Sixteen Days of Activism

It seems as though everything has a “national day”, but activism against sexual violence in Swaziland is so important that it gets sixteen days. The team at MSF Matsapha has been contributing to the cause in many ways.

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This pretty little girl, dressed in her best party frock to come to the clinic, has no connection with the subject of this post.

 

Last week, I was interviewed on Swazi TV with Bongiwe, psychosocial counsellor supervisor. Judging by the comments of people who watched me on TV, I am never going to be a natural. The interviewer, John Peres, manoeuvred me into position on the studio couch, making me look on edge and anxious. I had my hands cupped over my groin, never a good posture to adopt unless you are defending a free kick just outside the penalty area.

Yesterday I was interviewed on the Christian Swazi radio show (being broadcast as I type this) “Be The Best You Can Be – Swaziland” with Fundziwe.  She did another radio show at the start of the campaign and wanted me to accompany her because she was terrified. The radio show seemed to be going well until, at a record break, the interviewer said that he was running out of questions. He told us we needed to be more chatty, expand our answers and be more adventurous. That put us more at ease, so we openly discussed issues such as sodomy and termination of pregnancy. After the interview had finished he said, “Wow! I wasn’t expecting you to go that far.”

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We had a series of discussions with community leaders, men and women, girls and boys, in the neighbourhoods where most of the people accessing our sexual violence service live. We also spoke on three occasions to high school students. The culmination of this health education work was a daytime disco held on a dusty sports ground at Kwaluseni last Saturday. There were competitions, quizzes with prizes, poetry readings, dancing and general merriment. This was less successful than we had hoped because the venue wasn’t ideal, the timing during the day wasn’t right for older children and the local hip hop star, King Terry, failed to turn up as promised. The event also clashed with two other big shows being held at the same time. And most damning of all, we did not provide FOOD. We have learned these lessons and will amend next year’s activities accordingly.

We commissioned local artists to draw cartoons on the walls of three shops in the Matsapha area. I visited these and took photographs. We asked some young people what they understood by the images and they correctly identified our message – not that the message was complicated, but sometimes people can misinterpret what we are trying to convey.

 

Already we can see the effects of our efforts. In July, we only saw one survivor in Room 72, our clinic room for survivors of sexual violence. Last month, we saw seventeen survivors. I saw four survivors in one day last week.

Our free call telephone hotline allows people to get confidential advice, but we still get lots of silent calls where people don’t have the courage to speak. It hasn’t increased the numbers of survivors attending within 72 hours as we had hoped. The telephone number is “1515” which I thought looked a bit like “ISIS”, so we have used a font which clearly indicates you should call this number, not Daesh.

Clinical Work

Just in case readers of this blog have the impression that I spend most of my time in Swaziland gallivanting around having a long holiday, I thought that I should slip in a few examples of clinical problems I have encountered at the clinic this week.

This is the left hand of a woman in her mid-thirties who is HIV negative*. She says that the last joint of her ring finger has been swollen for three weeks. The index finger was also affected, but that just lasted a few days. It is warm, minimally tender, with a slightly limited range of movement.

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OK, doctor, what is going through your mind at this stage?

Initial presentation of rheumatoid arthritis? Unlikely. Doesn’t usually affect terminal interphalangeal joints, more likely to show in proximal joints. No family history . When it just affects one joint, it usually presents in a larger joint, such as a knee, first. Not symmetrical.

Trauma? No history. Relatively pain-free and capable of movement.

Low grade septic arthritis? Commoner in people living with HIV. The symptoms should have been getting worse. No infection of the anterior fat pad of the finger.

TB dactylitis? It occurs, not very common as a presentation of TB, but we see lots of TB, so I didn’t discount it. Or another granulomatous condition, such as sarcoid.

Gout? Not really painful enough. No previous attacks, no podagra.

Skin rashes? Psoriasis? No skin lesions, no nail pitting. Not a “sausage digit”.

Sickle cell? Unlikely in Swaziland.

Underlying bone problem? Growth too rapid for an enchondroma.

Tendon problem? Joint too mobile for this.

Syphilis? Perhaps only a GU physician would think of this!
I asked her about sexually transmitted infections and she denied having any. I was just about to prescribe some anti-inflammatory medication when she started ferreting about in her handbag. She produced a blue “contact slip”, which was the missing piece of the diagnostic jigsaw. Her husband had given her the contact slip when he attended our clinic a few weeks ago suffering from a urethral discharge.

She has sexually acquired reactive arthropathy (SARA). Gonococcal arthritis is also possible but I would have expected her symptoms to have been more florid. I prescribed the same treatment as her husband, along with the anti-inflammatory drug.

The next patient was a woman in her early twenties (HIV positive) with a sore at the corner of her mouth. Diagnosing this condition was easy – angular stomatitis or cheilitis. I most often see this in the UK in older people who wear poorly-fitting dentures (my grandfather used to buy his dentures from a market stall after trying them in). With the thinning of the gums and sagging muscles round the mouth, the lips don’t come together neatly. The overhang of skin at the edge of the vermillion of the lips allows moisture to remain in contact with the skin, predisposing to yeast and bacterial infections. It also occurs in people who are generally unwell, with poor nutritional status, vitamin B or iron deficiency. The continuous presence of saliva can cause an irritant contact dermatitis.

She felt as though she was about to come down with influenza and she also complained of painful lumps under her jaw. Looking carefully, one can see blisters or vesicles. I felt some tender lymph nodes under the mandible. This is a herpetic infection, cold sores, a uncommon presentation of angular stomatitis.

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Staying with the oral theme, here is a photograph of some pale lumps on the inside of a patient’s gums. The most likely cause is dental abscesses, but the teeth looked in reasonable condition with no glaring caries. I did a blood test to rule out syphilis. Doctors in UK don’t learn much about teeth in medical school. We are prohibited from treating dental conditions because it would be trespassing on dentists’ territory. I duly referred her to a dentist and gave her some antibiotics and pain killers.

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This man is a builder who had been grinding stone blocks. He felt something go into his eye four days before coming to the clinic. I don’t have fluorescein drops or papers, but it was obvious that he has a corneal ulcer. Using local anaesthetic, I numbed the eyeball, scraped out the grain of grit with a 21 needle and irrigated it well. Pain relief, topical antibiotics and review in a couple of days, sooner if he develops problems. Sorted.

 

* HIV status is so important when assessing a patient that it has become a “vital sign”, along with pulse, temperature, blood pressure, respiratory rate, etc.

Flying Ants

Flying ants have been abundant following the recent rain. Some of the larger ones may have been termites. My bedroom was invaded by copulating creeping crawlies. I stomped on as many as I could and swept them up. In the night, the squashed corpses which I had missed were disposed of by tiny golden-brown ants. It reminded me of Gulliver and the Lilliputians.

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These are flying ants attracted to the lights outside a restaurant. Eating al fresco was impossible.

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Here are the discarded ant wings with raindrops, on a pathway outside the clinic.

 

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.

Preparing for NaHSAR

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NaHSAR: The 12th National HIV Semi-Annual Review took place this weekend, here in Hhohho.

I must be going deaf. I misheard and thought I was bound for Houston when the clinic supervisor told me I was going to NaHSAR. It should have been held last weekend but there was no room at the Pigg’s Peak Hotel for all the delegates. The organisers tried to change the location to Ezulwini at short notice, but failed. So the three day meeting was deferred to this weekend, clashing with the Southern Africa Region HIV Review meeting. Timetabling is always a problem in Swaziland.

Prior to the meeting we had to write a poster explaining how we had tried to solve a problem related to HIV. Two reviews ago, MSF had done a great piece of work on the effect of “stepped up counselling” (monthly, individual sessions to improve the consistency of taking anti-HIV drugs). We found that about 60% of patients on Anti-Retroviral Therapy (ART) whose treatment was not working (they still had detectable virus in their blood) responded to three sessions of intensive counselling; their improved compliance resulted in ridding the virus from their blood. However, this still left 40% of patients failing their treatment, either because they were still not taking their medication properly or the virus had mutated to a resistant strain.

We couldn’t come up with such a useful piece of research to report. After a brainstorming session, I suggested the idea of measuring our progress to the UNAIDS target of 90-90-90. This means 90% of people know their HIV status, 90% of those who are HIV positive are on appropriate treatment and 90% of those on treatment have undetectable viral loads. If this is achieved by 2020 worldwide, then the HIV epidemic will be under control by 2030. The mathematical  model predicts that with so many people being successfully treated, there will be less virus to transmit to others. But the latest global figures show more people are being diagnosed than are starting treatment.

It is impossible to know if we are hitting the first 90% because we do not have a defined target population. There are estimates that just 40% of Swazis know their status. And how often do people have to test? We treat anyone who comes through the doors and do over 7,000 HIV tests a year in our clinic.

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I thought we were easily achieving the second 90%. Over 95% of our patients with an immune system damaged enough to warrant treatment complete three counselling sessions and start ART. Perhaps that is not the true picture as we don’t track those who test positive but fail to return for repeat testing to find out when they need to start ART.

But are these patients taking ART being successfully treated? The guidelines suggest that after six months of ART, we should check the patient’s viral load. If this and a second viral load test after another six months are both undetectable, we reduce the testing frequency to yearly. With almost 5,000 patients taking ART at the clinic, we do lots of tests. When we test depends on when the patient turns up for a refill of their medication, rather than adhering to a strict schedule.

It was my idea to check on two cohorts of patients – those whom we started on treatment a year ago  and those who transferred into our service after April 2015. The first group would be having their viral load checked six months after initiating treatment and the second group have baseline tests including viral load as part of our induction procedure. All new patients on treatment are allocated a code number (P17A followed by four digits for original patients and transfer in patients get TI-followed by four digits), which made it easier to define the cohort. So I looked at consecutive patients with codes P17A4200 and TI-1280 onwards.

Like all good audits, it raised more questions than it provided answers. We are on track to reach 90% by 2020, with the more stable transferred in patients at 89% and our home-grown patients at 86%. We discovered that a batch of several hundred blood test results from August had vanished into the aether. We should be able to fix this with some detective work. However, the main problem I discovered was what we are not doing for those patients who have detectable viral loads. Only a third of failing patients had been enrolled in stepped up counselling. At the next NaHSAR meeting we will no doubt be reporting on how we tackled this issue.

When I told my Swazi colleagues at work about the results of my audit, they were dismayed. “But no one ever reports bad things at these meetings, docotela. You will be savagely criticised if you present this.” I refused to whitewash the report. I can justify what we have done and how we are trying to solve any problems. No one gets it right first time.

I was delighted to find out that for this NaHSAR meeting, teams of data collectors had visited clinics collecting raw data from handwritten ledgers. At the opening session, a representative of “Monitoring & Evaluation” said that was to reduce the numbers of facilities self-reporting 100% on the indicators. So perhaps we will get a true picture of what is happening. But holding the meeting in a casino is always a bit of gamble.

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