NaHSAR at Pigg’s Peak Hotel & Casino

We were scheduled to leave after the project meeting on Friday morning, but I had a patient with HONK. That’s the abbreviation for HyperOsmolarNonKetoacidotic coma. A type 2 diabetic lady had inexplicably stopped taking her medication. She was as dry as a crisp and sweeter than honey. Once I was happy she was on the mend, we could leave for the two hour journey to Pigg’s Peak. (Should this have been OINK rather than HONK?)

We stopped off at the town of Pigg’s Peak. It is big enough to have a Kentucky Fried Chicken outlet, but blink twice and you have missed it. Its claim to fame is being the marijuana capital of Swaziland. The local term for marijuana is “school fees”, rather than Swazi Gold. Police are always arresting people, usually old women or gogos, for possession of bales of dope. The growing conditions are perfect in the rolling, forested hills outside town, intercropped between rows of pines.

We didn’t buy any marijuana. My colleague was feeling the cold, so she bought something to keep her feet warm. That’s really sock-and-roll.

The Hotel & Casino was rather angular and impressive, with a huge automatic plate glass door, which slid back when you approached. Think Architectural G-Plan. Our rooms were not ready so we stashed our weekend bags behind reception and set out to explore. My colleague saw a group of gogos leaving the hotel and said, “Ha, Ian, they are your patients, who have followed you here!” Instead I reckoned that they had probably been playing in the casino with their ill-gotten gains from cultivating marijuana.

We soon met some other health workers, milling about at the entrance to the dining room. The workshop was supposed to start at 12 noon with lunch, but the maitre d’ regretted to inform us that lunch was not included. This was like a red rag to a bull for starving Swazi health workers. There was some rebellious talk of leaving now, getting the driver to turn round to pick us up, but the insurrection didn’t happen. The maitre d’ capitulated and allowed us access to the buffet.

The food was G-Plan too, typical dishes from the 1970s. Very Abigail’s Party, but with lots of meat and starch. It tasted great after the plain meals I had been eating in Manzini. Diners get a free can of soft drink with meals, but most people secreted their Fanta into their voluminous handbags rather than drinking it. I went back for fruit and dessert – a selection of cakes and some excellent peanut brittle stuff made with chocolate. (Maria, I need the recipe if you managed to get it.)

We were called upstairs to the conference room to start the workshop. The hotel has four floors and stairs were difficult for some of the traditionally-built Swazi nurses. Proceedings started at 3pm, just an hour behind schedule. After the prayer, we heard about the relationship between TB and HIV. Then we broke into four small groups for an activity called “cluster-based quality gap analysis”. Which is exactly what it says on the tin.

Our “cluster” was based in the underground cinema. We waited for 20 minutes before the IT people turned up with a laptop and projector. This time should have allowed us to chat and introduce ourselves to break the ice. But we just sat silently in the dimmed light, waiting to have our health centre data displayed for dissection on the screen. It was tedious. I even thought of popping out to make polite conversation with a poster of Angelina Jolie, dressed as Lara Croft in lederhotpanten.

The facilitator set up the projector and just… read… out…. the… slide. Very slowly. In a French accent. Every line. “Number of patients screened for TB – 1234. Percentage screening positive 10%,  that’s 123.” There was no attempt to summarise, point out interesting facts, to compare / contrast one centre with another or draw the audience’s attention to an anomaly until I piped up. “Those figures are wrong. They don’t add up.” We had to get a data person from Measurement & Evaluation down into the twilight zone to explain it to us. It was a typographic error.

We were running late and still the facilitator kept droning on, stating the obvious. One slide showed every parameter was zero. “Number of children screened – zero. That’s zero percent. Number screening positive was also zero. Again, zero percent. Number of children starting treatment – zero, that’s zero percent, too.” I couldn’t stop myself from tittering. But I got my comeuppance. Someone had to be the cluster spokesperson to present possible solutions to the problems we had identified. Me.

As we were cluster B, I thought I was going to be the second speaker, so I would have some time to martial my thoughts. But cluster A had been dissolved when no one from the National TB Hospital turned up to lead the discussion. On TB.

By now, I should know how to do a presentation. I even teach people how to do presentations. But I was still a bit apprehensive facing over a hundred doctors, nurses, data wonks, epidemiologists and ministry officials as the first breakaway speaker. I usually start with a joke, but Swazis don’t always get my sense of humour.

I began by saying, “I apologise for my English, which I hope you will be able to understand. I speak the Queen’s version, not the King’s.” Tumbleweed moment, broken only by a screech of feedback from the microphone. Try again. “I apologise for not speaking much siSwati, but I’m the only Mlungu (white man) in the village. And as a Mkhulu (grandfather), I’m too old to learn to speak it.” That got a laugh. I spoke a bit about who I was and where I worked.

Meanwhile, someone was trying to connect a laptop to the projector to display our results, but when I turned to look at the wall, there was a screensaver of a beautiful African girl. I was on a roll now, and blurted out, “And this is my daughter.” Some of the audience took this seriously, but most burst out laughing.

“Not possible,” said one doctor.

“Ah, but I might have a Makwapeni (secret lover),” I replied. This brought the house down, and I had them eating out of my hand until question time.

First question: “So how do you propose to increase the numbers of patients producing sputum?”

“Well, we have sputum induction and gastric lavage. But at our clinic, it is the threat of anal lavage that gets our numbers up,” I replied, cheekily.

Our results were actually disappointing. I suspect this is because there are so many details to complete in the ledger (by a variety of different health workers) that we sometimes fail to record them. We are too busy treating people to record the minutiae of what we are doing. But without data, you’re just another person with an opinion (W. Edwards Deming).

What were the solutions to our failings? More health workers. More time to spend with patients at the start of treatment, explaining the advantages of compliance with medication. Making sure that equipment and drugs are always available.

At the end of the session, an assistant distributed the room keys. No rooms had been allocated to MSF. “Are you paying for the accommodation yourself, docotela?” she asked me. “No, I’m just a volunteer,” I replied. They eventually found me a room on the lower ground floor, past the life-size African figure chess set and the sweaty gym. “I hate it down here,” said Maria. “There are always drainage problems.”

In the room there was a notice by the window warning me not to open it because monkeys might invade. On the dressing table there was a ticket which offered to double my stake at the gaming tables from 50 Rand to 100 Rand (£5). This was not going to help me break the bank.

Breakfast the next morning was remarkable for the chips coated in cayenne pepper and mini fishcakes. Like most hotels, the omelette producer was extremely jovial as he mixed up the onions, tomato bits, peppers and ham on the hot plate before ladling over the beaten eggs. The Earl Grey tea was wonderful, a great start to the day.

The rest of the day was a bit of a blur. My attention span is limited to about four hours, but we kicked off at 8:30am and didn’t stop until 6:30pm. At tea breaks, doctors would clap me around the shoulders and call me “Mkhulu” or josh me about having a “Makwapeni”. One naive chap asked me where I was from as I had said that I didn’t speak English very well.

The highlight of the evening was the Awards Ceremony. It was a hoot. A couple had been married in the room earlier in the day, so we just took it over, decor and all. The DJ was struggling to put a set together, mixing soul and gospel, and largely failing. The Master of Ceremonies was dressed in a sharp suit but the gift of his gab was sharper. He smooched along with the music, forced embarrassed ladies in their cocktail dresses to come up and dance or sing. Invited guests opened envelopes and read out the winners of the various categories, just like at the Oscars. Someone from the Ministry gave a speech, reading from his notes for almost half an hour while we were waiting for dinner.

I confess, I did sneak out every fifteen minutes or so to see Leicester City versus Manchester United on the megatelly in the Sports Bar. It was tense, especially after Schweinsteiger equalised just on the half time whistle.

MSF were first runners up, twice. “Yer get nowt fur cumin second,” I said to the doctor who had asked me where I was from, in my best Yorkshire accent. I ought to mention at this point that I was dressed in the fanciest outfit I have – a maroon Indian frock coat, with stock collar and gold braid (no one batted an eyelid). Just in case I got the call, I had my speech ready. “And finally, I want to thank Jamie Vardy for demonstrating what boundless energy, passion and self belief can achieve…”

The final morning dragged on to 1pm and, of course, being Swazis, we had to enjoy a last lunch at the buffet. The sun came out and the hotel grounds looked lovely, but we couldn’t stay to enjoy the atmosphere. Samuel, the driver, was on double time so we had to make haste back to Manzini. At least my belly was so full, I didn’t need to make supper.

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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