I decided to go to Eswatini because I wanted to experience rural medicine in another culture and see what it's like at a Christian hospital. This elective destination, which I found to be incredibly eye-opening, challenging and fun, is one that is especially suited for anyone who is interested in rural healthcare, especially with a community focus, or ophthalmology.

main hospital, Ebenezer clinic, home visits

I was based in Siteki, a rural village 20 minutes from the Mozambique border. I arranged the placement with Medical Missions Eswatini (MME), who enabled me to experience a variety of different healthcare settings and services.

In Good Shepherd Hospital, which is the main hospital, I spent most of my time in the medical outpatient department, working alongside the specialist nurse. The limited number of investigations available challenged my clinical reasoning and meant that I could not just request every blood test available. Apart from the common cold, patients also came in with tropical illnesses like malaria and TB.

MME is linked with the Ebenezer Clinic, a rural nurse-led clinic, and a practical part of placement that I really enjoyed. I was often involved in history-taking, examination, and discussing with a nurse about the next steps before implementing a plan. I was also learning about different medications for conditions I had not seen before through the British National Formulary (BNF) app on my phone. Due to poor public awareness of a healthy lifestyle, there were many chronic disease reviews, typically diabetes and hypertension. I also became quite familiar with scabies, a disease I'd not seen before clinically.

During the one day I spent with the home-based palliative care team, with whom I'd love to have spent a longer time with, we packed up the team's 4x4 with medical supplies for home visits. Seeing nurses administer simple yet impactful care via bereavement visits, wound care and pain relief was very inspiring, especially in settings where people's homes weren't much more than straw-topped huts an hour away from more developed settlements!

eye clinic and helicopter trip

I spent a few days both in clinic and theatre with Dr Pons, a well-known ophthalmologist in both Eswatini and neighbouring Mozambique. It was a great learning opportunity in ophthalmology as the high prevalence of diabetes and hypertension meant higher rates of eye complications and retinopathies.

The eye clinic is also linked with MercyAir, a helicopter program set up to reach even further into the rural communities. I got to go as part of the dental team in what was my first ever helicopter trip and what I consider the most amazing experience! Others on the elective with me went with the SightFlight team that fits reading glasses, screens for cataracts and diabetic retinopathies and does general eye checks.

a typical day, and more

A typical day on my elective began with waking up in time for a run around Mabuda Farm, which has many nice trails, followed by a shower and then breakfast. I would head to the placement at about 8.30 am, with mornings often involving ward rounds, outpatients, or home visits depending on the team I was with. Lunch was often simply my packed lunch, though I would definitely recommend trying the 'dusty chicken' with pap from some stalls across the road from the hospital. Afternoons were much quieter, and I was often ready to go home by 4pm — usually on foot (it's only a two mile walk), though minibuses (called combis) are another option if you don't drive. I would try to be home before dark, and often head to bed early as it's not safe outside after dark due to the lack of street lighting, cows by the roadside, and drivers that sometimes do not have working car headlights.

I stayed at Pilgrim's Rest on Mabuda Farm, which is run by the Pons family, and has many lovely walking trails, horse-riding facilities, a pool, and a lovely coffee shop selling home-grown coffee and other fruit and vegetable produce. Other expatriate doctors and workers live on the farm, which has a really friendly community with activities throughout the week, including spaghetti and Bible study on a Wednesday evening (which is for everyone, and you don't have to be a Christian), porridge together on a Friday morning, and Friday Braai-day (BBQ in the evening). A beautiful spot on the farm called 'The Rocks' is the place to catch the most incredible sunsets. Dinner then is often followed by reading, journaling, or watching TV (usually National Geographic).

The main thing that I liked doing as a tourist in Eswatini was watching the wildlife. Only 30 minutes away from where I stayed is the Hlane Game Reserve where you can go for a safari drive. Mlilwane Nature Reserve is two hours away and ideal for a weekend trip, for walks and to get up close with zebra, and I even did the annual Mbuluzi trail run and saw a giraffe while running! Heading over the border to South Africa, it's very easy to get to Kruger for your chance to spot the 'big five' and to St Lucia too for your hippo and croc fix and the stunning coastline.

differences and challenges

There were some superficial differences, such as patient drapes and gowns being reusable rather than single use (as in the UK) and so requiring sterilisation after use. Having only experienced medicine in the context of the UK's NHS before, I also found it very different seeing health services where people pay for things themselves. There were many occasions where people had stopped taking their medication because they couldn't afford it, struggled to pay for transport for hospital, self-discharged from hospital stays because they had run out of money, and so on. Witnessing such poverty and unmet needs was quite heart-wrenching.

Not only was money an issue for patients, but the resources we had available for investigations and treatments meant we couldn't always do what NICE guidelines would recommend in the UK. There are very limited specialist doctors in Eswatini, with most of these being located in Mbabane, the capital, which is an expensive bus ride away for patients. Towards the end of my time there was a shortage of normal saline in the hospital! I often felt very limited with the impact I was having, but weekly teaching sessions with Dr Pons were a really good way to reflect on my experience and discuss the things that were troubling me.

highlights and closing words

The hospitality of patients, nurses, doctors, and generally everyone in Eswatini was the highlight of my experience. People were always saying sawubona (hello) on the streets as you walked past, and I loved feeling part of the community. The helicopter trip with MercyAir was a once-in-a-lifetime opportunity — the birds-eye view of Eswatini was simply stunning, as were the African sunsets, of which I tried to catch as many as I could.

By the end of my four weeks, I was just scraping the surface, and there was still so much I wanted to see and do. I would recommend trying to spend at least a week with each team to get to know them and how things are done. Another bit of advice would be to embrace the fact that some things operate in 'swazi time' — there's a different pace of life and a unique culture to be experienced. Practically, your own stethoscope, the BNF app, and the Oxford Clinical Handbook are invaluable items to have with you, as are a few warm jumpers if you are heading down during the summer as Eswatini is on the opposite side of the equator. Also, journaling is a wonderful way to reflect on the highlights and lowlights and to keep a record of your days. Finally, simply enjoy yourself — say yes to as many things as possible (within reason) and make the most of this once in a lifetime experience.