Dr. Mike Rekart: My year in Swaziland

by Dr. Michael Rekart

Swaziland is a little country with big problems. Swaziland is Africa’s smallest nation with its last absolute monarchy. With a population of 1.4 million, this landlocked nation is ninety percent surrounded by South Africa. The UN classifies Swaziland as a low middle-income country although 40 percent of Swazis live in poverty. The main industries are mining, agriculture, cattle and manufacturing but the country is heavily dependent on South Africa. In the midst of idyllic scenery, pleasant weather and friendly people, Swaziland has the world’s largest epidemics of HIV/AIDS, Tuberculosis and TB-HIV co-infection. Over 26 percent percent of 15-48 year olds and 42 percent of pregnant women are HIV-infected. Swaziland’s annual TB incidence peaked at 1300/100,000 in 2011 and 80 percent of all TB patients are HIV co-infected. Around 15 percent of TB cases are caused by multi-drug resistant strains of TB (MDR-TB); these are resistant to the 2 most important anti-TB drugs, isoniazid and rifampin. Drug-sensitive TB in Swaziland is called ‘normal TB’.

Due to the high HIV/AIDS rate the life expectancy in Swaziland dropped from 61 years in 2000, to 32 years in 2009. Since then, international donors, such as the United States, have responded with massive inputs of aid, resulting in a gradual decrease in new infections of both HIV and TB and a slow recovery of life expectancy. The government currently estimates that 80 percent of eligible HIV-infected patients are taking anti-retroviral drugs, one of the highest proportions in Africa.

This is compounded by traditional Swazi culture, which discourages safe sexual practices like condom use and monogamy. Swazis believe a woman should have a minimum of five children and that a man’s role is to impregnate as many partners as he can. Men may never marry, but will still have many children with multiple partners. Polygamy is part of traditional Swazi culture; the current monarch, King Mswati III, has 15 wives and 24 children. These factors combine to create high rates of sexual concurrency, HIV and sexually transmitted infections (STIs).

The Matsapha Medecins sans Frontieres (MSF) Comprehensive Healthcare Clinic is located in an industrial area outside Manzini, the largest city. As a result, our target population was over ten thousand factory workers. Most were poor, uneducated women from the countryside, with children but no husband. Many were HIV-infected without previous access to health care.

My role was as the supervising HIV and outpatient doctor. Matsapha is funded and managed by MSF itself, rather than the Swazi government, and this has allowed them to hire and train staff, deliver free services according to accepted guidelines, and maintain an adequate drug supply. Matsapha has its own pharmacy and laboratory, but no x-ray or inpatient beds. The clinic has sixty Swazi staff, including three doctors, twenty nurses, ten cough officers – who screened all patients for TB at every visit – and ten adherence officers. There was one other expatriate doctor from Bangladesh who dealt with TB, a medical team leader and nurse manager from Lesotho and a part-time lab advisor from Sri Lanka.

The clinic was always busy. We saw with to ten thousand patients per month, half of whom were new patients, two-thirds were female, and one-quarter were children. The cohort taking anti-retroviral drugs (ARVs) exceeded three thousand and we followed an additional 2,500 clients who were HIV-infected but not yet ARV-eligible. We managed around one thousand TB patients of whom 10-15 percent were MDR-TB.

Matsapha also delivered a full range of healthcare services including antenatal and postnatal care, family planning, sexual and reproductive health, and immunization. We had a sexual and gender based violence (SGBV) program and a large outpatient department (OPD) where we treated four to five thousand patients a month. The most common OPD diagnoses were upper and lower respiratory tract infections, sexually transmitted diseases, skin and musculoskeletal disorders, diabetes, hypertension, anemia, childhood diarrhea, and a variety of other aches and pains.

Matsapha has become a victim of its own success. Consistently outperforming the local Swazi healthcare system, Matsapha has attracted patients from all over the country, including retired teachers, government workers, rich businessmen, and even members of the royal family. They came, not because they had no access to healthcare, but because they did not like the healthcare to which they had access. This has resulted in situations where the single working mothers the clinic is intended to serve are being crowding out, causing unmanageable numbers and breeding resentment in the local health community. A situation, which will need to be addressed in the future.

I very much enjoyed my time in this lovely country with wonderful people and I certainly learned a great deal about HIV, TB, general medicine, and myself. I doubt that I will return to Swaziland, but I will work for MSF again. In fact, I have just secured a MSF EBOLA mission in Kailahun, Liberia, taking place over the Christmas holidays.