It has been three weeks since I left Swaziland, and I am missing it already. My debriefings have all been completed and I am back in Leicester. My head of mission told me that he had been reading my blog and thought it was a great insight into what it was like being a clinician in Matsapha. The UK office is going to look at some of my blogs and may be publishing them “officially”.

In order to fuel my blog with insights and ideas, I have kept a file of subjects which I dip into and write about. In this blog, I have cleared out the file.


What Swazi women want for sex?

It was a classic billboard headline, guaranteed to sell a few hundred extra copies of the paper. As we drove past it on the way to work, I read it out, as a rhetorical question, ” What do Swazi women want for sex?” Rather facetiously, someone suggested 500 Rand. One of our health workers in the vehicle said, “Maybe. Depends on whether it is at month-end (near payday) or not. The price does vary.” He had taken the question seriously and answered revealingly. The car fell into an embarrassed silence for the next few minutes until we reached the clinic.


I read the newspaper article which was based on some research done a few years ago. Three groups of women had been approached to give their views:  married, university and “aspirational” – women who hoped that their relationship would lead on to something more desirable, such as marriage.

“Most do it for love, despite financial gain”

High on the list of reasons to have sex were clothes, phones, airtime and other gifts, love and marriage, as well as having a good time out. Sexual satisfaction came midway down the lists. Sadly, “place to sleep for the night” and “takeaway meal” were listed by the university students.


I was wandering around SuperSPAR at Ezulwini when I came across a man wearing traditional dress, a cloak wrapped around his torso and a leopard skin loincloth, carrying a plastic shopping basket. This is not an unusual sight, but what drew my attention was a string of beads hanging over his shoulder, decorated with Christmas baubles and tinsel.

The driver who took me to the airport is called Justice. He told me that he was the first baby that his mother had ever taken to the clinic. She had never attended school and did not know how to read and write. She was intimidated by the clinic nurse, who asked her for the name of her baby. She panicked and told the nurse that she had forgotten his name. The nurse laughed scornfully and said that he must have a name. So she said the first thing which came into her head, “Plastic“.  Later on, his brother gave him his proper name, but that’s another story.

Another driver has an interesting moniker. His name translates as “Lift him up“, something which is impossible now as he must weigh well over 120kg.


I saw a lady in clinic and asked her what medication she was taking. She hunted around in her shopping bag for a while and finally brought out a single shoe. So much for my communication skills.


The man said he had two problems. He removed a plastic pair of shoes, worn without socks, to reveal the worst athlete’s foot I had seen in ages. I explained how to treat this and then he told me about his second problem. Last night, he dreamt that someone stabbed him in the upper arm. He woke up and felt something under the skin, but there was no wound. “Do you think this was a witch’s work?” he asked me. “Maybe, let’s take a look and see.” I could feel a foreign object, close to the surface of the skin, but without a puncture wound. He showed me a scar on his wrist, resulting from an injury 30 years ago when he was a schoolboy. I removed a 2cm sliver of wood (my mother would have called his a large “spelk”) from his arm under local anaesthetic. I have no idea where it came from, perhaps it had migrated over the years up his arm. Apart from witchcraft, he had no explanation for it.


Sometimes I add a bit of showmanship to my consultations. For example, when examining the abdomen of children, I often play a game with them by pretending I can tell what they had for breakfast by feeling their tummy. Of course, it helps when there are just a few options from which to choose. I was examining a child yesterday and the conversation went something like this:

“Now, I can’t feel any banana…but that might be because it has been mashed up.” – No.

“Is this squishy stuff here sour porridge?” – Noooo.

“Ah, I know what it is, emahewu!” – How did you know?

The child was delighted, but her mother was aghast. I realised she was thinking I was some kind of wizard who could magically detect what was inside her daughter. I smiled at her and told her it was just a trick to get children to relax when I was examining them.  She clearly didn’t believe me, and kept giving me sidelong glances, wondering what magic I was planning to perform next.

Bye Bye docotela



Virginity Testing

Warning – this post contains material of a sexual nature.

This young lady is an actor, who has played the role of an abused girl.
This young lady is an actor, who has played the role of an abused girl.

Despite the fact that most girls start having sex before they have reached the age of consent, this counts as statutory rape in Swaziland. The law says that girls under the age of 18 are not able to consent to sex. This is confusing, because traditional Swazi custom allows girls to be married at age 12. Occasionally the police send a girl to the clinic with an official request to find out if she has had “carnal knowledge”.

Previous MSF doctors in my role have refused to do virginity testing on principle. They felt it was not their job, it was not in the best interest of their patient and it put them at risk of prosecution. If doctors are aware that rape has occurred, the law states that they are obliged to report it to the police. If they don’t, they could be arrested and charged, although I have never heard of this happening since I have been working here. (In the UK, although the age of consent is 16, no legal action is taken if children aged 14 or 15 are having consensual sex with a similar-aged partner. However, if the child is 13 or under and having sex, reporting is mandatory. And it would also be an offence not to inform the authorities.)

 “That’s different,” say the police. “What we want to stamp out is exploitation of young girls by much older sugar daddies. The girls are naive, they believe that rich, older men really love them. Having a sexual relationship with a sugar daddy seems like their way out of poverty, until they are tossed aside and discarded.”

This blanket refusal had angered the police and soured the relationship between police and MSF. As usual, I take a different view. But I still put the interests of the child first. I interview the girls and make a clinical decision regarding their competency to consent to sex. According to section 33(1) of the Children Protection and Welfare Act (2012):

“If a medical officer believes on reasonable grounds that the child he is examining or treating is physically, psychologically or emotionally injured as a result of being ill-treated, neglected, or sexually abused, he shall immediately inform a police officer or social worker.”

However, it is challenging when I am confronted with angry parents waving an official police form requesting I examine their daughter. “We want to know if she has been raped!” they say. Their daughter usually sits quietly between them, head bowed, avoiding all eye contact. A lamb to the slaughter. Sometimes, they won’t even speak. I interpret this passivity as an “ostrich head in the sand” strategy. “If I don’t acknowledge or participate in what’s happening around me, perhaps it will all just go away.”

A typical scenario is when a sixteen year old girl has stayed out overnight, without her parents’ consent. The parents jump to the conclusion that she has been seeing a boy, and has been sexually active. She is underage, so this is rape, and the boy must be punished.

The first thing I do is to try to defuse the situation. I let the parents have their say, allow them to express their concern and what (ideally) they would like to happen. I take them seriously and don’t argue or challenge them. Then I ask if I can speak to the girl by myself, with my nurse or interpreter. Doctors have such high status in Swaziland that no parents have ever objected to this or insisted on being present when I talk to their daughter.

Using all the consulting skills I can muster, I try to break through the ice and get the girl to trust me. I explain about the limits to confidentiality. We talk about hypothetical situations, so she can avoid telling me outright what has happened. While we are talking, I am assessing her competence, knowledge and understanding. When I am satisfied she can give informed consent, I ask permission to examine her and usually she agrees.

If she refuses to be examined, and I feel she fully understands the possible consequences of that decision, I comply with her wishes. I tell the parents that I consider it would be an assault if I went ahead. This has only happened once. I was told that the police would have to get a court order requesting an examination by a gynaecologist at a government hospital.

However, refusing to co-operate in the investigation of a possible crime is an offence in Swaziland. The police are prepared to prosecute. On one occasion, the police threatened a girl (who refused to be examined) with being sent to a detention centre for young offenders.

If she agrees to be examined, I ask if she would allow her mother to come into the room during the examination. I explain exactly what I am going to do and talk through the stages. I explicitly state that although I will be touching her, I am not going to put anything inside her. Of course, we routinely offer tests for HIV infection and pregnancy, followed by appropriate preventive treatment.

Following consensual, occasional, gentle sex, it is uncommon to see certain signs of penetration. Even the damage following rough sex can heal quite rapidly, showing no definite signs after a few weeks. My report might typically contain the bald statement, “On genital examination, I found no signs of sexual penetration”.*

If there are signs of penetration, I am obliged to include this in my report.

As well as handwriting the police report, I type out my conclusions on a more detailed MSF confidential form, and hand this over to the family. This is what tends to be used in court, if the case gets that far.

Then my real work begins – counselling the family. Together with a psychosocial counsellor, I talk to the family about how difficult adolescence can be for both parents and children. I tell them that I know, I have experience in this matter; my wife and I brought up three daughters.

I say things like, “Your parents would not have brought you here if they didn’t love you.”

And “You are becoming a woman, you want to take decisions for yourself, but with independence there comes responsibility.”

Or even, “Sometimes when you insist that your daughter obeys you, she reacts against it. Being too controlling can have the opposite effect.”

Traditionally, Swazi parents expect blind obedience from their children, and the idea of compromise can be new to them. Doctors don’t spend a lot of time talking to patients here, especially about non-clinical matters. So my attempt at family counselling can come as a surprise.

You may regard my attempts to build bridges between controlling parent and wayward daughter as patronising, but the psychosocial counsellor has said to me, “You are talking as though you really mean it, like you really care. The girl and her parents appreciated what you said.”

This little girl got a present of a cuddly toy for allowing me to examine her. Sometimes bribery is necessary! I like the way her finger is pointing to her head, showing that she is deep in thought whilst making her choice.

There are other ways of assessing virginity. You could take your daughter to a sangoma (traditional healer) who would give you an answer by going into a trance, or throwing some bones into the dust. Or you could ask a gogo. Grannies know things because of their decades of experience.

One mother told me, “I suspected that she was not a virgin because she did not pass urine like a girl.”

What on earth was she talking about?

“She was passing urine like a grandmother,” she said.

And how does a gogo pass urine, as opposed to a maiden?

“Well, when a virgin girl passes urine it is quiet and sounds like piiisssss. But when a gogo passes urine, it is loud and strong, shuusssshhh, and often accompanied by a fart, prrfffttt at the end.”

I discussed this method with the psychosocial counsellors in the office and they all fell about, laughing. They told me that to test for virginity, some gogos make a pile of sand and ask the girl to crouch over it and pass urine. If the stream is single, making one hole in the sand, she is a virgin. If it sprays everywhere, she is not a virgin. “And what does it mean if she farts when passing urine?” I asked. “Oh, Doctor Ian!”

You learn something new every day in this job.



*When someone has been sexually assaulted, but the genital examination is normal, in my report I use the phrase, “There were no signs of sexual penetration, but this does NOT mean that a sexual assault did not occur.” This is a triple negative, I know, but the courts understand this terminology.


At the barber’s again

A colleague and I went to the barber’s this morning. My favourite tonsorial artist had boasted to me that he had customers coming 40 kilometres to have their hair done at his salon, “Nadia’s Fashions”. He said that he only charged 140 Rand for hair colouring – £6.50 – which undercuts (sorry) the hairdressers in the capital. My colleague wanted a touch of red added to her locks, so she was keen to try his services. I have less than a week to go in Swaziland, so I wanted to have one last crop.

Unfortunately, the maestro was fully occupied with my colleague and left my haircut to his younger, less experienced brother. My cut took five minutes. No scalp massage, no shoulder rub, no tip! It is not the worst haircut I’ve had here, but it is close. Not worth the £1.40 it cost me.

I got to meet Nadia, the owner’s daughter, who was watching a video on her dad’s smart phone. She took my money (and my tip) and I took her photograph. She even features on the calendar in the shop.

As we waited for the dye to take, I noticed that some men from the restaurant next door had laid out some corn on the pavement. I thought this was a generous act of feeding the birds. Then I noticed a noose and length of string hidden by the corn. It was a trap! I wondered if pigeon was on the menu.


I won’t embarrass my colleague by posting her photograph here, but in the background I could see the younger brother shaving a man’s head. Huh! He gave him a good scalp massage.


My last walk with the Natural History Society of Swaziland was calm and tranquil. The hills were cloaked in mist and the grass was heavy with dew. We followed a herd of cattle across the hillside, through the bracken.


The Tortoise Head Rock is situated on the north side of Strelitzia Gorge (see previous post). We could have scrambled to the top, but the rock was slippery and the average age of the group must be over 65. Broken bones are best avoided in remote areas.

We turned back and had an early lunch by a grove of tree ferns, close to a small stream. I was already full from eating wild blackberries. I snacked on white fruits from a large strawberry bush. I have a similar plant in a pot at home, but the fruits are small and red. They didn’t taste like strawberries at all.


I spent a lot of time trying to take close ups of tiny flowers and orchids. From a distance, the hillsides look homogeneous, apart from the occasional patch of dagga. But it isn’t just grass; there are hundreds of different plants.

At the end of the walk, some of us climbed a hillock to an old stonewall fort. This gave stupendous views across the landscape. No one is sure who built the fort. Some say it was used as a lookout during the Swazi-Zulu wars. Others say it was more recent, dating from the Anglo-Boer wars at the end of the 19th century.


Outside the dry stone wall there was a patch of bright blue agapanthus. I took some photographs as the clouds rolled in, obscuring Tortoise Head Rock and Sibebe in the distance behind it.

P1110567I have made many friends walking in the Swazi hills. Here’s a team photograph, taken on a timer. I didn’t notice the stick obscuring Catherine’s face (she’s the secretary).

Execution Rock

Each time I drive on the NR3 highway between Manzini and Mbabane, I am distracted by a rocky peak, Execution Rock. It is set apart from the ridge of hills which form the southern rim of the Ezulwini valley. Srinu was impressed by it, too. Here he is posing by Shoprite in The Gables Shopping Centre carpark, with Execution Rock in the background.


It has a macabre past history. Legend has it that miscreants who had been sentenced to death were marched up to the summit and offered the honourable option of leaping to their deaths. If they refused, they were goaded and prodded by spears until they plunged over the cliff. The siSwati name for the peak is “Nyonyani”, which means little bird. Perhaps a reference to the criminals flapping their arms as they dived to oblivion.

For the past eleven months, I have been telling myself that I ought to climb it before I leave. Last weekend was just three weeks before the end of my contract, so it was now or never. Accompanied by two doctors (my new walking buddies, Ann and Yuan), we parked the car by the dam in Mlilwane Game Reserve and set off on the summit trail.


All animals are protected in the Reserve, including Dung Beetles. I have seen two of these creatures co-operating in rolling a ball of manure along a path. I have even seen two males fighting each other over a female. Or it might have been a lump of pooh. But I have never seen a mob of dung beetles getting stuck into a recent pile of steaming shit. I wondered why this particular gnu pat was so attractive. Perhaps because it was fresh and malleable. The beetles lay their eggs in the dung ball and roll it somewhere safe before burying it. They mate underground, depositing their eggs into the dung so their offspring have a first meal ready for them. According to Wikipedia, they are the only non-human creatures known to navigate by the Milky Way. But why do they need an astral signpost to get anywhere?

We had made an early start, but already at 10am it was getting hot. We tramped up the track, enjoying the flowers and birds.

As the path became steeper, shade became rarer. Finally we scrambled up the rocks to reach the top and were rewarded by superb views. To the north west, across Lushushwana River we could see two pointed hills called Sheba’s Breasts. You can’t really make out the resemblance to bosoms from the road, but you can from the summit of Execution Rock. With the eye of faith, you could even imagine the gulleys running down the slope are like stretch marks.


Directly below us was the new US embassy. It is the huge building in the centre of the photograph. The British Foreign Office pulled out of Swaziland completely some years ago, leaving behind just an Honorary Consul. The Americans look like they are in Swaziland for the duration in their “bunker”.


A group of Taiwanese health workers joined us on the summit. We took each other’s photographs, flashing obligatory peace signs and staging pictures where a smiling doctor seemed to be falling over the cliff.

Looking south to the Mhlambanyatsi River and the Mlilwane Dam, we could just make out a tiny white dot which was our car. It took us half as long to get down as it did to climb. I offered to show my colleagues the white-throated bee eater burrows in a dried up donga. Unfortunately, we only saw one bird emerge from the cliff. These pictures are from a previous visit.


On the path back to the car, I wanted to see how much dung the beetles had disposed of. They had all vanished, presumably leaving the rejected leftovers. Or maybe they realised that Dr Yuan might be interested in collecting and drying dung beetles – qianglang (蜣蜋) – to make traditional Chinese medicine, used to cure ten different diseases.


It’s New Year’s Day and I decided to go out with the team to visit patients with drug resistant tuberculosis in the Mankayane area. I knew it was going to be an early start, so I went to bed early but the fireworks at the stroke of midnight woke me up. The driver arrived at 6:45am, which was a bit earlier than anticipated, but it didn’t take long for me to mount up. We picked up the nurse at KeKhosa, by the “Anointed Hands” hairstyle shop by 7am.

The weather was dull and grey, with low cloud over the hills outside Manzini. Our first patient lived a kilometre away from the road, down a rutted track. The view from the homestead was stunning. I suppose if you have a chronic, debilitating illness and can’t get up and about, a beautiful vista might help raise your spirits. While the nurse administered the injection, I chatted to some women chopping firewood. Two boys asked me to take their photograph, so I got them to pose next to the MSF logo on the back of the LandCruiser.

MSF runs the tuberculosis service at Mankayane Hospital. The clinic was closed, but we opened up to inject a patient whose own health centre was closed for the public holiday. I heard her scream when she was injected. Kanamycin and capreomycin are painful drugs to inject. I wondered about mixing the drugs with local anaesthetic, prior to injection. That would not help the initial pain, but it might reduce the discomfort after a few minutes.

The next patient lived some distance away from the hospital, well off the beaten track. We needed a four wheel drive vehicle with high clearance to get to his house. We had to cross a river, which because of the drought, we managed easily. We passed a general store in the middle of nowhere called the “Wonkhe Wonkhe Grocery & Hardware”. The patient’s home was perched on the side of a hill, with another spectacular view. He was feeling exhausted, so he asked me if I would take the horse into the field and do some ploughing for him. When I said that the last time I ploughed was in the 1960s, using a rotivator in our back garden. He offered to teach me, but we had more patients to see.

After leading the Israelites out of Egypt, Moses received the word of God from a burning bush. Canaan was the “promised land”, the “Land of Milk and Honey” of the Bible. In the village of Cana, just west of Mankayane, MSF supports a community of people suffering from drug resistant tuberculosis in Cana House. It was clean and tidy, with plenty of ventilation. A woman was preparing cook some spirals of sausage on a braai (barbecue) inside the house, so hopefully it would not be too smoky. For dessert, there was a New Year’s Day cake, which would be served with a dollop of thick custard, simmering on a Calor gaz ring.

The residents were delighted to see a docotela. I explained that I worked in Matsapha, but their new doctor, Yuan, has just arrived in Swaziland. I told them the news about their previous doctors, Khin and Srinu and showed them some photographs on my camera. Then the patients wanted their photographs taken. We would have been asked to stay to lunch, but we had to press on and see another patient on the far side of Cana, over the river (Jordan?).

It was interesting to visit the patients in their homes. It puts their treatment in context. The patients were very weak, with some of them not yet responding to treatment, but they were all able to smile and greet me enthusiastically. I think that they were happy that they were not being forgotten, sidelined as failures. They were grateful that someone cared about their welfare and wanted to visit them.

This aspect of MSF’s work is not spectacular and newsworthy, like treating Ebola victims in Sierra Leone, or providing emergency medical care where there has been an earthquake or a tsunami. There are no instant successes. It is a prolonged, tedious slog dealing with the “lepers of the modern world”, suffering from drug resistant TB. It is difficult keeping patients engaged in treatment, often when they are so disheartened and depressed that they feel like giving up. MSF is bringing new drugs to those who most need them and doing the research to find out if shorter, more intense treatment has better outcomes than the traditional regimens. No other organisation in the world is as well placed to do this research. It might not be a face of MSF which is well known to the public, but it is totally in keeping with its humanitarian ideals.

Siyabonga means thank you, in siSwati



Incwala – the First Fruits


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.


2015 in review

The 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.

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.


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.”