I could find nothing wrong. Although he said he couldn’t move his legs, he was able to push his legs strongly against my hands. He gave inconsistent replies when I did a sensory examination. The spine was normal and there were no signs of meningism.

“And he has been passing blood in his urine for months,” said the friend.

“Didn’t he go to a clinic for treatment?” It transpired that he had had two courses of antibiotics for a urine infection, which hadn’t helped.

Admittedly I was playing for time when I sent him off for a urine test. But I was taking him seriously and his walking seemed to improve markedly. The test indeed showed blood in his urine, with schistosoma haematobium ova seen on microscopy. He had Bilharzia.

A bell rang in my head. Schistosoma eggs can pass from the veins around the bladder into the plexus of veins around the spinal cord. There they produce inflammatory granulomas which can cause odd neurological symptoms. To prove this diagnosis, he should have a scan of his spinal cord, but the treatment is just the same. Praziquantel will kill the schistosomiasis and he should make a full recovery. I asked him to return if his legs became worse, when I could give him some oral steroids.

The next day, a lady was brought into the clinic with her head lolling over the back of the wheelchair. She was making soft, moaning noises. Her husband was very concerned and we managed to get her up the ramp into the treatment room, then onto the examination couch.

The history was that she became unwell last night, feeling generally ill, with headache, irritability and weakness. Rather dramatically, she lost the use of her legs as she got out of the taxi in the clinic car park. Her temperature was elevated at 37.7C and she said she didn’t want to be examined, just to lie down and rest.

I said I had to try to find out what was going on, so I needed to examine her. She rolled onto her back and I swiftly checked her out. I couldn’t find anything wrong. “She needs a drip, doctor,” insisted the husband. My colleague came in and asked her husband to leave. “Is he beating you? Does he have any girlfriends? Is he drinking too much?” she asked. She shook her head in response, but when I asked her to sit up, she slipped slowly off the couch and stretched out on the floor. “Leave me alone,” she said.

We did some blood tests, but nothing abnormal showed up. I prescribed  some paracetamol and oral rehydration solution, then asked a psychosocial counsellor to interview her. Half an hour later, she was feeling much better. “What did you do?” I asked the counsellor. “Oh, she just told me that she was exhausted from preparing the fields and planting all day yesterday in the heat. He husband wanted her to put in another shift today, but she became ill.” Suddenly, it all made perfect sense.

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One of our nurses wearing a red hat as part of her regulation uniform

The relationship between mind and body in dis-ease continues to fascinate me. Occasionally I see patients who have organic mental health problems, such as outright psychosis caused by the anti-HIV drug efavirenz. But I also diagnose obsessive compulsive disorder when I see hand dermatitis caused by excessive washing. I also diagnose patients suffering from major depression and, rarely, dementia.

A 55 year old patient was brought in by a relative because “she is losing her mind.” She was HIV positive but not yet on treatment with anti retroviral drugs. I asked how long this had been apparent and I was told “since Saturday”. But what was she like before Saturday? The relative didn’t know. She hadn’t seen the patient for months and had only come to visit for Christmas last Saturday. The patient lives alone, so there were no independent observers to bear witness. 

“Do you think you are losing your mind?” I asked her.

“Yes. I am going mad. I keep forgetting things. I forget where I am going and I get lost. I get confused.”

I told her I didn’t think she was going mad, but I was concerned that something was affecting her thinking. My working hypothesis was that she had mild cognitive impairment and needed more assessment. But here, the buck stops with me; there are no specialist psychogeriatricians in Swaziland. So I started trying to work out how to adapt the mini mental state examination to a Swazi context.

Is she oriented in time and place? “Where are you now?” “In hospital.”

Well, many patients call this a hospital, but it is just a clinic, with no inpatient beds.

“What is the date?” “Near Christmas.” “And the year?” “2016”, nearly right.

I showed her three objects, which she was able to identify correctly.

I had a brainwave and asked her who was the monarch. “King Mswati.” I’d have been surprised if she had said Queen Elizabeth II.

“And the prime minister?” “Don’t know.” A better answer would have been Dlamini, as this is the commonest surname in Swaziland.

Serial sevens next. “Take seven away from a 100 and what do you have left?” “A lot.”

I am not sure if innumeracy is evidence of dementia. Neither is illiteracy. She couldn’t sign her name, never mind draw two interlocking pentagons. And asking her to repeat a cryptic phrase which had been translated into siSwati wasn’t going to work either.

She clearly had some insight that something was not right. She wasn’t depressed, this was not pseudo-dementia of depression. There were no signs of syphilis or hypothyroidism. I wondered if this was early dementia, possibly related to HIV. Her relative said that she had been coughing, had lost some weight and had been sweating at night, so I felt we needed to rule out tuberculosis. And of course, TB can affect the brain insidiously, too.

If she tests positive for TB, we will treat this for a couple of weeks, then start treatment for HIV, choosing a drug regime which penetrates into the cerebrospinal fluid, in case this is early HIV encephalitis. If she tests negative, she will need to be seen and assessed regularly to detect any change or deterioration. Watchful waiting.

In previous posts, I have written about Nigerian holy water which is reputed to have special healing powers. Last week I saw two patients with pneumonia, both of whom had the sticky label from the holy water bottle attached to their chest. Listening with my stethoscope I could hear the rasping rub of pleurisy exactly where the label had been attached. I should write this up in a learned clinical journal as “Ian’s Sign” for my 15 minutes of medical fame.

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I saw five patients with HONK (hyperosmolar non-ketotic hyperglycaemia) last week. This is rather more than usual. Perhaps the seasonal feasting and overindulgence was to blame? Two ladies were newly diagnosed with type 2 diabetes, so I am always on the alert for unusual presentations of diabetes.

One gogo, who was attending for review and treatment of hypertension, told me that she felt tired (this is common in persons taking a beta blocker) and her joints have been playing up (hydrochlorthiazide increases the risk of gout). She had a dry cough (she is also taking an ACE inhibitor, which causes cough). Then she said her vision was blurred today.

This sparked my interest. What could this be? Why just today? Fluctuating blood glucose levels can alter visual acuity because of the osmotic effect on the eyeball fluid. Or was there something else going on? Cataracts, chronic open angle glaucoma, macular degeneration wet or dry?

I spent five minutes checking her vision. I looked inside her eye with an ophthalmoscope. It all seemed normal apart from my needing to alter the lens in the scope to get a clear view of the retina.

“All I can find is that you need spectacles,” I said.

“Yes, I know that. I left them at home today. That’s why I can’t see properly.”

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Tick

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This morning I picked this little beast off my leg. If you look closely, you can see a chunk of my white flesh in its jaws. It is an ixodid or hard bodied tick, a parasitic arachnid.

I’ve had tick borne fever twice in Africa. Apparently there are 13 different strains in Swaziland, and catching one doesn’t give you much, if any, protection against the others. Let’s hope I don’t get ill over Christmas. These ticks prefer to suck blood from cattle, but if a juicy human walks past, well, why not?

Ann and I were looking for somewhere to tramp in the hills near Malkerns. The dirt track led to a cattle grid with a chain across it and a guard. I stopped the car and greeted him warmly. He smiled and asked where we were going. I told him we wanted to walk. “Where to?” he asked. “Just a stroll in the hills over there,” I said. “Nowhere in particular.” “Ooohhh, you’ll never get there,” he said. “We’ll be coming back, don’t worry. Send out a search party if we are not back by nightfall.” This made him really worried. Swazis don’t always get my sense of humour.

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Hiking in the hills isn’t popular in Swaziland. My translator at the clinic regards it as “extreme sports”. The guard watched wistfully as we tramped off down the hill. He must have thought we were completely daft. Why walk when you’ve got a car? What’s the point of walking when you are going nowhere? Aish!

Sibebe Second Time Round

Sibebe is a massive lump of granite, the second biggest monolith in the world. It is 2.6 billion years old and 1350 metres above sea level, reducing by half a centimetre each year. The summit is strewn with huge boulders, improbably perched or split through fault lines into segments. The high plateau forms a microclimate, with its own plants. It reminds me of the “land that time forgot”.

Usually it is verdant green, with lakes, streams and marshes at this time of year, but with the failure of the early rains, it is dry and parched. Traversing the spongey plants of the bog felt like walking on a bouncy castle.

Steve took us through a secret tunnel and a crevasse to a rock formation known as the cathedral. It was stunning.

The views from the summit are spectacular, from the Mbuluzi River to the Mahlokohla mountain range across the valley. We could just make out the Lebombo Range of hills to the east. Emlembe to the north west, and 500 metres taller, was clearly visible.

Sangomas

With a long queue of patients waiting to be seen, consultations tend to be brief and functional. Closed questions predominate, rather than open ones. Gogos, who have been starving prior to their fasting glucose blood tests, are keen to get home for breakfast with their medication. But when we are fully staffed, there is less pressure to deal with patients quickly. Sometimes, allowing patients to ramble on telling their stories makes it easier to get to the nub of the matter and to discover what they are really bothered about.

Last week, during one consult, I was spending a lot of time writing. I had to record my findings in the patient’s notebook, add basic data such as blood pressure, weight, glucose and medication to my NCD database, and finalise the prescription. While I was occupied, my interpreter was chatting with the patient. When I’d completed the paperwork, I interrupted their conversation. I explained again about the changes I made to her medication and told her when I’d like to see her again.

As she walked out the door, I turned to the translator and said, “Did you think she looked depressed?”

The translator replied, “She has ten children, but only one who looks after her. That is what we were talking about.”

“Fill me in on the details, tell me what happened.”

“I didn’t get the whole story because you broke into the conversation, but it seems the one who is helping her did very well in school, but instead of getting a conventional job, he became a sangoma,” she said.

A sangoma is a witchdoctor or traditional healer, depending on your point of view. Obviously he is doing well because he can support her financially. I wondered why he didn’t sort out her diabetes and hypertension. Perhaps he abides by the General Medical Council’s advice in “Good Medical Practice” and declines to treat a family member.

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This lady is not the patient referred to in the text.

A young man was referred to me by one of the nurses because he was a “complicated case”. He had told her that he had a heart problem when he was a child and now his heart problem had come back. She didn’t have a clue how to deal with this.

Before I set eyes on him, I was thinking about the complexities of adults who have survived congenital heart defects. But he had not needed surgery and he didn’t know his diagnosis. All he remembered was frequently being taken by his gogo (grandmother) to the clinic with “heart problems”, receiving medication but not getting better.

“Why did your gogo take you? Where was your mother?” I asked.

“She died when I was seven, and I had to go to stay with my gogo in Siteke,” he said.

“Did you have any special tests, such as Xrays?” I asked.

“No, they just kept giving me different medicines which didn’t help,” he replied. “The pain just went away by itself. But it came back a few weeks ago.”

I asked him to tell me more about his pain and he said it was as though he had a wound in his heart, which was burning through to his backbone.

I asked him to take off his shirt and went through the rigmarole of a full cardiovascular examination, including the fancy bits, such as testing for tactile vocal fremitus (“Say ninety-nine”), percussing the borders of the heart, listening for bruits in the main arteries. The Full Monty. Sometimes I do this when I am playing for time to think. Other times, the detailed examination demonstrates to the patient that I am taking him seriously and using all my skills to detect what is wrong.  On this occasion, it was a bit of both.

“Years ago, in my country, we thought that all our feelings and emotions came from the heart. Is it like this in Swaziland?” I asked him. He nodded so I went on, “Do you remember what it was like when your mother died?”  He spoke about this for a while and then said, “Do you think my heart pain was caused by my losing my mother?” I said that it could be that he was so distraught that he felt the emotional pain in the left side of his chest, where he thought his heart was.

“So was my heart broken?” he asked.

“Not literally. It probably just felt as though it was. The stress of bereavement can cause physical pain which hurts just as much as a broken bone.” I stopped talking and waited for this point to sink in, before asking him, “Have you suffered a recent loss?”

He told me he had broken up with his fiancée a few weeks ago, before the chest pain restarted. Then he said, “Do you believe in witchcraft, docotela?”  I replied that although I personally did not believe in it, I understood how important it was to many Swazis. “They believe it exists, it is powerful and it explains many things which would otherwise be seen as random or coincidental. That belief can be so strong it can make some people ill.”

“I went to see a sangoma,” he told me. “But he couldn’t help. He said that I had been affected by a spell which was meant for someone else, and this made it difficult to put right.”

“How did that happen?” I asked.

“I must have stepped over some ‘muti’ where I was not supposed to be walking,” he replied. I thought this was a bit like the plot of A Midsummer Night’s Dream.

“Let’s consider what could be causing your pain,” I said. “We’ll start on the outside and work our way in.” Skin, soft tissue, muscle, rib, cartilage, pericardium, heart, pleura, lungs and finally getting to the stomach.

“Sometimes people describe the pain of an ulcer or an inflamed stomach lining as ‘burning’, which can seem to move through to the back.” He agreed that this was a possible diagnosis and I prescribed a course of omeprazole, to reduce the gastric acidity.

“Job done,” I thought to myself as he walked to the door. With his hand on the doorknob, he turned and said, “Will this medicine counter the ‘muti’, docotela?” I smiled at him and said, “We’ll just have to see, won’t we?”

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After working with me for almost a year, my translator has learned a few of my tricks. When an embarrassed young man shuffles into the consulting room, avoiding eye contact, she ignores his opening gambit of a “headache”, and turns to me and raises her eyebrows. She knows the routine way I take a sexual history, breaking down the barriers with a bit of humour, accepting that condom use is the exception rather than the norm, and using local terms for genitalia and common sexually transmitted diseases. When telling the patient that it is important that sexual partners attend for treatment, she offers half a dozen “contact slips”, not just assuming a single partner.

It reminded me of one Lothario from the past, who asked the clinic to provide a kombi to collect and bring his ladies for treatment. Prolific and profligate, I bet he was getting some help from a sangoma.

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