Monday 12 April 2010

Final reflections from 30,000 feet..................

12th April

So I am on the plane headed for London and will be back on English soil in a few hours (following a short touch down on Italian soil in Rome as this is the way the Ethiopian airlines routing to Europe works). My "adventure" is coming to an end and although I have no regrets at all about coming to Ethiopia, I have reached the stage where I am ready to be home.

People I meet are often admiring of the fact that I have done charity work in Ethiopia (they are all Ethiopians) and are surprised when I point out that the experience has been one of mutual benefit and I also suggest that they should be aware that people who undertake such work actually have an agenda of their own that they are fulfilling although I acknowledge (as is true for me) that it is not always possible to verbalise exactly what this agenda is- one thing I do know is that I come back from Ethiopia a slightly different person to the one who went- whether I am a better person is not for me to judge but I certainly have face up to things both professionally and personally that I had not face before. There are so many ways that I could reflect on my time in Ethiopia and the half-time reflections that I made previously all still stand but at this point I am now in a position to look back on my time as a memory and also to look forward to being home.

Things that I will miss (which are often also things that could go in to a thing to remember category):

-       The warm smiles of people everywhere in Ethiopia- this is a universal feature both in Gimbi and everywhere we travelled to. I know that by nature I am rather a serious person (given to a frown rather than a smile as a natural expression) but I would swear that I have learned to smile more due to the need to return the gesture virtually constantly and perhaps because it is infectious.

-       The wonderful birdlife- Ethiopia has the most amazing variety of endemic & migrating birdlife. Whilst not a particularly enthusiastic bird-watcher, their constant song is a reminder of what a terrible place the world would be without their presence.

-       The warm sunshine- definitely not sorry to have missed such a bad winter (catching up on magazines one estimate says the worst for 23years). The climate in Ethiopia in January through March is lovely as the days were rarely too hot, rain was limited to the occasional short tropical downpour and clear blue skies were common. Sadly as it was a working trip (and the holiday definitely didn't include sunbathing destinations) my tan is limited to face, arms and feet but at least I look healthy.

-       New friends both Ethiopian & "Faringe" that I made- keeping in touch is always difficult but I hope to do my best!

-       Living a simple life with more time for reading, writing and thinking about life. This includes getting away from deadlines at work and at home, which seem to be ever present in my life.

Things that I would prefer to forget (i.e. the lows of the trip that unfortunately will probably constitute the most lasting memories as the emotions they evoke are strong):

-       The initial feelings of terrible homesickness so bad that it is the one thing that might prevent me from doing it all again. A period away from home is a reminder of the importance of family and friends as you realise just how much you miss everyone when contact becomes difficult.

-       When children broke into my bungalow in Gimbi in my third week (didn't write about it in my blog as it felt too negative at the time and thankfully I lost only the sort of items children would steal and nothing of great value). It was countered by the heart-felt apologies of everyone in the hospital and the humour of the response to it which was to pay the police to round up all the children in the compound who were not meant to be there (at that stage it was common to get them knocking on doors to ask for money or food) on the basis that although not all perpetrators they almost certainly knew who the culprits were and to take them all to the police station where they solemnly thumb-printed a document that they were told stated that they understood if they were found on the compound again without reason they would be arrested. Ethiopian discipline is stern but it solved the problem for everyone as the door-to-door begging ceased immediately.

-       Having food poisoning one night at the end of my first week in Gimbi when I lived alone in my bungalow, I was on-call with Tekle away so no option but to soldier through. This also created anxiety that this would be a regular occurrence but thankfully it has not been the case- in spite of eating in local restaurants regularly with the exception of one other brief episode I have been well throughout- it will amaze you all to hear that I even drank tap-water (though this was filtered) as Ethiopia has a clean water supply in towns.

-       The one maternal death that I encountered which will stay with me forever- one maternal death may not sound like a big deal  for a doctor but in 22years as an obstetrician I had previously been directly involved with the care of only three women who died in pregnancy  (and can still tell you the details of each of them). Maternal death remains a tragedy on so many levels that if I ever fail to feel the emotion of failure associated with failing to save a woman it is a sign that I have become too hard and it will be time to do something else. I feel thankful that it was only one as I know from email correspondence that in the 2 weeks since I left a further death has occurred in a woman at term with very high blood pressure (eclampsia).

-       The terrible roads but enough said as I have mentioned it so often before.

-       The poverty that is Ethiopia- this is a thing that I put in this list but will be impossible to forget nor would it would be appropriate to try. During our holiday Mark and I considered other poor countries we have travelled to and concluded that Ethiopia is the poorest (Madagascar & Mozambique are close seconds), this is a country where even a discarded plastic water bottle is a cherished item and villagers will almost fight to be the recipient of a bar of "hotel" soap. On the positive side the people appear happier than in many countries almost content with what they have rather than struggling with aspirations against terrible adversity. The poverty that is everywhere such that the radiant smile & wave from many children turns quickly into an outstretched palm and a "1 birr", "1 pen" or "highland" (the latter a used water bottle) request. The need is so great that the only way is to decline as to give individually as this could create a localised riot of need (we witnessed this with one tourist giving out pens & our guide giving soap) and reinforces the benefits of begging. However much you rationalise it you end up feeling terribly guilty for being rich and at the same time powerless to know what the answer is to change things (with many much more knowledgeable people than me struggling with this question in aid agencies all over the world).

Well I could keep going on any of these lists but as this is already one of the longest blog in the series it is time to draw to a close. My blog has been a great discipline (although sometimes it created the deadlines I was happy to avoid)- I started it for me as it seemed a good way of documenting the things that I saw around me but I have been enormously flattered by the number of people who have bothered to read it- so thank you to all of you.

Also a big thank-you for the generous support that many of you have given to Maternity Worldwide via my Just Giving site- my time has confirmed that it is a very worthwhile charity that is making a big difference to the lives of pregnant women in the West Wollega, who due to the Safe-birth fund feel able to come to the hospital when they encounter problems.

Three months in a country creates an affection and understanding of it that it is not possible to achieve on a shorter holiday and so I feel sure that whilst Ethiopia is not a country begin a "love-affair" with, I will definitely go back there in one way or another in the future and at that stage I will resume my blog again!

Sunday 11 April 2010

Happy to see tarmac again.................

11th April

Now back in Addis again after our two weeks of travelling and on the eve of my departure from Ethiopia back to the UK. I have to admit to being ready to go home now as although travel is always a wonderful experience-you always want to be home in the end. This will also be my penultimate blog, this one to document briefly our holiday with a final blog on the reflections of my whole time in Ethiopia (should keep me occupied for some of the 9-hour flight tomorrow).

We have had two amazing weeks of travel that were complete contrasts to one another:  In the first week we travelled south into a place called the Omo valley. Illona (Steppes Travel - an advert as they have a link to my blog on their website) recommended that we include this trip in the itinerary but did caution that it was for people with a spirit of adventure and that we would need to be flexible as things might change and to "go with the flow" - I had assumed that this comment was meant metaphorically but it turned out to also have a more literal meaning! The best time to visit the Omo doesn't technically include late March and certainly from mid-April visits are not recommended as the roads become impassable as the rainy season, which begins in May throughout most of Ethiopia arrives earlier in the Omo valley.

South Omo is a bit like the land that time forgot- it is stunningly beautiful with rolling hillsides, sparse population and dense green forests, although the temperatures reach very high levels in the summer, courtesy of the plant life being drought resistant and periodic very heavy rainfall the area remains verdant year round (not really what you are expecting in a country notorious for drought and famine) - the landscapes are such that a dinosaur or two would not look out of place wandering the vast landscapes and this would be in keeping with the tribal people of the area who live a pastoral life (a large herd of cows marks out a man of wealth) and for whom the comforts of even the 11th century (dragging back school memories of descriptions of life around the time of the battle of Hastings!) have yet to reach (although beer and coca cola are the notable exceptions to this). Visiting the different and often isolated tribes is the reason that tourists visit the South Omo valley.

The travelling was difficult in the extreme with severely rutted, muddy (doesn't really begin to describe it) roads with the additional problem of numerous streams/small rivers to cross. At one stage we had to leave the car on the banks of a newly formed "wadi" river for two nights and wade across with backpacks (new experience for us) and walk to our hotel. Thankfully the car was good and the driver skilled (although we did requiring towing out of a ditch by a second 4x4 on one occasion).

The tribes we visited are straight out of National Geographic and although you know that there are people who continue to live in this way it is still hard to believe when witnessed first hand. As an example of ways of life we can't even begin to comprehend we witnessed what is called a "bull-leaping ceremony". This is the occasion where a teenage boy (14-15 years) from the Hamer tribe in order to prove his bravery (and thus eligibility to chose a bride - read this how you will!) must jump (in reality run along the backs) stark naked of a row of large (particularly the horns) cattle - one slip of the foot would have disastrous consequences. If this isn't bizarre enough prior to this act (which takes only a few minutes) all the women in his family put themselves forwards to be whipped with birch branches (drawing blood) as a sign of their devotion to him and other men in the family.  It was fascinating although I have to confess some qualms about being an observer on such occasions and I still can't quite get my head around it all. As the Tribal people are pastoralists and subsistence farmers they are incredibly poor even by Ethiopian standards (we sheltered from the rain in the hut of a family who appeared to have no other material possession apart from a single cooking pot). This creates an unexpected commercialism where the old maxim of responsible tourism ("take only photos - leave only footprints") doesn't apply as these incredibly photogenic people have realised that their image has a value. As a result every photograph taken must be negotiated and paid for.  This creates difficulties as although the fees they ask are in reality small (1-5birr=5-25p) it feels wrong to be singling out an individual from a group as more worthy of a photograph that the others but as the birr do eventually run out this is what you must do.

The second week of our holiday was in the North of Ethiopia. We flew a number of legs of the journey and thus avoided the long road journeys that were unavoidable in the first week. We still had a number of excursions by four wheel drive minibus  (much less comfortable that a 4x4) over terrible roads and this has left us concluding that one thing we will not miss on return home is Ethiopian roads (from previous blogs you will know I had probably reached this conclusion already). The landscapes of the north are completely different to the south with vistas much more in keeping with expectations of what Ethiopia should look like. Rugged, rocky, biblical type landscapes that are very dry and although not desert support little in the way of vegetation. This is the Ethiopia that can be severely affected by drought as if the rains fall to come then the livestock die as they are unable to find any food and the limited crops fail resulting in widespread famine.

So the amazing thing is that in this bleak and remote landscape early Christians built monolithic rock churches (like those in Petra in Jordan) and 16-18th century Ethiopian Emperors held their courts. All this creates more heritage than the rest of sub-Saharan Africa put together. Even more amazing (and rather sadly) is the fact that relatively little seems to be known about it all including why it all developed here (churches particularly) - this maybe due to the difficulties in access for foreign archaeologists or simply that there are more pressing humanitarian projects demanding funding in Ethiopia.

There is no doubt that travel like many things in Ethiopia is difficult but at the same time very rewarding for the effort- the hospitality culture exists even amongst people who own virtually nothing and they remember something I sometimes think that we may have forgotten in the west- offering a smile of welcome to a stranger is free!

 

Saturday 3 April 2010

An Ethiopian fable.............

26th March

Kumara the Maternity Worldwide driver who drove us to Addis told us an Ethiopian fable- A donkey, a goat and a dog decided to take a journey on a bus- the donkey solidly paid his fare, the goat avoided the conductor and didn't pay and the dog paid his fare but the conductor forgot to give him his change. This is the why donkey feels that he now owns the road and moves only slowly and reluctantly for anyone, goat on the other hand is mindful that he still owes someone his fare and so runs at the sight of any vehicle lest he be asked to pay, this just leaves poor old dog chasing every van that goes past in an attempt to get his change! The fable doesn't seem to include sheep or cow but they tend to behave like goat and donkey respectively. Nor does the fable mention small boys who also love to practice their sprinting skills and run along side the vans for as long as possible (which is often quite a long time and must partly explain why the Ethiopians are such formidable contestants in International athletics these days).

The fable was told to as we were setting off on the journey from Gimbi to Addis, which is the fourth and final time I had to make this trip- as least for the foreseeable future. This trip was better than previous as Kume made good time (he is known for his love of multiple coffee stops but this journey we kept to two) and so with a 6am (well 6.15am after a bit of faffiing about and a few goodbyes) we arrived in Addis at 3pm- in time for to start luxuriating in the comforts available in the Sheraton including a swim and a gin & tonic (complete with ice & lemon i.e. with no missing ingredient which was a first since my last trip to Addis).  I am not sorry to have finished this last journey safely as the road trips to and from Gimbi were the only part of my adventure that ever felt dangerous. Thankfully if/when I return to Gimbi the road will be improved as the Chinese road building project is under way to finish the middle section that is currently so worn that it is much worse than travel on a mud or rubble road where the surface is at least predictably poor unlike the current irregular pot-holes- that just leaves a requirement for an improvement in driving standards (in particular the blind faith that nothing will coming the other way when overtaking will only yield appropriate returns if the roads stay quiet) and someone to control the cows, goats, sheep, donkeys, dogs and apparently suicidal pedestrians (so frankly I am not holding my breath that the journey will be anything other than safer by virtue of the fact that it is quicker, so you are in harms way for a shorter time).

My time in Gimbi has been rewarding on so many levels that I don't discount the possibility of returning at some point in the future and this fact made it easier to say goodbye when the inevitable refrain from people was "when will you be coming back?" allowing me to say with honesty that I hope I will come back one day although omitting to add that the realities of my work in the UK are that this is unlikely to be for a number of years.

Saturday 27 March 2010

Almost at the end..............

March 24th

It all comes around so fast and the last few days have been a whirlwind of activity (my excuse for not posting my blog very regularly this week) as I try to finish things off and say my goodbyes.

I finished my OR teaching module with my students including giving them a 2-hour test paper last week and hearing their project & marking presentations. It is part of student culture here (it would seem) to whine about everything including questioning the grading so I received cries that my test was too difficult which fortunately I was able to counter by pointing out that it was so difficult that one student had managed to achieve 89%- they were able to see that this fact that not supportive of their argument.  There was only one student who failed who sadly really struggled with the English that the course has to be taught in- it was sweet that it was not she who questioned her grade but some of the men in the group who have tried hard to help her to get through- there is no doubt that they will be good team-workers in the future!

I did my last caesarean section before handing over my small remaining supply of good uterine sutures- I managed to make these last as in the first week I decided that it would be a good discipline given the serious resource lack (sutures are one of the most expensive items the hospital has to purchase and are always in short supply resulting in compromises on the best suture choice on many occasions) to adapt my technique to use only one suture for the uterus rather than the wasteful two sutures I was trained to use. This was perfectly possible in most cases and should lead me to question my practice in the UK when I get back but I have a suspicion on this one I will rapidly slip back into my profligate ways!

The caesarean was an unusual one of Gimbi and served as a reminder of what I will be going home to. I have mentioned before that women here labour silently and that we have virtually no pain relief on offer-the woman in question had unusually needed induction as she had not gone into labour after her membranes rupture (due to the infection risks to the baby here we don't manage them conservatively for very long) and additionally the baby had passed meconium which can be a sign of fetal distress or of infection (this is uncommon in the UK but for reasons I can't explain is very common even in babies that turn out to be well).  Unfortunately the labour progressed slowly and perhaps due to the position of the baby, she was in a lot of pain throughout the labour. I was called to see her a number of times through the night when I advised that we should keep going as she was making progress albeit. By 8am she was begging for a caesarean- this is something that I encounter all the time in the UK but was a new experience in Gimbi where women expect and want to deliver vaginally. The woman's distress was also leading the midwives to question whether she needed delivery by caesarean and also causing a reluctance to continue the medicine (oxytocin) that she needed to keep the contractions going.- the baby thankfully was unconcerned by the whole process with no suggestion of any problem In the UK the management in this situation is easy-I would have called upon the expertise of my anaesthetic colleagues to perform an epidual and relieve her pain but in Gimbi this is not an option. I managed to persuade the woman and the midwives that we should continue for a few hours more but agreed a strict time limit. Needless to say the lack of oxytocin combined with the high stress levels of all involved conspired to result in no significant progress and so delivery by caesarean was arranged. This was uncomplicated, the baby was average size and in a normal position so the true indication for the operation was lack of pain relief resulting in maternal, midwife and obstetrician distress!

Sadly we had another death of a 40-year old woman today. She was not pregnant but was a gynaecology patient.  An operation for prolapse (a vaginal hysterectomy) had been performed in another hospital some distance from Gimbi. Unfortunately after discharge from hospital she had been unwell but had stoically assumed that this was normal after an operation and thus failed to seek help. On arrival in Gimbi she was seriously unwell with all the appearances suggesting severe infection originating from a problem in her abdomen. We resuscitated her and performed a laparotomy (an exploratory operation to find out what the problem was). The operation revealed that a hole had been made in her bladder during the vaginal hysterectomy and she had been leaking urine into her abdomen (5 litres of urine has accumulated). This was repaired but sadly she had arrived with us too late and in the absence of any intensive care she died 12hours after our operation. Without a doubt a similar post-operative complication could occur  in the UK but the idea that it would go undetected for a week after surgery is unimaginable-thus women are not only more likely to have prolapse (large families from a very young age, poor nutrition, exceptionally  heavy manual labour) but the risks of surgery are proportionally greater.  Just how great is impossible to say as there is no recording system for post-operative complications-I asked if we should let the people in the hospital who performed the operation know  but the response to this suggestion was negative suggesting that this was not considered necessary or desirable. An impossibly heavy price to pay  for the attempted cure of a non-life threatening condition.

It was hard saying goodbye to Tekle- his guidance when I first started in Gimbi  three months ago was invaluable and without it I can't imagine I would have ever settled in and found my niche. It is also very hard for him to say goodbye as Steve is leaving at the same time as I am and so he will return to his solitary 1:1 rota. The tragedies that occur on a daily basis here are so much easier to cope with when you can talk to other people about them and must be hard to reconcile when you are working alone. There are a number of examples where  we have worked together (mental brain-storming and physical presence) with very sick women  and achieved good outcomes that might have happened anyway but it seems likely the team working helped. At the current time there are no specific plans for other Obstetrican volunteers but I will definitely be doing my best to encourage others to follow me in going to Gimbi as an experience with mutual benefits to them and the women cared for by Maternity Worldwide in Gimbi.

Wednesday 24 March 2010

Why Gimbi needs Western midwives..............

March 23rd
 
I have only 48 hours until I leave Gimbi on the first leg of my journey home and so I am trying to collect statistics for my time here and finish off other bits and pieces- it suddenly feels a bit like being at King's with too much to do and too little time. Perhaps as I am coming to the end of my time, I am also starting to dwell more on some of the problems that I leave behind and on thoughts about how these can be addressed in the future.
This blog is written with Emma who is one of our midwives at King's who (assuming my blog so far hasn't put her off) is keen to volunteer with Maternity Worldwide and come to Gimbi (and of course also for any other midwife who wants to do some time abroad) in mind as it will to give her some idea of the challenges she will face and why she has invaluable training/experience that she can pass on.
The midwives here are not in reality midwives although throughout my blog I have called them this and on a day-to-day basis everyone in the hospital calls them midwives as well. To be entirely correct they are Skilled birth attendants (SBA) all of them were Ethiopian qualified nurses (this technically requires a 3-year course taught in English but as previously described the standard of courses can vary hugely from institution to institution) who have undergone an additional 9-month in service training to be allowed to work as SBA. To be a midwife in the UK the training is much longer & more intensive (a minimum of two years full time which includes a lot of supervised practice) training and in addition to this the educational qualifications of those entering midwifery training is much higher than here (they now require a degree). The SBA training was all organised by Maternity Worldwide and there is a need to keep running such training to keep the numbers of Skilled birth Attendants at a level that allows the 24-hour rota on the labour ward to be maintained.
Although the training is relatively brief the midwives (I will continue to use this term due to habit) are amazing in the things that they are able to do. Since I have been here I have never been asked to do any perineal suturing (they even expect to suture for my deliveries which I have refused as I believe the person who cuts an episiotomy should suture it-helps reflection on whether such a large one was really necessary!). They manage a large proportion of vaginal deliveries without any involvement of the medical staff even doing straightforward vacuum (Ventouse) deliveries, which in the UK are always done by doctors. They are good at resuscitation of babies when required, put up all the drips (I've done 3 since I've been here) and are happy giving intravenous injections of anything that is prescribed. They have had the need for monitoring vital signs (another terrible Americanism I will need to try to forget when I get back to the UK and start doing observations again) drilled into them and generally do this well and report any abnormality such as raised blood pressure in labour promptly which makes a significant contribution to reducing maternal morbidity and mortality.
So this is the positive bit-is there a down side? Sadly any sort of pastoral care as part of midwifery has yet to reach Ethiopia. The women labour alone without any relative or support in labour and there is no analgesia (Pethidine is available but due to the depression it can cause in the neonate and the cost constraints (a single dose costs about 50burr=£2.50) it is rarely used) but in spite of this the midwives do not see their role is to offer any support either by verbal reassurance or explanation or by physical actions such as holding a hand or rubbing a back (I do a lot more of this than they ever do).  Fortunately the fortitude of women here is a marvel and most labour without complaint (I am told that as a very god-fearing nation pain is generally considered as "god-given" and thus if god does not see fit to cure it, then it must be borne without complaint), they appear relaxed and this shows in the labour progress of the majority which is fast- I find their apparent lack of fear amazing given the extreme hazard that childbirth presents to women here (they all must know of friends and relatives who have died in childbirth). In fact the occasional woman who does behave as many women would in the UK without pain relief, support or reassurance (crying out in pain during a contraction and being fearful of the next contraction in between times) will result in multiple calls for medical assistance and thus depending on the threshold of the Obstetrician a high chance of caesarean section.
Women all deliver flat on their backs again a source of amazement to me as it seems unlikely that this is what women would do if they were at home in the care of a traditional birth attendant. I have questioned this but sadly got nowhere in making any change in practice.
Help with breast-feeding is almost non-existent with a belief amongst midwives that women should be able to do this unaided. Thankfully women here are fantastic at breast feeding helped by their excellent skin, culturally it is expected and the incentive that formula feeding is too expensive for them even to contemplate (Nestlé's brand Nan is the equivalent of $10 per small tin) so that for their baby to survive breast feeding must be established. However some of them do struggle in spite of this and getting help is difficult (I know a lot more about breast-feeding now than when I left the UK).
English can also be a problem as the skill varies and there can be misunderstandings. I remember one night when I was reviewing a baby who was struggling in the first few hours of life in spite of being in good condition initially at birth. I was wondering about the possibility of some sort of congenital abnormality such as a heart defect when the midwife helping me said, "babies mother is sister". Immediately the complications of births that result from incestuous relationships flooded through my mind although fortunately I said nothing but perhaps the look on my face led the midwife to offer clarification by adding "she works on male ward" leading me to a rapid realisation that we were dealing with a nursing sister rather than the sibling variety. On a simpler level the communication issues can result in orders being followed slowly or not at all with the obvious potential consequences on patient care.
Sadly the most serious issue is that the very high perinatal mortality rate creates a casual attitude to fetal monitoring. We are not able to monitor continuously so rely on the midwives to listen in on the baby during the labour. Just this week I was called to a labour (the guard has to come to my house to tell me as we have no phones or pagers and no message of any particular urgency was sent) and when I arrived the midwives told me that they thought the baby had died in labour. They showed no concern, remorse or fear of being chastised for this possible outcome which when I delivered the baby immediately  (and very easily) with the vacuum proved to be the case with a fresh stillbirth of a beautiful full-grown baby.  On reviewing their monitoring they had not listened to the heartbeat for over half an hour despite other signs that there might be problems. Although I try hard not to be angry they were aware that I was not happy but all I was offered were excuses although eventually I managed to get them to reflect on things that they can learn to prevent this happening in future deliveries.
I have been working with Marie who is a very experience midwife from Denmark. She is trying hard to set an example to the local "midwives" by offering support to a labouring mother by simple things like walking around with her, rubbing her backs through contractions and holding her hand- seemingly very simple things. She has already made herself popular with the anaesthetist who has noticed that the women she is caring for are calmer when they go to theatre and thus easier to anaesthetise- all this in spite of the fact that Marie speaks only occasional words of Oromifa (the old adage that actions speak louder than words coming immediately to mind).
So I believe that the skills of a western trained midwife are exactly what Gimbi needs (Marie is here for a long stint but this finishes in November and there is plenty of work for two anyway).  Because the deficiencies in the practice of the skilled birth attendants ofteninvolve cultural attitudes, formal teaching has limited effect and what they really need is to see a good midwife practising and to learn from this example. Progress will be slow but will be there and for the individual women fortunate enough to be cared for by an empathic midwife the benefits will be immediate.

Saturday 20 March 2010

Thank goodness for the lack of Nescafe...............

March 20th
A fog has descended over Gimbi blocking the sun to a moon-bright disc in what should be an otherwise clear sky. This started yesterday and as the valley appeared evenly shrouded in this white mist I initially assumed it was part of the change in the weather that is occurring gradually as we move towards the rainy season which begins in May (the weather has become noticeably hotter so that it is a necessity to keep out of the sun during most of the day and so that unfortunately sleeping at night without a fan is now difficult- the choice being the heat of closed windows with a sound barrier or the slight cool of opening them with the downside of constant dog barks, mosque calls, cockerels who seem to think dawn is at 3am and the ubiquitous to Africa, over-amplified loud speaker music/orthodox church sermons that begins at about 6am and cicadas who like to perch on the outside of the mosquito net chirping loudly- so far I have settled for the closed window option but as the heat increases I may have to seek out ear plugs). I was a bit surprised when the midday heat had done nothing to shift the mist and enquiry established that the mist is in fact smoke that descends at this time of year for days or weeks as the farmers burn off the stubble from their coffee crops picked in January in preparation for the next planting when the rains come- as this is the major crop in this area, this creates a lot of smoke. Surprisingly there is no smoky smell and there is none of the dark residue that I associate with smoky bonfires in the UK (causing neighbours to be upset as their washing gets grubby)- I assume this is because the burning stubble is very dry and entirely natural.
Coffee is one of the home comforts that I have not had to forego in Ethiopia. Some of you will know that Ethiopia is thought to be where coffee was first discovered, near a town in the north called Kaffe (there are stories about frisky over caffeinated goats and monks noting the aroma of roasting coffee beans after they inadvertently burned coffee plants on a bonfire to add colour to the story of it's discovery). Coffee is one of Ethiopia's biggest export crops- thus pre-packed ground coffee is easily bought in the "supermerketi" and unroasted coffee beans are available in the market to be brought home and roasted before grinding. As a result although I have detoxed in relation to many things, caffeine hasn't been one of them with two big cups of coffee made in an Italian stovetop coffee makers every morning to get me going.
I think the majority of us would agree that we have many things to thank the Italians for (if I list mozzarella cheese, mushroom risotto, Brunello, beautiful shoes and handbags it also gives away some of the things I have missed in my time here) and certainly I have reason to thank the Italians for the time they spent with Ethiopia as a protectorate (having their colonial aspirations thwarted by Ethiopian strength at various stages this was the most they achieved) as their legacy is that excellent coffee ("buna" as it is locally know )is available everywhere. In Addis, old Italian "gaggia" type espresso makers abound but even in the streets of Gimbi you can pick up an excellent coffee on the street. The establishments are far from fancy and to my chagrin I have to confess that appearances are such that if I had not been taken the first time by Ethiopians I might have been concerned about the risk that water had not been boiled properly etc., I now feel ashamed of my precious western ideals as the hygiene standards are very good albeit with a washing-up bowl and a water canister rather than some fancy dishwasher.
The Gimbi style"Starbucks" is a small shack on the street side that consists of a brightly coloured tarpaulin to keep sun & rain off customers who sit on benches around a table with thermos flasks of coffee & tea. This has been made (always very recently as turn-over is high) by putting home roasted & ground coffee into a kettle of water boiled on a charcoal burner (always in evidence in the corner). The coffee is served black in small (espresso size) miniature teacups. The default position is that the bottom third of the cup will be filled with sugar but the option of no sugar is not considered unusual although it is requested less frequently than salt coffee where a teaspoon of a solution of coffee with dissolved salt is added instead of sugar (needless to say I have declined the offer of trying this type of coffee as I suspect it is something you have to grow-up drinking to appreciate).   The "branch" we go to is a little place with an orange cover next to the hospital gate. We go regularly after the morning ward round and I now no longer need to ask for coffee without sugar as it arrives automatically. An espresso habit here is not the same expense that it is in the UK, as a cup cost 1burr (5p) and homemade donuts are also available for the same princely sum (Steve assures me they are very good).
Coffee is such an important part of life here that everyone aspires to own a coffee set  (there are shops in Gimbi that sell only coffee sets) so that they can perform a coffee ceremony on special occasions and for guests. One of the long-standing American nurses-Scott left last week (he goes home to work in Yosemite for 6-months to earn enough money for him and his family to work here for the other 6-months of each year) and a coffee ceremony was organised to mark his departure. The ceremony involves the making of coffee including bean roasting with the pan taken around for everyone to experience the aroma of the freshly roasted coffee and thus the ceremony takes about an hour in total. As might be expected coffee is made by women (even the stalls seem to be female owned & run) and all girls learn how to make coffee from an early age and to perform the coffee ceremony.
Thankfully I have not seen or been served in Ethiopia is instant coffee and I am not at all sorry to have found a country in Africa where "Nescafe" is not considered the desired drink when coffee is requested!

Wednesday 17 March 2010

If only she knew how much I wish I had a prescription to prevent stillbirth................

March 16th
 
I find it hard to believe that I only have eight days until I finish my time in Gimbi. Of course there are certain things that have made the time seem long (missing Mark, the healthy but predictable food & the absence of red wine to name a few) but in most ways the time has flown by in a way that I didn't expect when I was homesick in my first few days. Although it is inevitable that I will begin a countdown and start to make packing lists in my head, I have to remind myself that there is still plenty to do each day and that the remaining eight days are still 10% of my overall time here and so to keep at it.
Apart from covering labour ward and doing occasional theatre cases (although I have revisited my gynaecology skills you will be relieved to hear that gynae surgery is limited to me being either supervised or acting as a skilled assistant in a complex case for Tekle or Steve (Gynaecologist from Australia)) most of the day is spent doing outpatients.
I always joke that the King's maternal assessment unit is the most used part of the hospital based on square feet of space (it is a small area with a bit attendance rate) but the "out-patient clinic" here vastly exceeds its performance on a space per consultation basis.
The clinic room is about 8 feet by 8 feet- contains desk, couch, scan machine, the hand washing station (in the absence of a sink we use a water canister with plastic tap and washing up bowel below to catch the water) and three chairs.
The three chairs may seem like a luxury given the size of the room but it is not uncommon to have five people in this room (1-2 doctors with possible medical student, patient, Ashemi (our fabulous practical worker- who is below the level of a nurse in qualifications but acts as translator Oromo-Amharic-English as necessary and does blood pressures, couch clean ups and assists in procedures if required) and a nursing student. The partners (in this society almost always husbands) of the women are never allowed in the room to the point where the door will be slammed in their faces by Ashemi if the try to follow her in- I suspect in a society where the status of women is still less than that of the men and where domestic violence is very common this is a good practice as it allows them to speak for themselves without fear although I am not sure that these are the reasons that would be given for partner exclusion as oppose to the physical constraints of the consulting room and that the doctors here like to keep confrontation to a minimum. The women will often call their husbands in at the end of the consultation if surgery has been recommended, as the issue of whether he can & will pay for the operation needs to be discussed.
So in this space we see between 15-20 patients (we see the most on Wednesday which is the main market day and there is also a season increase in numbers after the coffee harvest in February when people have "relatively" more money to address health issues) between 10am & 4pm with a strict break for lunch 1pm-2.30pm. (the clinic is open six days a week with a break for the Adventist Sabbath on Saturday). The uncertainty in numbers is because there is no appointment system and we effectively see all "comers", the majority of the women arrive through the morning with the afternoon being for a few women who have travelled far to get here or for reviewing of results from any investigations from the morning clinic. There is no waiting room and the women & their relatives wait in the corridor outside, clamouring around the door every time it is opened in belief that this will make it more likely that they will seen next (actually a wasted effort as we operate a  strict first come first served system unless someone is obviously unwell). Overall it is not a clinic environment for any one with even mild claustrophobia!
The patients may be follow-ups after surgery or antenatal women with known risk factors (such as twins, recurrent stillbirth, raise BP). Women will also be referred from other external clinics or even from the new Gimbi government hospital  (they don't seem to have a gynaecologist there yet) with a suspected significant obstetric/gynaecology problem rather like the referral from a GP in the UK.  However the majority of the women come from internal clinics within this hospital. There is an antenatal clinic run by skilled birth attendants every day and women will be referred from there if there is uncertainty about dates (very common as women rarely know when their last period was let alone the date if they do remember) or a risk factor has been identified requiring a doctor to review)-these referrals are usually appropriate but unfortunately the problem referrals come from the main medical/GP outpatient clinic. This clinic is "over-run" with patients and is staffed only by trained nurses (there is sometimes a GP type doctor but this is a post that the hospital struggles to fill and so often there is no medical supervision). Thus what I call the "in-tray phenomenon" is common, this involves a need to shift a segment of your workload into someone else's in-tray regardless of whether this is appropriate or not- as a result we get women with minor period problems or abdominal pain sent down to us, referrals in the UK that would be managed by a GP and never require "specialist" review. More worryingly, it is not uncommon to get a card that read, "Complaining of shortness of breath, night time fevers, joint pains-also difficulty in conceiving (or insert any other minor gynaecological problem). Refer gynaecology OPD". This is tiresome for the patient as inevitably we have to send them back for their TB/malaria/worm infestation to be treated as the other problems uncovered by questioning are not issues for them or the main issues need to be addressed first.
History taking is fraught with difficulty- some created by the need for translation but some related to what can only be summarised as an "inability to answer a straight question" (women often seem to have an agenda and want to answer their own set of questions that may be of little help in making a diagnosis). A straight question like "how many children does she have?", can result in a two-way discourse between the woman and Ashemi (clinic translator) lasting a number of  minutes with the answer "two "(or whatever) being returned at the end of the discussion- it is a bit of a mystery. The other problem is that cultural taboos mean it can be difficult to elicit the true complaint for a significant part of the consultation if a woman has come because of infertility, worries about pregnancy losses or even certain types of pain- I often wonder how many women have gone through the whole consultation without being able to find the courage to tell me why they have really come.
Having elicited some sort of history most women require some sort of examination and we are fortunate to have our trusty little scan machine which is a god-send especially for obstetric patients allowing us to accurately date their pregnancy and confirm or refute twins. It is also useful for gynaecology and it is amazing how much gynae pathology a fetal medicine doctor can pick up when she has to but then again who knows how much pathology I have missed?
Internal examination initially caused me some surprise (and amusement) as underwear choices here are different compared to a clinic in the UK- women seem to split three ways in their garment selection with about one third of women choosing the Marilyn Munroe option (for completely different underlying reasons I assume although not absolutely sure of the motivation of MM or the women here in going combat) and wearing no underwear, one third wearing M&S type big knickers and the final third wearing silky football shorts (I reliably informed that these are most often in English club colours). Regardless of the style you will be relieved to hear that they are known by that good Oromifa/Amharic word "panties"!
Making a gynaecological or other diagnosis can be difficult as we have few investigation available (no laparoscopy, colposcopy, smear test, hormonal blood tests or even swabs for infection) and even if we make a diagnosis the list of drugs available for treatment is very short with the contraceptive pill or depot injection being our only available hormonal treatment of any kind. This creates difficulty as I've mentioned before that patients feel that they have value for money from their outpatient visit only if they have investigations and leave with a prescription. As an example yesterday a woman with a history of two previous stillbirths at home, asked me for a prescription of" pills" to help her problem after I had confirmed she wasn't rhesus negative (we don't give any anti-D here so "rhesus" babies will still occur commonly) , didn't have syphilis (still relatively common here) and recommended that we see and follow her from an early stage in her next pregnancy.
Perhaps there is some beneficial placebo effect in investigating/prescribing unnecessarily but I have stubbornly refused to do this. As a result some of my patients may be disappointed that I won't organise unhelpful investigations for the sake of it or give a short prescription of anti-depressants or other non-specific medication so that they leave clinic feeling good in the short-term but with the result that they are significantly poorer as every test and medication costs their hard-earned burr.

Sunday 14 March 2010

Will I recover from the reverse culture shock?........................

March 14th
 
Just assisted (well a few hours ago now) a woman in having a "normal" vaginal twin delivery (with no junior doctors or keen midwives wanting to conduct/do the delivery I am allowed to do this here- I enjoy this "hands-on" involvement although in all honesty I didn't really do anything other than be there in case there was a problem as the woman did it all herself).
She was a woman who had attended for antenatal care previously and thus we had diagnosed her twins some weeks ago. The news that it was twins didn't really surprise her as she has already delivered two sets of non-identical twins (predictably here one of the babies from her first delivery was stillborn but the other three are alive and well). The first baby was in a breech (bottom first) position and we also predicted (based on the position in the uterus) that the second twin would also deliver as a breech as well. When we saw her in clinic last week we recommended caesarean birth with tubal ligation to her- as this is recommended practice here the same as it would be in the UK although I have not been able to get a very concrete reason for this recommendation in view of the maternal morbidity attached to caesarean birth (both now and in future pregnancies) and the fact that the evidence from big studies suggests that there is actually only limited if any benefit for the babies in caesarean when they are breech in populations with a high perinatal mortality (which is definitely where we are here). However we do have difficultly in monitoring twins (most have continuous monitoring in the UK which is not an option her) and of course my resuscitation skills although now better honed than when I arrived are still not those of a neonatologist. So I decided that in spite of misgivings I would make the recommended recommendation!
Perhaps for the first time since I have been in Ethiopia the mother's response was to disagree with the recommendation and to say that she wanted to plan to deliver her babies vaginally- a long discussion with the clinic translator was roughly interpreted to us as "she says she delivered the other babies normally and two of them were bottom first , and  also she needs to get back to working on the farm soon after delivery"-in the circumstances this did not seem an unreasonable argument. So we persuaded her that she should come to Gimbi Hospital for the births (her other births were at home) and she agreed that she would do this. She was 37weeks at this point looked marvellous and had no complaints about anything at all (not even backache) - I have a photograph of this tiny woman with a huge bump smiling that wonderful Ethiopian smile (shame I can't attach pictures with email postings!).
She arrived in the early hours of this morning in labour and was happy with her plan for vaginal birth. The labour progressed normal but as is sometimes the way with third babies it was not quite as quick as her second labour. The midwife Sintaiyu, who was caring for her seemed u happy that the woman had "chosen" to deliver vaginally against the recommendation of the doctors (the idea of patient choice in most things is at best embryonic in Ethiopian practice and it is something I have spent a significant amount of time "banging" on about to try to increase the acceptance of involving women in decisions about their care) and muttered repeatedly that she didn't want caesarean section in a slightly disapproving way. I had assumed that she was repeating the conclusion of the clinic counselling but it transpired that she was asking the woman again repeatedly through her labour if she would agree to have a caesarean section. This fact became apparent when Sintaiyu came to me 10minutes after we had diagnosed full dilatation (i.e. it is getting very close to the birth of the babies normally) so say (very proudly) that she had now succeeded in getting the woman to agree to have a caesarean section.
At this point anyone reading who works with me will be smiling, knowing exactly what my response to such a request at this point in labour would be in the UK- a straight forward and categorical "No" . I'm not mean but on the balance of risks we are now at the stage where safe vaginal delivery has become very likely and at the same time the chances of complications from caesarean birth are much higher so that for a doctor who wants to do the best for their patient and particularly if they want to do the thing that is likely to involve least harm it is a very easy decision. In Ethiopia the decision was even easier as although our caesarean sections generally do fine, they definitely have more complications than the successful vaginal births. You can add to this the financial argument (which in the past we have had the luxury of ignoring in the UK although I suspect those days may soon be over) which is that in this hospital normal birth cost about 400burr (£20) and caesarean section about 1200burr (£60) - I don't know if this woman will require the safe birth fund but the fund will go a lot further if women are able to deliver vaginally.
Unfortunately poor Sintaiyu is now confused as she felt that she was doing as I would have wished her to do by involving the woman in choices about her care- more work needed for a complete understanding of difference between choice and brow-beating I think!
Anyway the woman seemed to cope with my refusal to agree to her "wish"  and 30-minutes later she delivered the first twin, a boy as a breech and 20-minutes after this  a girl who somersaulted into the pelvis and came out headfirst. Neither baby required any resuscitation, weighing in at 2.5kg each. This weight would be considered respectable here for a singleton and for 38week twins are very healthy weights. When I think that this means shat this 45kg woman was carrying 5kg of baby (plus at least 3kg of fluid and placenta), I can only marvel at the constitution that allowed her to smile and make no complaint in clinic less than a week ago-not to mention the fact that between that clinic appointment and delivery today she has been out working in the fields where she will almost certainly be again in a few days with breast-feeding twins in tow.
I realise that I am going to have to steel myself for a reverse culture shock experience when I come home and in particular force myself to dig deep to find my old sympathy for the women in my antenatal clinic who come complaining of minor aches and pains but who don't realise how lucky they are not to have to work in the fields when heavily pregnant.

Friday 12 March 2010

Will I ever know what happened?....................

March 12th
 
The saddest photograph that I have taken in Gimbi is one that shows a brown cardboard box sitting on top of a silver pedal bin. The box is one that previously had latex gloves for surgery packed in it and this old content is printed in large blue letters on the sides of the box. The box top is closed, in time honour fashion by folding the top edges inside on one another, as there is no tape or string available here. The only clues about the contents of the box are the letters "F1" written in black marker pen on the top.
F1 is a bed number (female ward-bed 1) and the box contains the body of the dead baby of the woman in this bed. Sadly even I can't remember why this particular baby died as the death of a baby occurs so frequently here. Looking at the statistics for February more than 1 in 7 babies were stillborn or died soon after delivery- as a result it is not uncommon to arrive in the morning and find one or more cardboard boxes packed and waiting for the parents to take when they leave the hospital.
Not surprisingly women protect themselves against the chances of pain of loss by an apparent refusal to become attached to their babies until it is born (when survival even if for only a short time are more guaranteed). When ultrasound scans are performed in clinic in is unusual for a woman to want to look at the screen or to know the sex of the baby. Telling a woman that her baby has died (something I have to give on an almost daily basis) is met with resignation- in my time here I have seen only three women cry although the majority of them do appear very sad at the death of their baby with fewer of the broad Ethiopian smiles and an introversion in speech and manner which is uncharacteristic. Women arrive with nothing in labour  for the newborn baby which is partly the fact that many of them own little but even the better off do not tempt providence by arriving with so much as a blanket before the baby is born.
The midwives also have what on first encounter can appear to be a shockingly casual attitude to the death of a baby- but this is just a way of getting through a daily event without becoming emotionally involved (as to do this would make coming to work very draining psychologically). Unfortunately this attitude from mothers and midwives leaves them where we were in the UK 20years ago, with a dead baby whisked away with no enquiry about whether the mother wants to see, let alone hold it. There is little discussion about what happened- and although there is often little to tell by way of medical explanation (due to the lack of any post-mortems or investigations) we can still offer advice about having more care next pregnancy but it sometimes is difficult even to get this information translated & relayed to the woman.
So why do so many babies die you might ask? In fact it is very hard to fathom even when you are "part"of their care- a significant number of babies die before the onset of labour (or arriving at the hospital for any care), further investigation if it were possible might reveal that the baby was not growing properly or that there was a congenital abnormality but the sheer numbers suggest that the poor nutritional status, chronic parasite infections and social deprivation in these women must also be contributing to this sad outcome of their pregnancy.  There are also a number of babies that die following prolonged labour at home where the women come too late for us to be able to save the baby who has become very short of oxygen and may also be infected. In addition there are a much smaller number of babies who die because of monitoring or care issues after delivery, which could have been avoided if things were done differently but the attitudes to the baby are such that it is difficult to get rapid changes in practice.
A small number of babies die in Gimbi hospital as a result of prematurity- these are babies that are born 6-8weeks early who struggle through for days or even weeks but finally succumb to feeding issues and infection. We don't see more extreme prematurity at the hospital, but as labour must happen in at least 10% of women before 32weeks I can only assume that the reason is that the families realise there is no hope for the baby at this gestation and so don't waste time, money & effort in coming to hospital, choosing instead to stay at home and let natural course of events occur. The hospital deaths due to mild prematurity feel particularly tragic, as I know that if these babies had been born in any developed country they would survive with only minimal intervention but unfortunately even that level of care is not available here and so survival is only possible if the baby is able to put up a fight against nature.
Thankfully some premature babies are amazingly strong- yesterday I saw a woman who came to outpatients with a tiny, 6-day old baby girl in her arms. (1.61kg on weighing her), she wanted the baby to be checked as she had been born prematurely. The mother had been attending outpatients regularly as she had a history of delivering four previous babies at about 28weeks (7 months) gestation (they talk in months which can be confusing) who as expected died soon after birth.  There was not a lot we could do to ensure a better outcome for this pregnancy but as there is evidence that regular antenatal care can prolong pregnancy in this sort of history, we encouraged her to attend regularly. Not sure it was anything to do with the clinic visits but this time she did get to 33weeks gestation (which was a date confirmed by ultrasound) before going into labour and had delivered her baby at home. Miraculously this baby was vigorous with no apparent breathing problem and a good suck/swallow reflex (witnessed by the fact that at 6 days of age it had no dehydration)- I contemplated whether we should admit mother and baby to the ward but the risks of hospital acquired infection (including TB) are not insignificant and the reality is that there is very little that the mother was not already providing that we could do so I explained about ensuring the baby was kept warm (we recommend "kangaroo care" with skin-skin for long periods) and recommended breast feeding every 2-hours if possible and she went home again-I just hope to see her in clinic again next week( this was suggested) as if she doesn't come I will never know if it is because the baby is doing well or has gone the same way as its siblings.

 

Monday 8 March 2010

The test of acquired greeting skills...........................

March 8th
The local language is called Oromifa and although I had not previously heard of it, it is the third most commonly spoken language in Africa after Swahili & Arabic. The official language of Ethiopia is Amharic, which is in reality only spoken by a minority of the country's population. In the past there have been political moves to make Oromifa the official language but as the Amharic speakers tend to be the most educated people (and hence often the" ruling" class) and as Amharic is a language that is particular to Ethiopia (Oromifa is spoken in Sudan, Uganda & Northern Kenya as well) these moves were unsuccessful. Amharic is a Semitic language whereas Ofomifa is a tribally derived language and thus there are absolutely no similarities between the two. Hence the few words of Oromifa that I have toiled to learn (languages were never my forte and it definitely gets harder as you get older) will be almost useless to me once I leave Gimbi to go travelling as the language of the North is Amharic and the South has other rare tribal languages & Amharic. Oromifa is spoken in Addis but as Ethiopians there also speak the best English (and like to practice) I am unlikely to use it much.
In Gimbi and the surrounding areas the majority of people speak Oromifa with only a small number speaking some Amharic as well. The nurses and midwives usually speak Oromifa & Amharic and in addition to this they will have a varying ability in English. Tekle (the Ethiopian Obstetrician) doesn't speak Oromifa only Amharic (see earlier comment about educated/ruling class) and so also requires translation.  As a result the ward round and clinic (if Tekle is there as well) require a 3-way translation-Oromifa to Amharic and Oromifa to English (or Tekle will do Amharic to English in a relay).
The translations in clinic can be bewildering-to start with one thing that I have learned not to question is the age that is written on the outpatient card. Often a woman will appear to be a older than the age that there cards states (and in case you wonder there are no sensitivities that mean that women beyond a certain age start to subtract years here) I used to ask about this but learned that the discrepancy is because people do not know how old they are as there is no birth notification, few people have calendars or anyway of recording dates as they don't read and write (apparently those with some education will write the dates of birth of their children in the family bible). So if I questioned the age of a patient I would sit through a protracted discussion between the clinic nurse and the patient that seemed to involve reminiscences about memorable events (droughts, bumper coffee harvests etc.) that allowed her to gauge her likely age- the summary of this would be along the lines of "yes-she might be a bit older" so I have learned to judge by appearances and only ask the question if it will make a material difference to my management (which is very rare). The other problem with translation is when as apparently simple question like "how many children does she have?" leads to a long and sometimes heated exchange between the nurse and the patient- the answer will come back eventually as "five" (or whatever) leaving me none the wiser about what was being discussed. for so long and so animatedly.
Greetings in Oromifa are one of the most amusing things, as they seem to involve a competition to see who will run out of possible greetings first. The most commonly used greetings are either "Nagada?" which literally means "is there enough?" or "Fayada?" which means is there health?" The responses are "Naga"-"there is enough" or "faya"-"there is health". These can be used as a response to either question (which given the questions does make sense). In addition to this there is "akkum" which sort of means "hello" and "Atembulteh" which is "good morning" - the response to either of these is also "faya" or "naga". So an exchange on arriving on the ward may go along the lines of "Akkum", "Naga-fayada", "Faya-Atembulteh", "Faya-Nagada", "Naga"-well this is the way it seems anyway and whether or not I start the exchange or am the respondent unsurprisingly it is always me who runs out of greetings. Greetings are common as you would greet or be greeted by strangers on the street with a"fayada""naga" exchange (thankfully it need go no further) and on meeting someone you know the full exchange is expected along with a minimum of a hand-shake (a very casual acquaintance) through to grasping hands in a hand shake and leaning forwards to "bump" shoulders right then left then right again (a bit like the movement to kiss on alternate cheeks without the cheek contact or air kissing) which you would do for someone you see regularly or know fairly well.
As if the extensive greetings are not enough the patients will often shake hands in clinic as well particularly the older ones-the very elderly will proffer their wrist rather than their hand, which is done as a sign of respect to you as a doctor (this practice is also used if you have dirty or wet hands when the hand shaking uses hand to wrist but does not cease).
The fact that you are a "faringe" makes it no less likely that you will be greeted where ever you go and in fact I suspect it may make it slightly more likely as seems to be used as a sort of test to see how much you have learned by judging in how many greetings physical and verbal you can string together before you run out!
 

Saturday 6 March 2010

As if more threats to a mother's life are needed...........

March 7th
 
Regardless of whether you feel termination of pregnancy for "choice" is ethically appropriate, the reality of the situation here in relation to induced abortion is such that it results in serious morbidity and mortality for women.
My (limited) understanding is that termination of pregnancy is legal in Ethiopia but only in the limited circumstances where the pregnancy is serious threat to the health of the mother or where the baby has an abnormality that is lethal or very severe (which is on paper much more limited than in the UK). However although not technically legal termination of pregnancy is undertaken in some "private" medical clinics and Marie Stoppes International also runs some clinics with the law apparently "turning a blind eye" if the procedure is undertaken very early-the problem is that the former charge high fees that many women can't afford and the latter although free or low cost are few and far between.
Unfortunately sex education in schools is at best rudimentary, culturally parents do not tell their children anything (I have heard stories of girl's who thought they were dying when their first menses occurred rather like in Victorian England) and free contraceptive advice although technically supported by the government is not well advertised or widely available. In a society where a "virgin" bride remains prized, falling pregnant outside wedlock is a social disaster with repercussions for mother and child for the rest of their lives. This background sets the scene for two very tangible types of problem for us at the hospital: one sad and difficult and the other tragic and life threatening.
The first issue is that a number of unmarried pregnant women (frequently teenagers) will come to the hospital to deliver each week and then want to have their babies adopted. Sadly adoption is not a common practice in Ethiopian society (men will divorce a woman who appears incapable of bearing children-even though it may be due to a male problem & remarry rather than consider giving a home to someone else's child) so that the only option for true orphans is usually an orphanage of some kind.  The maternal mortality rate & low life expectancy for both men and women means that there are plenty of orphans although many will be taken in by the extended family.
Gimbi has a number (about 20) of orphan street boys (from babies through to early teens) who are cared for by one of the big-hearted long-term Faringe (Monica) who has created an orphanage by renting a room for them in the town. She pays someone to ensure that they are fed and receive clothing & basic medical care- I did ask what happened to the girls and was told that they are "taken in" by families and basically become unpaid servants. You see these orphans around and about in the town when you go to the market-they are distinctive as they invariably wear the same T-shirt (donated in batches) and unlike other children they do not ask for money or food as they are taught not to beg. As you are walking down the street you will feel a sticky, grubby hand slip into yours if you leave it dangling free-it is heart rendering that all they want is to walk the street holding hands with a grown-up like other children do all the time and will eventually decide it is time to go their own way without asking for anything more than this human contact. These children all have mother's who died in childbirth at the hospital and have extended families who unusually were unable to support them- the nearest proper orphanage is in Addis but unfortunately there is now a lot of "red-tape" to prevent child trafficking (and underhand practices in procuring children for adoption abroad) which means that it is very difficult to arrange transfer of a child from Gimbi to Addis.
In Ethiopia abandoning a baby is a crime, which is fortunate as otherwise it would be hard to prevent women with social issues leaving their babies with us but they know that attempts to trace them by the police and that this will only make the situation worse. However hard it may seem, the hospital is not an orphanage so we are not able to take the babies from them but there is a system of basic social work to try to help them financially to keep the baby.
The second problem is that "back-street" abortion is very common. We saw a pregnant 17year old yesterday who came to the outpatient clinic bleeding, doubled over with severe abdominal pain and also with a high fever. Initially she claimed she was miscarrying spontaneously but on questioning admitted she had seen a village woman and had undergone a procedure to "bring on" the miscarriage- details beyond this are sketchy as the girl herself was not really sure what had been done.  Examination & a scan showed that she had not "miscarried" completely and suggested that there was either a serious infection in her abdomen or that the uterus had been perforated during whatever probably non-sterile "operation" had taken place.
We arranged for her to be admitted for high dose intravenous antibiotics and planned to open her abdomen later in the day to view & repair any damage that had been done (this could be done by a key-hole surgery procedure in the UK but here the only option is to do a large operation).  Unfortunately without the knowledge of any of the doctors, she was sent by the ward staff to pay a deposit for her treatment (these sort of procedures are classified as gynaecology and so does not technically get covered by the Safe Birth Fund). We don't know what happened but after a discussion with the cashier about the cost she left the hospital-it is possible that she is younger than 17 and unlikely that her parents know so she has no access to money. The chances that she will survive without medical treatment are slim and certainly if by some miracle she does pull through she will be unlikely to ever fall pregnant again (this is unlikely even if we had been able to treat her). Tracing patients here is very difficult and doing it quickly is almost impossible as we do not have a specific address for them with only the name of the Kebele they come from (a sort of village district) recorded, which for her is about 2-hours from here. Someone has been sent out to her Kebele on the hospital motorcycle this morning to try to find her and bring her back (we can worry about the funding later) but as yet there has been no word- as her condition is "sensitive" enquiry is going to be difficult anyway.
When I was out at the rural clinic in Muggi I took a photograph of a poster that I thought was rather macabre- it is a drawing depicting a young woman undergoing a "bloody" non-specific procedure in a village hut by a older woman in traditional dress with a skeleton "grim reaper" figure looking over her shoulder- the caption read "Backyard abortion-threatens lives". I now realise that such a stark warning is very necessary here.
 

Thursday 4 March 2010

Much better than a box of chocolates.......................

March 4th
 
Into my final month in Gimbi- I can hardly believe I have been here for 8 weeks and now have only 3 weeks until I go back to Addis to meet Mark for our holiday travelling in Ethiopia- There is so much to do here that sometimes the bit that I can do really does feel like a drop in the ocean (a phrase from my original fundraising statement)- so it is reassuring to have some confirmation that what you have done has made a difference to the life of a woman (as how ever much we feel we can soldier on regardless positive feedback always feels good).
In the future some epidemiologist is going to struggle to work out why there is a  localised popularity of the name "Leonie" in South London and the "Leonies" so often had premature or other  problem births  but it will create a bit of academic interest. You will be relieved to hear that so far no Ethiopian girls have been named after me here but I did get the opportunity to name a boy born in Gimbi this week.
It was the mother's first pregnancy and thankfully as she has a relative who works at the hospital she chose to come to hospital to give birth (this is unusual as the majority of women with apparently uncomplicated pregnancies will deliver at home with only a traditional birth attendant or a female relative to care for them) . I say thankfully as although she had a quick labour and a normal birth of her son (who was a healthy 3.9kg-huge by Ethiopian standards) she proceeded to have an unexpected and very severe post-partum haemorrhage (loosing almost 2lires of blood). In the UK about 5-10% of women have increased bleeding after delivery (but most of these are still much less than 2litres) and this was one area that I was expecting to be a big problem here due to the lack of transfusion and the fact that women have lots of babies (which increases the chances of a haemorrhage even more) but the rate of haemorrhage for reasons I cannot fathom is much lower than the UK in our hospital (I've wondered whether it is genetic that women have uteruses that contract better after delivery  due to "natural selection" or maybe that it is something to do with the altitude making blood "thicker"- neither theory has any foundation in medical fact that I am aware of but my resources fro research are non-existent at the moment).
The midwives here called me very promptly but by the time I arrived she had already lost a lot of blood. We worked quickly in stopping her bleeding (compressing the uterus to make it stop immediately & giving drugs to ensure it stayed contracted), resuscitated her and lined her relatives up to donate blood to transfuse to her. The midwives were fantastic and followed every direction I gave promptly, working together as a team. Throughout the woman herself appeared calm in spite of the fact that my limited vocabulary in Oromifa was definitely not sufficient to explain what was happening, to give her much reassurance. Or to apologise for the discomfort that treatment inevitably causes in such an urgent situation.
As things calmed down and came under control I asked the midwife to apologise if I had hurt her (any kind of apology is not typical behaviour amongst Ethiopian doctors and midwives but they have learned to humour the strange habits of foreign doctors) and I also suggested that we brought her baby to her and put him to the breast as this also helps the uterus to remain contracted preventing further bleeding. The midwives were not absolutely convinced that breast feeding was appropriate at this time as when there are problems with the mother the immediate response here is to put the baby to one side often for a number of hours but I persisted, explaining that it would be beneficial for both of them and they slightly reluctantly agreed to do as I suggested.
She was delighted to have her baby brought to her and my efforts were rewarded with that wonderful Ethiopian smile from her and a baby that latched on quickly and was equally contented.
In the UK we are perhaps a little complacent about blood loss as we know that we can get blood cross-matched easily and have a large selection of drugs to try to ensure the bleeding stops but in her case I decided to stay around a little while to ensure the bleeding really had stopped as I was still not certain we would get blood (we did get two units donated by her family) and I had given her both the drugs we possess to stop haemorrhage (the next sep here is hysterectomy as you can't afford to waste time and allow a woman to become seriously compromised).
After 20-minutes I was happy that all was going to be well - I communicated this to her and indicated that I would leave her in the care of the midwives. She responded by asking me a question in Oromifa which I asked the midwife to translate-"she is very grateful for your care and wishes you to name her baby" I was told. I smiled and declined, saying I didn't think I could do that as I didn't know Ethiopian names & their meanings well enough- "she doesn't mind & will call the baby by an English name in your honour" came the reply-it somehow didn't seem fair to call the baby Harold or Ernest or any of the other equally unsuitable names that flooded my mind at that moment as I realised that she was very serious about me naming the baby and also that she might be insulted if I declined the honour I had been offered. Fortunately I managed to remember that biblical names are popular here (& I knew that they are a Christian family) and so I suggested John as a boys name feeling it was unlikely to cause any offence now or in the future. She was very happy with the suggestion and so he was named Johannes, the Oromifa translation of John
Johannes and his mother were discharged home this morning both doing well- in the UK I might have received a card or a box of chocolates but the honour of naming a family's first born son will live on as a memory for me beyond any such material thank-you.