Leonie's trip to Ethiopia

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

2010-04-12T22:17:00.001-07:00

12^th 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!

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

2010-04-11T13:12:00.001-07:00

11^th 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 11^th 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 16-18^th 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!

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

2010-04-03T12:57:00.001-07:00

26^th 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.

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

2010-03-27T21:01:00.001-07:00

March 24^th

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.

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

2010-03-24T03:22:00.001-07:00

March 23^rd

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.

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

2010-03-20T05:43:00.001-07:00

March 20^th

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!

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

2010-03-17T05:16:00.000-07:00

March 16^th

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.

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

2010-03-14T06:50:00.001-07:00

March 14^th

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.

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

2010-03-12T02:52:00.000-08:00

March 12^th

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.

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

2010-03-08T01:06:00.000-08:00

March 8^th

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!

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

2010-03-06T20:58:00.001-08:00

March 7^th

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.

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

2010-03-04T05:33:00.000-08:00

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.

Tidying up & rethinking the location-specific implication of Down's syndrome...............

2010-02-28T21:59:00.001-08:00

February 28^th

Believe it or not Friday was another public holiday in Ethiopia (3 in my stay so far & another on tuesday)-it was a Muslim holiday, most people seem to think that it was to celebrate the birth of Prophet Mohammed but no one is absolutely certain and my Bradt guide has failed me as for once this holiday is not listed. That a predominantly Orthodox Christian country should have Muslim public holidays is a testament to the apparent peaceful co-existence of Muslims and Christians here with no evidence of any of the cultural tensions sadly so common in more developed countries.

This holiday meant that there was no outpatient clinic to occupy my time in the morning and there were no women in labour either so I decided it was time to force a tidying of the labour & delivery room (Mark knows to his cost that leaving me with unexpected time on my hands is likely to prompt me to embark on some sort of "clear out" exercise). The lack of resources results in a reluctance to throw anything away which is laudable until the place is so full of items saved for a "rainy day" that finding the things you actually need becomes difficult (and obviously in a hospital such items can become an infection hazard). There were a number of things that in spite of extensive enquiry no one could remember (if they ever knew) the function of, there were drugs & other packaged supplies that had expiry dates in the last century (in a country like Ethiopia there are reasons to be flexible in such matters but never with drugs that could become ineffective and even for other items there are limits!) and in addition to these things there were large numbers of stored empty boxes (just in case). I'm not absolutely sure what the midwives thought of the whole exercise (eccentric "Faringe" most likely) but they went along with it and only a few items that I threw away were retrieved from the bin!

Laundry is another area that was very chaotic in the delivery room and I felt a bit like Florence Nightingale must have, as I insisted that everything was pulled out of the cupboards prior to being sorted, folded and then being returned to the cupboards in orderly piles- allowing things to be found more easily. Unfortunately this order also made it much more obvious what a severe shortage there is of linen there is as folded neatly it looks a lot less. I use the term linen very loosely- it compromises: 1) large plastic aprons (for the midwives and doctors to wear to save their scrubs or clothing during delivery- rarely with both neck band and ties but I have learned how to tie an apron very effectively with only a single string), 2) a very small number of gowns for women who require caesarean section (fortunately we rarely do more than 3 per day), 3) plastic aprons now devoid of any strings that will serve on for anything requiring a waterproof sheet (with a selection of other plastic "tarpaulins"), 4) pieces of sheeting (we might also use the term rags!) in a variety of sizes that are multi-purpose from wrapping babies after delivery, to cleaning mothers or surfaces or more rarely as a dignity cover for a mother- these are all carefully laundered in spite of the fact that some of them have more hole than cloth! and finally 5) rectangular pieces of thick plastic that are used to cover the delivery beds. Describing this I realise how much I have moved on as when I first arrived the bleakness of these items was shocking but 2 months on I realise that although newer & less thread-bear items would be nicer, patients care is not materially affected by them as they are carefully, regularly and well cleaned The stationary supply was also in chaos with a shortage of the items we use on all women and massive overstocking of items we use rarely (I can only conclude that someone enjoys photocopying). I was able to take 300 proformas for observation of women undergoing induction of labour to the Maternity Worldwide storeroom on the basis that we have induced no more than 10 women since I arrived at the hospital (5 years stock in circulation seems excessive).

So at the end of our efforts the delivery room is much more orderly with everything in an appropriate place- of course it now remains to be seen how long it will stay this way!

I was about to go for lunch when our first labouring woman of the day arrived. As is so often the case she had travelled from far and had been in labour since the previous evening. This was surprising (and immediately worrying) as it was her 6^th baby- with her five previous children having been born normally at home. The baby was alive with a normal heart-beat (as ever against the odds) and on feeling her abdomen it was unusually difficult to tell which way around the baby was, so I immediately assessed her internally and for a moment thought that she had a breech (bottom first) baby in advanced labour. However it didn't feel quite right and I realised that it was not a foot but a hand and not buttocks but the shoulder of the baby that I could feel. I hope that even the non-medical readers will be able to appreciate that a baby trying to exit shoulder first is not good- it being technically impossible & possibly causing the uterus to rupture as the labour is obstructed but the contractions remain very strong trying to overcome the obstruction (a bit like squeezing a toothpaste tube hard with the top on). We moved quickly to do deliver the baby by a caesarean section- this proved to be one of the more difficult caesarean deliveries I have ever done as the baby was sort of folded in half (head and feet up and the arm & shoulder down- not a very comfortable position even for a flexible fetus) making it very difficult to effectively unfold in order to allow delivery through the incision. Anyway I managed to deliver a live girl with a bit of a struggle (happy to explain to the details at a future date to the initiated or interested), resuscitated her as she was very floppy at birth (not sure if I've mentioned that if the baby needs more help than the midwife is able to give I have to leave the operation mid-way and resuscitate the baby, returning to the mother when the baby is stable) and returned to the mother repairing a bigger uterine incision than is usual for a caesarean section but thankfully without further complication or excessive bleeding.

I hadn't really had chance to look at the baby in closely during the resuscitation as I was keen to get back to her mother as quickly as possible but immediately after I finished the operation the midwife asked me to look at her again. She had a hugely swollen arm (easy to explain as that had been the front bit that was being pushed down the birth canal) and swollen legs and one side of her face (less easy to explain but I think the result of being folded and squeezed for a number of hours). However these were not what was concerning the midwife- who had noticed a typical facial appearance. I examined her and agreed that she has features strongly suggestive of Down's syndrome. Thankfully her heart appears to be normal, she also rapidly established breastfeeding suggesting she doesn't have any of the bowel abnormalities and the initial floppiness (which can be a feature of Down's syndrome) seems not to be very severe. I was worried about the future for a child with such a significant handicap in an environment where even normal children seem to struggle to survive.

On the ward round next morning I asked the midwife if anyone had explained to the mother that I thought that her baby has Down's syndrome (no blood tests available to confirm here- so clinical suspicions have to be acted on). The midwife shrugged and said what did I want to tell her as there is no Oromifa word for Down's (not absolutely sure even the midwife knew what we were talking about although there is a Down's syndrome orphan in Gimbi town). In the end we agreed she would tell her that this child would be different to her other children, that would require everyone in the family to encourage her by playing with her and helping her to learn to walk and talk. The mother accepted this without question and it made me realise that I must not to make assumptions based on my views of the world as a citizen of a developed country: in a society where few people can read or write, where the majority of people will do manual work and the extended family is very strong- being born with Down's syndrome is not the same handicap as is in the UK.

I won't be switching to General Practice in the foreseeable future......................

2010-02-26T09:10:00.000-08:00

February 25^th

Back from my clinic trip to Muggi and am now able to appreciate what a thriving metropolis Gimbi is by comparison. Also enjoying the feeling of knowing what I am doing in clinic and of having what now feels like a large diagnostic and therapeutic armamentarium in the hospital compared to a remote clinic.

Muggi is a very small town about 40km (as the crow flies much longer by road) from the border with Sudan and about 120km from Gimbi. Unfortunately only the first 15km are asphalt road and the rest is "gravel" so the journey there takes 5 hours. The countryside on the way is stunningly beautiful with rolling hillsides, traditional thatched circular hut villages (& one refugee tarpaulin camp with migrants from Sudan) and a lot of vegetation as it is at a slightly lower altitude than Gimbi. The lower elevation also means that this is the heart of coffee growing country and the clinic was held shortly after coffee harvest meaning that the local population were feeling relatively affluent and hence potentially keen to see to lingering health needs. The nearest large town to Muggi is called Dembi Dollo and this has a small government hospital but this is still an hours drive away. There is a very large town called Gambella about three hours drive further along the road towards the Sudanese border (which is not technically open fro crossing). Gamebella & the immediate surrounding area is the only part of Ethiopia that was a protectorate of anyone, as the British managed to make a stand there. This was because there is river access in the wet season that allows boats to pass all the way through to the Mediterranean and thus it was important for coffee supply (information courtesy of my knowledgeable husband). The boats ceased going some time ago and there is now a National Park in the area unfortunately if you look at the Foreign Office website Gambella is also the only area in Ethiopia with an advisory notice not to travel there so I was happy to stay three hours away.

Muggi is one of 6 out-reach clinics that the Adventist hospital runs- each clinic has a small staff (2 nurses, a guard/caretaker, a lab technician and a cleaner). This allows local people who live very far from a hospital to have some access to basic healthcare as the clinics carry basic drugs (for example painkillers, antibiotics, TB & malaria treatment). As there are limits to the things that the nurses feel able to manage, the hospital tries to send doctors out to the clinics every few months with the trips advertised in advance so that the patients can attend for review if the wish. Unfortunately it is often difficult to find doctors to go as they are needed at the hospital so on this trip it was myself (theoretically advertised in advance as someone coming to see obstetric and gynaecology patients) and Daisy who is a very competent final year medical student from Edinburgh doing an elective in Gimbi. Daisy had an advantage over me in that she has had the opportunity to spend some time in the medical outpatients at the hospital and so knows how to manage some of the common problems found in Gimbi and the surrounding areas.

In spite of the "advertising" there were few obstetric and gynaecology patients came to clinic over the two days. This was a great disappointment to me as there must be lots of pregnant women in Muggi and the surrounding area (people travelled from significant distances to the clinic) and it seems unlikely that they are all well, low risk and experiencing no pregnancy complications! As one of the important strategies in reducing maternal mortality is to try to identify risk and recommend delivery in hospital (this would have been Dembi Dollo Government hospital rather than Gimbi) I had hoped in some small way to help- but it was not to be the case on this occasion. Instead I became a "bush" GP- I'm afraid I wimped out and declined to see men (22years of specialisation means that there are some things that are just too foreign to me now and the first man I was offered had "swollen testicle"- "to Daisy " was my response.), so I saw all the women (and children although there were remarkably few of these) and Daisy did a male clinic. Goitre (swelling of the thyroid) gland is endemic in the area due to the lack of iodine in the soil and about a third of consultations were for this problem. The remainder were a mixture of joint pains, abdominal symptoms and the occasional lump and bump. I sat with my Oxford textbook of Tropical medicine to hand but no one seemed to have TB and although I requested a few blood films for malaria all were negative. I will always wonder if I missed some other rare and fascinating tropical disease but if I did the presentation was subtle.

One good point is that the women here & especially in Muggi (it would be different in Addis) never smoke or drink. However the bad point is that many of the problems I saw are largely intractable as they are related to poor nutrition (constipation due to poor fibre, headaches due to the lack of fluid) and to the field work that women do here carrying heavy loads from dawn until dusk resulting in knee & back pain. This can also create difficulties as there is a great desire for investigations and prescriptions amongst the patients regardless of their problem and the administration of basic "life-style" advice can leave them dissatisfied with their clinic visit. One consultation exemplified this well- a 17year old came in and declared that she has swollen and painful feet. In order to examine her feet, I asked that she remove her shoes (in Ethiopia the majority of people do wear shoes usually made of single piece of moulded plastic, rather than flip-flops or going barefoot as is the case in many other poor countries). As she struggled to remove her shoes it was clear that they were not only about three sizes too small (perfect imprint of the shoe remained on her foot after removal) but they were also ridiculously pointed (like the ones I wear albeit in the correct size for reasons of female vanity for brief periods when I will not be required to walk far) and although slim she had broad feet. I naively asked whether she had other shoes fully knowing the answer without a real need for a response. I gently explained that her problems were because she had outgrown her shoes and that these were an unsuitable shape for her feet. This was translated was followed by an exchange of some length between her and the interpreter. Eventually I interrupted & enquired as to the nature of the conversation and was told, "she wanted me to prescribe something to cure her tight shoes". I tried to point out that the cost of any prescription (if I were to have an Alice in Wonderland "drink-me" solution to shrink her growing feet) would be more than the cost of going to the market and purchasing new, bigger and broader shoes.

We stayed in a small hotel opposite the clinic which was basic (and this is not English understatement) but then it only cost 20burr (£1) for the room that I shared with Daisy so it would seem unreasonable to expect more than a double bed, relative cleanliness (no roaches seen) and a plastic wash bowl with water from a canister in the communal wash cubicle (the toilet is best left without description but suffice to say I have used worse in French railway stations). Any way it was sufficient to clean up after the journey (very dusty) and for a good nights rest (braying donkey and 5am prayer call aside). We had brought sleeping bags and didn't inspect the sheets too closely but it seems unlikely the room rate included regular laundry. The room also had a bare electric light bulb and a candle but we made more use of the latter as there was only electricity for 3 hours of our 48hours in Muggi- some towns are not more atmospheric by candle light. Anyway the fact that I survived my two nights in this hotel should stop Illona (our travel agent at Steppes Travel who is arranging our trip at the end of my time in Gimbi) worrying about whether we are tough enough to cope with the two star hotels we will be staying in for some of the trip.

We returned to Gimbi (along the same beautiful but bumpy road) slightly earlier than originally planned as the initial torrent of patients dried up by lunchtime on the second day and the symptoms were becoming less serious (if you have a genuine problem you come as soon as possible on the first day) and also more bizarre (my interpreter declined to translate to me when amongst an array of other symptoms one women said "she believed that she was being nibbled by cats" suggesting instead that I might break my non-prescribing rule just to get her out of the clinic room). In total I saw 64 patient- the four O&G cases I was well qualified to deal with and thankfully on reflection I don't feel I missed anything serious or did anything too harmful to the other 60 who technically I am less qualified to deal with.

I always have had an enormous respect for GPs, as doing a good job is stressful and difficult. So my experience in Muggi has consolidated this opinion and made me absolutely certain that I made the right career choice!

Feeling a welcome guest..................

2010-02-21T09:00:00.000-08:00

February 21^st

A short interval from my last blog but making up for lost time last week and also for the fact that my next posting after today will be on Friday at the earliest as tomorrow I am going off to a distant outside clinic to spend three days returning on Thursday evening. Not exactly sure what I will be doing in this clinic but I am sure it will be interesting as I seem to be the only doctor going so I will be packing my tropical medicine book!

I suspect that Gimbi is going to feel like a massive metropolis compared to where I will be for the next few days but in fact it is far from that: the town is rather like those that exist in Western (i.e. cowboy) movies with everything revolving around the single road through the centre of the town. Gimbi begins slowly with increasing signs of habitation from the sign that says "Gimbi' on the road from Addis and gradually peters out at some unmarked point on the road towards Assossa and the Sudanese border (as Ethiopian road markings do not stretch to signage for the end of a town). The road through town is tarmacked (an improvement courtesy of the Chinese in the last two years) and there is a pavement of sorts on either side- I say of sorts as it is made of concrete blocks that like many things in Ethiopia probably had another life before becoming the pavement in Gimbi as the blocks have a metal ring embedded making them a little hazardous to walk along especially in darkness (there is only limited lighting in the evenings). As a result most people choose to walk in the road in spite of the hazard that through traffic doesn't slow much as it passes through town and the minibuses may pull into the edge as any time expecting the paedestrians to move rapidly out of their way. There is some unspoken rule that there is a "one-way" system so that you walk into town on one side of the road and back from town on the other side. This means that you need to be organised as shopping around for an item can increase the hazard by requiring more crossing of the road multiple times so in general the shops on the side of the road on the out-bound trip tend to do better business from me than the shops on the other return side but I assume it all works out as there must be people coming from the other end of town in the opposite direction.

The road from the hospital (we are at the Assossa end of town just off the main road) to the market is a distance of about a mile, it does take 20-30minutes to walk there due to the need to detour around cows, sheep, goats and groups of people who gather along the roadside to pass the time of day. The market is not like the one of your imagination as it is all at ground level with everyone laying out their produce on mats, this in itself creates problems as it is not an entirely satisfactory solution to selling given the free range goats and it requires constant vigilance on the part of the seller not to lose a proportion of their stock to these wily & persistent animals. Remarkably the mats seem to be laid out in the same places from one day to the next so that there must be some rules about ownership of a particular pitch. This is useful as it means you can have a reasonable idea of where to find the things you are looking for. There are also a number of shops described as "supermarkets" but this is nothing like what we mean by a supermarket and simply describes a small shop in the ground floor of a building that opens onto the street (in a stall like fashion) selling dry goods, all these supermarkets sell similar things and there is no price differential so everyone tends to find their favourite places and stick with them.

Going into town is an experience designed to remind you (in case you had forgotten) that you are different to everyone else around: Calls of "faringe,faringe"or "you , you" abound from adults and children alike as you walk along, more unusually "china, china" is also called out (foreigners all looking the same and Chinese road builder's having been here in large numbers in the recent past). However these calls are always made in a friendly way (albeit it can get slightly wearing) and the wonderful smiles you receive from everyone make this very clear that you are a always a welcome guest in their town.

Sorry about the inability to accept comments on my blog

2010-02-20T03:52:00.001-08:00

Just a quick note and an apology for any of you have tried to post comments but failed. Unfortunately I am unable to access my blog directly online as the Ethiopian filters block all blogspot sites- thankfully I have a way of email my postings to the site but this doesn't allow me to review the comments you try to post and the site will only accept them if I accept them first (to stop malicious comments I assume).

Email is better than I ever expected (although requiring perseverance and patience) so always delighted to receive a message to lkpenna@aol.com if you want to comment on something.

Always remember to look at the bigger picture.................

2010-02-20T03:45:00.001-08:00

February 20^th

I travelled back to Gimbi on Wednesday, thankfully having a safe and uneventful trip (only two accidents observed on the roadside this time!). The second half of my trip is going to be different to the first half as I now have a housemate (Marie who is the midwife from Denmark) as well as sharing the on-call with Steve (American ObGy who is here from Australia where he now lives). It has made me realise that I had settled into a slightly solitary existence with a lot of time spent writing journal, blog and emails as well as reading. Currently Camilla & Sycret (journalists) are also staying in the Maternity Worldwide bungalows (sharing with Steve) so meals in particular have become a sociable affair compared to my previous meals for one. Another change is that there are now people who are keen to accompany me into town for a beer after work so this aspect of my detox diet is going to be much less severe in this half of the trip.

So back to business- I was on call yesterday and had my busiest and also saddest night on duty since I arrived. I think that I finally realised yesterday that although the obstetrics in many ways appears the same as in the UK, in fact we are playing by a completely different set of rules (and unfortunately sometimes it feels like they have forgotten to give me a copy of the new rule book).

I know that it was inevitable that it would happen eventually but yesterday we had our first maternal death since I have been here- the inevitability has done nothing to make the sense of helplessness any less. When I arrive here one of the other "fairnge" said to me to remember not to take it personally as "people die very easily here", perhaps true and good advice but when it happens still not easy to heed.

The mother was 18 years old and in her first pregnancy. The case is a double tragedy as although the baby is currently alive, he too will die in the next few days as he has suffered severe brain damage due to lack of oxygen during his birth. The mother was from one of the tribal villages some distance from the hospital and she laboured at home for many hours before going to a local clinic for help. There are a number of peripheral clinics that are administered and staffed by the hospital but there are no doctors (or midwives) in these remote locations and the nurses who work there have to do the best that they can to help given their limited experience and resources. At the clinic they had tried unsuccessfully to help the baby deliver using suction equipment (something used more commonly than forceps as it is much safer for the mother) and so transferred her to Gimbi for further management. The transfer took a few more hours, amazingly the baby was still alive when she arrived and so she was assessed and delivered by a caesarean section (all this occurred whilst I was in Addis). The caesarean all seemed uncomplicated (although this sort of caesarean is always difficult as the baby's head is very deep and impacted in the pelvis) and the baby resuscitated easily. The next day it was clear from the baby's posture/behaviour that he had severe brain damage with the result that he was unable to swallow at all. This was "discussed" with the parents and the plan made was to allow the natural course of events to occur and not to give the baby tube feeding (directly into his stomach) which overall would just prolong the inevitable. All this was all tragic enough when the mother, who had seemed well on that first morning became severely unwell and deteriorated at an alarming rate- all her clinical signs suggested that she had a severe infection. We managed her overnight with the strongest antibiotics that we have here but by the next day she was critically ill and Tekle (local obstetrician) made the decision that we must operate on her again to see if we could find the cause of her infection. The expectation had been that we would find some problem related to her bowel but at operation we found that her uterus was the cause of the infection, as for reasons impossible to explain it had become ischaemic (this means the blood supply was cut off to it and as a result the tissues die). A rapid hysterectomy was performed and we continued with the antibiotics, fluids, blood transfusion (donated by "faringes" as no family were available due to the distance), oxygen and the basic monitoring that we can do here. In the West she would have been immediately admitted to a high-level intensive care unit, kept ventilated, received high tech monitoring and multiple drugs to stabilise her heart, kidney and lung function not to mention specialist transfusions to keep her blood count and clotting as normal as possible.

She was young and her body fought hard to try to recover although she never regained consciousness. Sadly by 11pm she was showing signs that her lungs were failing and also that her blood was no longer clotting properly, forcing me to accept that there was no more that I could do and that it was only a matter of time until she died. She was restless and possibly in pain so I gave her a very small dose of painkiller, avoiding a larger more effective dose as I was obviously not completely accepting what was going to happen didn't want to depress her breathing any further.

Bizarrely although she died in the early hours of the morning, this is so much accepted as a "normal" event here that the midwives didn't call me to see her again or even to certify her death (a legal requirement in the UK). In the UK all deaths of women who are pregnant or have been pregnant in the last 12-months have to be reported (in addition to the normal death registration) there is no such system in Ethiopia -death recording happens within the hospital but no other notification is required. Sorry for the sad detail but this is a partially cathartic exercise for me!

On the face of it not a very uplifting blog but I have to remember the bigger picture: although I keep thinking that we should have been able to do more for this particular woman, I push these feelings away by reminding myself that before the arrival of Maternity Worldwide in Gimbi the maternal mortality rate was 6% (now about 1%)- this would have meant 12 deaths in the time period I have been here so that however inadequate it may feel, something we do is saving lives.

I apologise for this entirely necessary weekend of self indulgence.......

2010-02-15T09:49:00.000-08:00

February 15^th

So the weekend that I seem to have been waiting for ever since I arrived in Ethiopia has been and gone in a flash.

Thankfully my journey back to Addis was uneventful although longer (11-hours) as the four-wheel drive vehicle is still under repair having had a close encounter with an ox some weeks ago (new part are slow to arrive and body-work repair takes forever I am told) so a different driver with a sturdy but slow mini-bus was enlisted to deliver me to my destination. Doing the journey as the only passenger in a minibus created a new feeling of guilt about being well off in a very poor country as almost all minibuses on the road are a stopping bus/taxi service and are overflowing with people and cargo. In spite of the fact that the bus was a different colour to the usual stopping services (all taxis and buses are painted blue and white which I assume must be some sort of regulation as it is so strictly adhered to in Addis, Gimbi and all the places in between), people constantly ran to the roadside and tried to flag us down throughout the journey and seemed disappointed that we didn't stop for them and their goats, fire wood bundles, numerous water canisters or whatever else they were transporting.

The second piece of transport good news was that Mark's flight on Air Ethiopia arrived on time rather than encountering some sort of delay for which the airline is notorious. Unfortunately the website I was tracking the flight arrival time on seems to have gone on past performance and so showed the flight as arriving 20 minutes late rather than the 30-minutes early that was the reality- this resulted in me not being there to meet him as he sped through immigration (multiple entry tourist visa obtained in advance), bank (he assumed incorrectly I would have money), baggage collection (terminal 5 could learn a thing or two from the baggage handling in Bole international airport which is very fast) and customs (he seems to have walked so fast no-one managed to stop him to try to interview him about the bit of obstetric equipment in his bag lucky as on questioning he would have been forced to reveal he had not the foggiest clue about purpose) and got from the gate to the arrivals area in 15minutes. Thankfully his initial grumpiness as documented in a series of "where are you?" texts (and an accusation that I appeared to be living on "Ethiopian" time schedules already) quickly disappeared once I arrived in person.

We had a great weekend, relaxing together, getting uncharacteristically rather sun-burned (never under-estimate the equatorial sun even when cloudy), swimming, eating good food, drinking goodish wines, pretending to do a bit of culture with one museum visit to see "Lucy", the replica skeleton of a 3million year old biped, lost-link ancestor found in Ethiopia and of course filling one another in on the events in both our lives over the last six weeks (there was plenty to tell on both sides describing very different life styles resulting in virtually non-stop talking for 2-days). The only problem of course was that like all much anticipated good things it all passed far too quickly. I have also enjoyed soaking in a bath (rather than my hand-held shower), having a massage, wearing clothes other than "scrubs" for a few days, having clean feet rather than red from the Gimbi dust, sleeping in a bed with a proper mattress & bedding and abandoning my detox diet for a few days with meat, red wine/G&Ts (definitely out of practice) and chocolate! Mark has also supplied me with a number of food special requests (like pesto, parmesan and mayonnaise) that should ensure I lose less weight in the second half of my trip that I have in the first six weeks.

So Mark flew back this morning (brief return of home-sickness but I pulled myself together) and I have a couple more days in Addis before the journey to Gimbi on Wednesday in the company of Marie, a new midwife (arriving for a 9-month stay at the hospital) and two journalists (arriving for a 1-2week stay)-all from Denmark where there is the another branch of Maternity Worldwide.

I expect to be back in the thick of it on Thursday and so will resume my blog with more interesting & charitable tales of others rather than the self-indulgence described in this posting!

A time for reflection (and a hug & a glass of red wine)................................

2010-02-11T05:35:00.001-08:00

February 11^th

Tomorrow I will do the 10-hour journey again to Addis in order to be there on Saturday morning when Mark's flight arrives from London bringing us together for a short weekend (he returns first thing on Monday morning). This weekend was a distant beacon of light, to look forward to in the first week when I was so very homesick but as I settled in I have sped towards it very rapidly. It was chosen as it is not only Valentine's day on Sunday but also is the weekend where I am exactly half way through my "working time" in Ethiopia (our planned holiday at the end would make it less than half way but I see this as a separate chapter in my journey here). Although I am sure I will continue to see new and challenging things and still have so much to learn about how to provide the best care with few resources, I thought that this would be a good time to reflect on my experiences over the last five weeks.

There are very many things that I have learned although these are rarely things that will be very useful to my clinical practice back home as the myriad of Health & Safety and infection control recommendation, not to mention risk management processes would take a dim view of many of the practices here.

Some of the things I have learned:

- That the Ethiopian pelvis is tricky and so babies get stuck more commonly.

- That the Epthiopian midwives despite relatively basic training manage amazingly well (although there are occasional short-falls in care that I feel are understandable though need work to try to avoid).

- That you can manage obstetric problems effectively with a lot less resources than I would ever have believed possible (we only have a choice of five antibiotics here compared to dozens in the UK).

- That fortunately I was well trained in gynaecology and so after 12-years I managed to drag the skills and knowledge out of storage and back into use.

- That yet again I wish I had done neonates when I was training but that even a relatively old dog can learn new tricks when put through immersion/flooding therapy.

- The importance of avoiding waste and considering a second life for many items that we usually throw away (more about this in a future blog).

- That I never want to work anywhere with anything other than a state funded Healthcare system (a controversial statement I realise- but completely heart-felt).

- How people appear happy in spite of adversity- often of the worst type I can imagine.

- How easily a full term babies can get sick and die and how unlikely to survive even a slightly premature baby is (the first lottery we unknowingly enter with the winners fortunate enough to be born on a developed country)

- On a personal level how easily you can adjust to having less comfort than you are used to without any detriment to real happiness (although this is not a hardship experience by any means).

- That I can manage without a glass of wine at the end of a busy day (however reluctantly).

- How well you can feel on a diet of vegetables, beans and pulses (but no epiphany here I'm afraid as I do miss meat and chocolate).

I am plan to continue my blog which more than anything I intended as a permanent memoire for me but I have been heartened by the messages from friends & family who are following it and finding it interesting. There is still so much to tell as I have written little about the wonderful people with their cheerful fortitude or of the complexities of the Oromifa & Amharic languages, or of Gimbi town itself and the surrounding countryside, of the pitfalls of an Ethiopian outpatient consultation (which I am still learning to avoid) or the terrible perinatal mortality rate and the response of local people to it- so I have plenty of things that I want to write down and that is before I write about any of the interesting cases I manage on a day to day basis.

The pargmatism that comes with being poor....................

2010-02-08T05:00:00.000-08:00

February 8^th

Sometimes it is frustrating here as even though we can too our bit obstetrically, other resources are so limited that it is not enough to avoid tragic outcomes.

This week a young 18year old was admitted in labour. She was an amazingly beautiful woman from a tribal area about 3-hours drive from Gimbie. The people are ethnically distinct tall; slim with perfect erect posture and ebony skin. They practice skin scarification, which is not just on the face but also all over the chest and abdomen and was particularly beautiful in this woman (I am told that the practice is now disappearing as more "education" occurs in the tribes).

She had been in labour for 3-days and had travelled many hours to get here walking part of the way due to lack of transport. On arrival the baby was still alive and seemed to be in reasonable shape (compared to many). The baby did not feel particularly big but that is not particularly unusual as the narrow diameter of the pelvis (from back to front) that exists in women here means that there can be problem during birth even if a small baby is not in the ideal position. However when I examined this woman although the labour was obstructed and she was not fully dilated it felt different to other seemingly similar situations that I have managed here. Being a scan doctor when faced with anything seemingly unusual the natural response is to do a scan, which is what I did. The scan revealed that the baby had a lot of fluid on the brain (hydrocephalus) making the head so big that it would be impossible for the baby to deliver through any pelvis. Sadly I was also suspicious that the brain development might already have been affected. Sometimes operations are performed here when babies have died during the labour to decompress the head so that the mother can avoid the morbidity of a caesarean section and deliver vaginally. In this case this was not an option as the baby was alive and also the head was in a position that this sort of operation can be associated with a lot of maternal complications and therefore could not be performed.

I delivered her by caesarean section, which was still a struggle to get the very large head to deliver. The baby was born in good condition and at birth required no resuscitation. It is definitely the worst case of hydrocephalus that I have ever seen. In the UK most cases like this would be found on the 20week scan and the majority of women would choose not to continue the pregnancy as the long-term prognosis for mental and physical handicap is very poor. Initially the baby handled well, she had a good suck reflex and so she breast fed well albeit she had classic textbook signs of severe hydrocephalus (an enlarged head & a sign called "sunset eyes" where the pressure of the fluid in the brain presses on the eye balls so that they are pushed downwards so that only upper half of the pupil is visible above the lower eye lid- hence the name of the sign) and a rather unusual high-pitched cry.

In the UK a brain scan would occur virtually immediately and then a special drain called a shunt would be inserted to relieve the pressure on the brain. There is no question of anything like that being done in Gimbie so any further treatment would have meant going to Addis but even this assumes that the family can afford to pay for treatment and that there is someone in Addis able to do the surgery. The family could not afford to pay but sometimes there are charitable funds to help with this sort of treatment available but unfortunately it all proved theoretical, as when he phoned around we could not find the details of a neurosurgeon able to undertake the surgery anyway.

In the meantime the tragedy-unfolded further: the woman is unmarried and the pregnancy was the result of a rape by a distant family member, this had been reported to the police (although I am told successful prosecutions are rare). By the 3^rd day of life the condition of the baby deteriorated significantly- she developed a high temperature, her head was getting bigger, she developed very abnormal postures/tone and was irritable with movements suggesting she was fitting whenever she was touched. The prognosis even if we could find immediate treatment for her was clearly very poor. So the pragmatism that poverty seems to promote took over, such that the woman unprompted (supported by her parents) asked if she could take her baby home to await the natural course of events. There was never any question of us disagreeing with this suggestion, as we had nothing further we were able to do so that we too were waiting for same outcome. Thus it seemed a small positiveto allow them to go home to the privacy & dignity not available in a public ward.

It's hard to believe my hand-writing could look any worse................

2010-02-05T07:36:00.001-08:00

February 5^th

Although the work in the labour ward is very rewarding, I have been looking for ways to add a more lasting value to maternity and the hospital in general. With this in mind I have agreed to teach a module to the 2^nd year students in the Gimbi hospital nursing school. I have to apologise that the module is known as the "OR module" rather than by its full title "Provision of pre, intra & post operative nursing care"- yet another Americanism but entirely understandable as the theatres here are known as the OR (Operating Room).

There are a number of nursing schools in Gimbi and unfortunately some of them work on the principle that if you pay a fee you should get a diploma with no emphasis/requirement that this process involves learning anything. This can result in a poor standard of nurses applying for positions in the hospital and it can be difficult to tell. A good from a bad diploma .I should also point out that the midwives I might have written about in previous blogs are not midwives in the way we think of midwives, but are nurses (usually the brightest and best) who through sponsorship by Maternity Worldwide have been able to do a short course on midwifery to give them more understanding of labour and delivery. Thus having a poor quality of nurses will result in problems finding the midwives of the future for Gimbi.

To try to circumvent this problem the hospital decided to set up it's own nursing school where a better quality of graduate could be guaranteed and through donations specifically for this purpose to Adventist International they are in the process of building a new brand new school although classes have been running for three years in older buildings. The fees charged for the hospital school are low compared to most schools and it is made clear to applicants and to the students at all stages that in order to graduate both attendance and performance are required. The presence of a school also allows the hospital to sponsor people who come to work as practical workers (similar to what are called healthcare assistants in the UK) and are good at their job.

However I am told, there have been stormy times over the past two years with occasional small student rebellions over the high expectations of the school. The last one was over anatomy textbooks provided for each of them by a previous"faringe" lecturer that they were expected to read. It required the head of the hospital to explain to them the reasons for the school wanting them to have real knowledge and skills (the argument is strengthened by the fact that currently Ethiopia is producing a lot of nursing graduates and there are unlikely to be jobs for all of them). A refund was offered to students who wanted to leave. Three students chose to leave and all are known to have enrolled in the worst "diploma for cash" school (where 2-hour lessons last 15minutes) so all in all everyone is happy!

There is a requirement from the Ethiopian Government that the course is taught in English and they also set a detail curriculum (which at this school is followed properly). My module is sixteen 2-hour lessons which as this is not an area where I can "wing" it, require quite a lot of lesson prep but I am learning all sorts of things I probably should have known about such as infection control and other topics. Teaching the students here is very hard work. Their education to this point has been "Victorian- style" i.e. teacher stand by black-board and writes list, student memorises list and recounts with no requirement for understanding or any encouragement of any sort of creative thinking or problem solving. Unfortunately being a good nurse doesn't require list memorisation but the ability to problem solve and particularly to do this in a rapid way and also in the face of a rapidly evolving clinical deterioration. I am drawing on every resource from my "Teaching the teachers" courses to try to engage them, get them to interact and to engender thinking behaviour rather than rote learning. Add to this the very mixed ability in English and sometimes the problems can feel insurmountable but I am not one to be beaten and I take solace from the fact that although I am not sure how much is going in, they all in their different ways seem to be enjoying the classes (done 4 now) and the attendance is better than I would expect from students in the UK.

If I learn nothing else it will be an appreciation of my medical students in London who can be persuaded to think and actually object to having to rote learn. It has also reminded to me that bad handwriting looks even worse in cheap chalk on a blackboard.

Is there any option but to go along with it?........................

2010-02-02T07:54:00.001-08:00

February 2^nd

So I am into my second month in Ethiopia (both in calendar terms and also this is day 29 of my trip). There are so many things to write about that it is always difficult to know where to start but I have decided that today I will write about the wards.

The wards are strictly single sex (well this is as far as patients go) which considering there are no curtains between the beds in the ward at all it would seem just as well. The men's ward is on one floor and the women's ward (where the women I look after are cared for is on the floor below next to the four bedded labour and delivery area). There are officially 29 beds but extra beds often supplement this number as the solution to capacity issues is very simple - they just bring more beds into the ward (if only addressing capacity were so simple in the UK!). The beds are very close together with barely enough space to get along side them to examine the patient especially at the times when extra beds have been brought in. The ward takes maternity, gynaecology, surgical and medical patients. This is an issue as the medical women may be having treatment for TB or other infectious diseases, which is a significant risk for a newborn baby. There are three bays and the nurses are strict about ensuring that the majority of mothers and babies are in the first bay and the majority of medical women are in the third bay with the second bay being the first place for surgical and gynaecology women, this creates some barrier but of course women and babies do go into bay 2 when it is busy.

The ward is full already but then visitors swell the numbers. further These people are entirely necessary as they provide care for their sick relative in helping them mobilise to the toilet, washing and feeding (the nurses do not expect to or have time to provide this sort of care and there are no Physios or OTs here). The relatives also go to the market and purchase food for the women (a very rudimentary ration is provided twice a day by the hospital which makes NHS portions look positively generous) and will also go to pharmacy to purchase drugs & IV fluids that are prescribed (if they are not a maternity patient with a voucher). The other issue for visitors is that home may be many hours away and although there are hotels in town the chances that they can afford a hotel and the hospital charges for their relative are slim. Thus the relatives are present all day and all night. Going to the ward after 10pm is a source of amusement to me as there will be at least two people but often three people in every bed with additional people sleeping on the floor and on the benches in the communal areas outside the ward. I should point out that there are no cots for babies and these sleep in bed with the mother as well as the other relatives. Fortunately as previously described Ethiopian people are lean or otherwise there might be more issues related to these sleeping arrangements (sadly we did have a healthy baby die in the night 2-weeks ago as the mother accidentally rolled on to it in her sleep).

There is a clean sheet and blanket provided for each bed on admission by the hospital (well most of the time-unfortunately there are significant issues of linen going "missing" in the laundry so that it is not uncommon to run out.) Due to the fact that these are donated from a variety of sources I am not sure I have ever seen two sheets or blankets the same yet (or a sheet without holes). Add to this the fact that all the beds are different (many over 20years old but still with working back rests and raising mechanisms- they don't make them like that any more) and it does mean that the ward have that slightly disorganised appearance reminiscent of the pretend- hospitals I used to create as a child, when the beds & covers for my doll patients were whatever I could get hold of.

The biggest issue on the ward that I still find difficult to deal with on a day-day basis is the lack of privacy for the women. At ward round times all the visitors are banished from the ward (and they obey unquestioningly) and the doors are locked but at any of the windows there will be a crowd of faces peering in. There are curtains but these are rudimentary and certainly do not stop every prying eye. On the ward round "intimate" examinations (I will leave to your imaginations as you know I look after obstetric and gynaecology patients) may be undertaken which the women seem to accept as entirely normal without any concern for who is watching. These sort of procedures also occur outside the ward rounds when the ward may be full of visitors and no one seems to think it inappropriate to carry on. The nurses have got used to the fact that other than in an emergency I will take the woman into one of the obstetric observation beds to be examined where there will be a maximum of one other woman (and no visitors) present during the procedure, however they clearly consider it rather eccentric and unnecessary.

I realise this lack of privacy and dignity all poses an ethical question about my being complicit in perpetuating this behaviour but given the ward environment there doesn't seem to be any option other than to go along with it . There is no doubt the women consent to be examined in this way never showing any hesitation but I suspect that they feel like me that there is no option that to go along with it and unlike me they do not know that anything else is possible.

Anyone for Valpolicella and lentils?.........

2010-01-30T00:31:00.001-08:00

January 30^th

I mentioned previously that the diet here can be poor and it takes effort to ensure you eat properly. The local people vary in body shape due to different tribal origins but the one thing that they have in common is that they are all extremely lean. The average weight of women in the antenatal clinic is 50kg (and they are often at quite an advanced stage of pregnancy). It does make the management of problems easier (you can feel which way round a baby is and scan with a much higher accuracy with no body fat) and certainly the anaesthetics are easier because all the women are so slim. In the UK we use an aid called a "Pat-slide" to move women off the operating table but thus far nothing has been needed to help move a patient (with the one exception where it was all hands on deck).

One effect of the diet is that iodine deficiency is very common and so goitres (a swelling in the neck due to an enlarged thyroid) are almost universal. Likewise although I have not seen it yet spinal bifida in newborn babies is more common due to lack of folate (there are no folate supplements recommended routinely here).

The poor diet is mainly a result of a lack of money to buy food but also the fact that the traditional diet is very low in fruit and vegetables (with calories/protein coming from a grain called Tef made into a rubbery unleven bread called injura, served with oily stews of meat or pulses). In fact the market has a good range of fresh produce depending on the season. Currently red onions, tomatoes, avocados, (with the largest stones you have ever seen but as they are only 1burr (5p) for 3, you are getting what you paid for) potatoes, carrots, bananas (2-types), oranges, limes (that they call lemons) and fantastic large papayas are plentiful and I am told these "staples" are available all year round. With quality and price varying according to how abundant they are. There are two green vegetables that you can get hold of the are both called "rafu" one is recognisable as a sort of white cabbage and the other is a bit like spring greens (but very bitter). You can also find pumpkin (sold in slices) and beetroot (unfortunately they discard to beet tops). I managed to get some green beans this week but these are seasonal and considered very expensive at 10burr (50p)/kg. The other problem for the local diet is that any fruit and vegetables they do eat are cooked for a long time, a habit I assume that developed to avoid food poisoning but unfortunately destroying important vitamins.

I have seen no evidence of meat in town but am told if you want it you can find it but that it is very tough by western standards. Ethiopians are meat eaters if and when they can afford it (they even eat raw beef with a resultant tape-worm problem). I made the decision to eat vegetarian in Gimbi (as I think it is easier to avoid stomach upsets) but I will be looking forward to a steak when I get to Addis in a couple of weeks.

My diet here is pretty healthy as unlike Ethiopians I am going out of my way to get a good variety of vegetables. One of the gardeners in the compound grows lettuce so it is even possible to have a carefully washed salad (lettuce, white cabbage, tomatoes, beetroot and avocado). I have also managed to find a number of different ways to cook all of the available vegetables, this is helped as chillies, and garlic and fresh ginger are also widely sold in the market. I have learned to like to lentils, which is fortunate as these are my main source of protein although there are also excellent (if very small) eggs available for baking and omelettes. I have a cook (Tadilho) who sadly doesn't seem to want to make Ethiopian food even occasionally however much I ask but I have persuaded her that chilli is fine and so her lentil stew (with extra added vegetables) is not quite a gourmet meal but something I can look forward to. She makes good (slightly sweet) bread and excellent carrot cake so this is preventing me from loosing a lot of weight. There is also no dairy available, which is a bit of a mystery since there are goats and cows galore roaming the streets of the town. If you want milk it comes in the form of dried "Nido" (the wonderful Nestle monopoly on the African market means that a small tin that makes 10lites of milk is 140burr-£7, which is a fortune here in real terms). So I use it sparingly in porridge and I also treated myself to homemade rice pudding one night (which was really good). You may wonder about the term "sparingly" as I know that I can afford dried milk but it is amazing that surrounded by so much need you become acutely aware of what you spend on food and you also become obsessed with ensuring that absolutely nothing gets wasted, planning meals to reuse left-over's and to eat anything that might be nearing the end of it usable life.

Finally, no alcohol for three weeks, which as many of you know a record for me as I suspect that the last time I abstained for this length of time, was before I went to college i.e. when I was eighteen. There is beer available in town but the establishments are not very conducive to a quiet beer and as the majority of the other "faringe" are Seventh Day Adventists (who don't drink, smoke, eat meat or have caffeine if they are doing it properly- although they are not evangelical and intolerant of all of these behaviours in others) there is no one to go with me. The good news is that my alcoholic fast ended yesterday as Tekle (the local Obstetrician) brought me a bottle of Italian wine when he returned from Addis. It is much better than expected but then after three weeks I'm not sure I can be relied upon for my wine criticism as I may have a temporary bias. I am planning to make the bottle last as I don't drink when on-call (alternate nights now) and I think that 1-2glasses is all I really need to wash down spicy lentil stew!

That's an awful lot of nothing................

2010-01-27T05:44:00.000-08:00

January 27^th

So before you all think that I am already getting remiss in my blog updates, we have had a period with no internet connection. It seems that Ethiopia telecom is just like the trains in the UK and the slightest inclement weather takes the lines downs (or something of that sort anyway). I was told it was the dry season (which should last until end of April i.e. long after I am back in the UK- thus I came with no clothing for wet weather. No doubt someone in some meteorogical department will say that it is due to global warming but we had 2-days of intermittent torrential rain- there is no doubt that these 2-days left me relieved that I am not here in the wet season. One return trip from my bungalow left me soak to the skin (in spite of a plastic apron to make me both look like a local using whatever is to hand and theoretically to offer some degree of rain protection), thankfully "scrubs' & Crocs (which are standard wear for work here) dry out very quickly.

So back to life on labour ward in Gimbi. Monday presented me with my biggest challenge yet- this is meant in both a literal and a metaphorical sense. Late in the afternoon, a woman was transferred from the Government hospital in Assossa which is 5hours drive (300km) further west almost on the Sudanese border. A brief letter presented the facts that they had tried to delivery her by caesarean section (reason for caesarean not given) under general anaesthetic and that she had had a cardiac arrest but been resuscitated and they had abandoned the planned operation and transferred her to us. What the letter didn't say (but perhaps they felt it unnecessary as it was immediately apparent on looking at her) was that she weighed 150kg. This is the sort of weight that in the UK creates comment but we do deliver women who are very overweight relatively often but here where the women of all ages are all incredibly lean and have no body fat at all (there is the occasional wealthy person who might be reaching a BMI at the upper limit of normal) this woman was massively obese. Being this overweight is a health issue in the UK in spite of having special equipment (hoists and a bariatric operating table) and extremely experienced anaesthetist who will see the woman and careful plan the anaesthetic to try to make it as safe as possible. So you can imagine the issues involved in caring for a woman of this size here, the only good news was that looking at her it seemed unlikely that she had had a genuine cardiac arrest as she was well in herself. The reason that they were going to deliver her was because she was in very early labour having previously had a caesarean section and they suspected she was carrying a large baby. I agreed with their suspicions about the size of the baby but of course the accuracy of clinical examination in this situation can be poor (the faithful scan machine was not able to add any information in a woman this big). So I bad a dilemma- should I let her labour and wait to do an emergency caesarean or just get on and do it now whilst there was no apparent urgency? On balance I decide to go for the latter option on the basis that it would be safer for her- the risks of the whole situation were explained to her and her family (or at least something was said).

In this situation it is the anaesthetic that is the issue not really the surgery (which is just more difficult) and so this was a serious challenge for Abate the nurse-anaesthetist. He tried a spinal anaesthetic but the needle wasn't long enough to reach her spine (we have special long needles in the UK) and so he was forced to give her a general anaesthetic. Obesity makes this particularly dangerous as it is difficult to get the tube into their airway that is required to allow them to breath (they have fat, swelling and relatively shorter necks due to their body shape) and this is something that you only get one attempt at. Thankfully he managed to get the tube in place first time although her oxygen levels did fall to an alarmingly low level very briefly (which we suspect is what happened in Assossa resulting in them panicking and abandoning the operation).

So I was able to do the caesarean and delivery a large 4.5kg (9lb9oz) baby who has the body fat distribution of a laughing Buddha. This is a very large baby for here where the average birth-weight is about 3kg (6lb6oz) and the appearances all suggest that the mother had diabetes in pregnancy which would be in keeping with her weight. The operation was uneventful other than having to finish the skin with local anaesthetic as she was waking up and in the circumstances giving more general anaesthetic was not an option.

Thankfully 35hours on she is doing remarkably well and is mobilising better than an equivalent woman would back home. Her baby has a few feeding issues (unusually she is refusing to breast feed which only the very wealthy do here as formula milk cost $16 a tin).

I couldn't help but ask the midwife to ask her what she ate as on the basis of the diet I am eating here it is difficult to maintain weight never mind gain to any degree. The midwife asked her, she responded in a serious way and the midwife smiled and translated "she says she eats nothing doctor"!

Gimbi bibles..............

2010-01-24T07:39:00.000-08:00

January 24th

There is no such thing as anomaly scanning here and so I had been a bit surprised not to see any abnormalities in the babies so far.
That changed overnight last night as there were two babies delivered with problems that in the UK would have been diagnosed before birth thus allowing a plan to be made for management after birth or allowing the parents to consider the option of a termination of pregnancy (depending on the stage of the pregnancy and the nature of the abnormality). Termination of pregnancy for severe abnormality is also legal in Ethiopia although in the absence of any scanning I assume this is rarely undertaken.
The first baby has a cleft lip and palate on one side (they can be in the midline or on both sides which is worse). The problem with this is that babies require an intact palate to be able to create the suction needed to breast-feed and also to prevent them accidentally breathing the milk in (aspiration) during feeding. In the UK this is all addressed by regional cleft lip and palate teams who spring into action when a baby with this problem is born and use a variety of devices to make sure the baby is able to feed. Of course here there is nothing locally- there is a hospital in Addis called the Cure Hospital that specialises in paediatric problems like this and will treat the babies for free but this is only possible if we can manage to keep the baby well enough to travel and undergo surgery, thus the challenge at the moment is to try to get the mother to learn to feed the baby via a naso-gastic tube, simple enough in a clean environment but here the big worry is infection and gastroenteritis.
The second baby has bilateral talipes (we used to call this "club-foot" but the term is no longer considered PC in the UK although it will not surprise you to hear that it is the term most commonly used here). This baby can also be sent free of charge to the Cure Hospital but more is available locally. In a visiting Canadian Orthopaedic surgeon who left just last week did some training on treatment of this condition and the local Ethiopian Surgeon is going to put some special casts on the baby to get treatment started. His baby also has problems with its wrists, which is worrying as it suggests that he may have a more global problem but at the moment he is behaving normally and I have no-one else to consult about him.
This and the other neonatal problems that I have had to manage is a bit of a l like a crash course in neonatology and I am very thankful of the help of one of the other visitors Joyce who is a neonatal nurse, however as she points out the responsibility for prescribing any treatment she undertakes in mine! I have fortuately found a Unicef publication "Management of newborn problems" which is now one of my bibles here.

The NHS may have his failings but at least we don't turn many people away.................

2010-01-22T06:45:00.000-08:00

January 22^nd

My experiences in Gimbi are making me appreciate the advantages of a centrally funded Health service.

What happens here is that anyone can come to the hospital and pay a fee of 9Burr (about 45p) to be seen in general outpatients. This general OPD acts as a sort of "clearing house" come minor problem GP practice with the patients being seen initially by outpatient nurses who are able to prescribe a limited number of drugs (which the patient has to buy from pharmacy). They can also decide to refer on to one of three specialists: a GP who sees all medical problems, a surgeon who sees all surgical and orthopaedic problems or an obstetrician/gynaecologist (currently myself) who sees any thing pregnancy related or gynaecological. If required this specialist consultation is covered in the initial 9burr fee but again any medication or further treatment has to be paid for separately. The other way of accessing medical care is that they can pay 15burr (higher fee as it is open 24-hours I think) and be seen in the emergency room (sorry American terminology again) but any drugs, fluids, treatment or admission to hospital is charged separately. The Adventist Church tries to help out in very extreme or serious cases but overall their charity aims to support the infrastructure required in the hospital ( lie the building and equipment, electricity/water, supply network from Addis for drugs etc., "faringe" organisational & administrative staff and so on) requiring local people only to pay to cover the salaries of the local staff and consumables required for care.

Now 9/15burr may not sound like a lot of money but when you consider that the average daily wage is of the order of 15burr, it follows that most people scrape together the money for the initial consultation but are not able to afford surgery or referral on for other treatment. The other problem is that to come to outpatients or the emergency room may involve a journey of up to 12hours and this also requires Burr to pay for transport.

I saw three women yesterday with the sort of uterine prolapse you only rarely see in the UK (the high rate here is a result of the average birth rate of 6.2/babies per woman in this area) but is definitely operated on virtually immediately when it does occur. All three women are unable to afford an operation-this would normally mean that the only option for them was to continue to live with their prolapse (which is a pretty unpleasant condition but I will leave it to the imagination of the non-medical readers rather than risk upsetting the squeamish). Fortunately there is a ray of hope for these women at the moment, as a vaginal surgical team (not sure who/what exactly yet) are coming from the States for 2-weeks next month and so will be offering cut-price surgery (these sort of sales are very popular here!). Thus, I have added the names of the women I saw to the list that is being kept and if we are able to contact them (all three live more than three hours journey from the hospital and have no mobile phone) hopefully they will get surgery.

A more tragic case was a 50-year old woman who came to consult because of a three-month history of bleeding (she stopped her periods 12years ago-multiple children and nutritional status means that they all seem to have their menopause a lot earlier than the Western average of 51years). The hard lives people lead here means that at 50 years most women look very old (certainly older than their Western age equivalent)but unusually this woman looked extremely fit and well for her age (only 2-years older than me). Unfortunately on examination I found that she has a cervical cancer (no smear test here) that has spread such that an operation in Gimbi would not be ideal as the surgery will be difficult, she is likely to require a larger blood transfusion than we can provide and also would not be curative (in the UK a tumour like this would be treated with radiotherapy and chemotherapy not surgery). The best option should be to travel to the main Black Lion hospital (named I am told after some famous British regiment) in Addis where cancer care is available- although even if you have the necessary fee the waiting times to be treated can be long. Sadly she does not have any money and her daughter wept in the clinic pointing out that her mother "has no sons" to help care for her. She will come back next week when the Ethiopian gynaecologist has returned from holiday and perhaps he will decide to do some sort of palliative surgery in spite of the risks and the inability to cure her as this will be cheaper for the family and thus the only option available.

Thankfully the situation in obstetrics is different and I now fully understand why Gimbi was recommended to me as a good place to come for a first experience of work in Africa. Thankfully the backing of Maternity Worldwide in obstetrics means that I don't have question whether a woman can afford to give birth in hospital or have a caesarean section, I can just get on and do whatever is necessary. Any woman who is pregnant can come to Gimbi to deliver, if they can afford to pay they will be asked to pay the full amount (about 2000burr for a caesarean delivery) but otherwise they have to find a smaller amount (30burr for a normal birth and 400burr for a caesarean section) and Maternity Worldwide via what is called the "Safe Birth Fund" voucher scheme pick up the rest. I am not absolutely clear how they work out who can afford to pay and who can't but the system does seem to work as I am not asked for vouchers for everyone (Ethiopian bureaucracy means I have to fill out and sign lots of forms that require an additional very impressive looking stamp). So for the many of you who generously gave donations to MWW, I see on a daily basis the difference that this makes in allowing poor women access to safer care in childbirth.

Did you know we take our Christmas trees down at Epiphany?

2010-01-20T08:01:00.001-08:00

January 20^th

Yesterday was another bank-holidayin Ethiopia for Epiphany- not sure I had ever really registered that Epiphany was twelfth night but as we only mark it by taking our Christmas trees down and I'm not the most diligent of church goers I suppose it is hardly surprising. Another holiday meant a quiet day with no outpatients although I did do a normal breech delivery in the afternoon (these are not very common in the UK any more) avoiding a caesarean birth (that would make delivery more compicated next time which is important here).

Instead of medical stuff this time I thought it might be time to fill in a few details about my life when I am not working (especially since I have received a report that my accounts maybe too graphic for some-Nicola?). I am staying in a small bungalow, one of two that were built by Maternity Worldwide for visiting doctors such as myself. Bungalow is perhaps a slightly grand term for it but it is brick built albeit with a corrugated tin roof that almost all house in Ethiopia (and certainly Gimbi) have. The main disadvantage of the tin roof is the noise that the birds (crows and pigeons) make first thing in the morning as I discovered on my first morning when I was awoke with a start as it sounded like something was trying to remove the roof. So there is no lie in here and definitely no need to have an alarm clock, as they are at least regular in their activities at about 7am each day.

The bungalow is built on the hillside below the back of the hospital and have a lovely view over a small valley behind looking east so that the terrace gets the morning sun. Someone has fashioned a bird-table out of some pieces of wood and a small amount of bread or rice attracts an array of bird-life to watch from the terrace. The disadvantage of the position is that it means an uphill walk to the hospital which, given the elevation of 2000m in Gimbi, leaves me out of breath although I am sure my blood is getting thicker by the day.

The bungalow has a couple of bedrooms and there will be a midwife from Australia to keep me company from next month (which will be good as it can be a bit lonely). It is all quite compact but a lot more comfortable than I was expecting. I have a mosquito net over my bed which is just as well as I am one of those people who you want around as that they preferentially bite me before anyone else. It is also something very smug about lying in bed hearing a mosquito whining close by and knowing that it can't get you!

There is a small central seating area with an old style 3-piece suite which whilst ugly is amazingly comfortable and also a table and chairs. I have my IPod here, which is a lifesaver as familiar music definitely makes a place feel more like home. The kitchen is very small but has a modern fridge-freezer and an oven/hob. Only problem here is that currently they are waiting for new gas supplies from Addis and my gas bottle has been empty since I arrived- any way it is amazing what you can manage to do on a single ring!

The bathroom has hot water (unexpected) but it will be a novelty to stand under a shower again rather than use a hand-held nozzle and to have cold water in the basin (the cold tap doesn't work). The water doesn't stop too often (1-2xweekly so far) and as I am only one in my house at the moment the tank holds out for a while and there are big plastic "dustbins" of water on standby for use in kitchen & bathroom (which suggests to me that it can be for longer periods than have occurred so far). Electricity is a bit more hit and miss with power cut for some period of time most days (the hospital has an emergency though ailing generator for these occasions) but I have my candles at the ready and don't open the freezer door.

The weather during the day here is pretty glorious (sorry I do know about the terrible snow in the UK). I don't know how hot it is but it is probably around 24-28 degree Celsius for most of the day with a few hours that are hotter in the early afternoons. Although I could sit out on the terrace, the sun is hot and local sensitivities mean it is "not done" to be scantily clad so I will save sunbathing for the holiday at the end. Thankfully the temperatures fall during the night and so I am able to sleep without a problem (although no covers are required until the hour or so before dawn). I am not sure if the weather will get warmer during my stay and no-one local seems to have any idea either with the only distinction they make in weather terms being between the dry season (now) and the rainy season (May-September) which they say is hotter. During the day I can open all the windows to let the breezes in and then can close them at night that keeps the insects and the noise of barking dogs, the mosque call to prayer and Orthodox Church loudspeaker sermons out.

I said I would tell you about my "anaesthetist" (& other stories)

2010-01-18T08:14:00.001-08:00

January 18^th

I have now survived 4-nights on call and recon that I am probably about half way through my stint as the solo obstetrician and gynaecologist here (although the exact date and time of Tekle's return will be known only when I see him). Thankfully it is much quieter here than other places I have worked albeit the problems I see are much more extreme and everyone is well aware that on a 1:1 shift it is important that there are rest times.

Things also happen quickly, in that the decision about what to do next is obvious by the time a woman arrives on the labour ward here and so we are able to move swiftly into action. And when I say swiftly I mean exactly that, if I recommend a caesarean section (I could say order as there seems to be no question of anyone disagreeing with my recommendation) then the nurse midwife takes the consent (signature or more commonly a thumb-print), does the needful pre-op bits and wheels down to theatre (know as the "OR" as American terminology seems to have gained the upper hand). In theatre the team will be waiting and we will be ready to start within a very short time. All this is a far cry from the UK where at every stage there is massive discussion, coercion and even begging required to get anything to happen especially if you want it done quickly. The result of the speed here is that I can be called from my bungalow, see and assess a woman, do the caesarean, write notes and be back in my bungalow in only a little over an hour!

The only delay is if the surgeon is doing an emergency case as there is only one theatre. The level of workload is such that this doesn't happen very often. I did have to wait last night as they were patching up a guy involved in a stabbing incident (unfortunately the other protagonist was beyond the help of any hospital). It occurred to me that Gimbi on a weekend night is not dissimilar to Peckham as stabbings are the things that sometimes prevent caesareans (albeit in a second theatre) happening back home in King's.

There is no anaesthetist doctor in the hospital and an anaesthetic nurse gives all anaesthetics. He works 1:1 as well and has an even tougher deal than the on-call surgeon and myself as he covers both the emergency obstetrics, surgery and gynaecology as well as doing any elective operations that are required. Through all this he remains good-humoured and quite amazingly competent. So far he hasn't failed on any of the spinal blocks he has given for me which have all been rapidly highly effective with the woman apparently completely pain free. I have also done a few cases with Ketamine (a drug with many uses including as a Field anaesthetic in the army and more famously as a drug abused recreationally) for an anaesthetic. He can also administers general anaesthetics but I have not needed this so far. The latter is something I will try to avoid, as although his technical skills are fantastic I am not sure there is a great understanding of underlying physiology and so if things start to go wrong, the outcome might not be good.

It isn't quite like riding a bicycle..........

2010-01-16T07:06:00.001-08:00

January 16^th

So this entry of my blog has seen me face a few more challenges (as I knew I would). The obstetrics is going fine (well I don't feel out of my depth) but the gynaecology is proving more challenging.

As most of you know although fully trained in gynaecology I gave up practicing over 10 years ago when I became a Consultant, so it is all a bit rusty to say the least. Now add to this the need to practice in a completely different way due to resource limitations and that is where I am. This morning, I was faced with a woman with an ectopic pregnancy. Because she was very anaemic (from bleeding from the ectopic), the male anaesthetic nurse Abate (who I will tell you more about on another occasion but is amazingly skilled) felt that giving her a general or spinal anaesthetic was too dangerous and thus I had to do her operation with only local anaesthetic and some sedation. As is often the case she had also presented very late so that everything in her pelvis was very damaged, making the surgery difficult with the result that I was unable to stop her bleeding without removing both her fallopian tubes. Committing a young woman to a lifetime of infertility is serious anywhere in the world but here where there is no IVF and people depend on offspring to care for them in old age, it has left me feeling pretty terrible and wondering of someone with greater skill could have done a better job. However on the day I was her best chance and at least I managed to stop her bleeding

I was told to look for the uplifting part of any case when I feel down and in this case it is that she clearly has a very a supportive family (she is young and unmarried)- how do I know this? At 10pm last night her predominantly male relatives lined up to be checked to ensure they had normal blood pressure (and were HIV negative) before having their blood groups checked to see if they were a suitable cross-match for her. Thankfully two of them were (and had very high blood counts) so they donated blood without which she would not have made it through the surgery (with or without her tubes).

Otherwise today is quiet in the Hospital as being a Seventh Day Adventist organisation Saturday is the Sabbath and thus there are no outpatient clinics or other elective work. The labour ward has been quiet this afternoon or at least I assume so as I have had no visits from the guard (there is no bleep system or telephones and so if the midwives need me the compound guard who speaks only a little English is sent with a note to fetch me). Hopefully it will stay that way for a little while to allow me the time to post this message!

In at the deep end

2010-01-14T09:09:00.001-08:00

14^th January

Tekle the Ethiopian Obstetrician & Gynaecologist has left for a well earned holiday, hopefully he will be back in 8 or 9 days or so (the uncertainty is not because I am concerned he won't come back but because the reality of finding transport for the 10 hour journey from Addis back to Gimbi, is that a degree of flexibility in timing is required). So that leaves me in at the deep end doing a 1:1 on-call for anything they deem to be roughly within my sphere of competence.

Fortunately the gynaecology is coming flooding back which is just as well as the clinic today presented me with an array of gynaecology complaints. to manage including both a cervical and an ovarian cancer. I also saw my first woman with a urinary fistula, which is a problem virtually unheard of in the UK (I have seen it once before in my entire career) and is a result of labouring usually for days when the baby is stuck and can't get out (obstructed labour for medical readers). This woman delivered in September, she had delivered 4 children previously without a problem but with her fifth baby laboured for 3-days at home before presenting to the hospital. Her uterus had ruptured, the baby had died and she required a hysterectomy. Today was a routine follow-up and it was obvious (olfactory assessment) as soon as she arrived that she was leaking urine uncontrollably. She will require further very specialist surgery, the light at the end of the tunnel is that there is a specialist fistula hospital in Addis where she can receive treatment with a high chance of success for free.

More of an issue for my competence is the neonatology as in the absence of any other doctor this is my remit as well. Neonatal resuscitation was something I was prepared for but the management of postnatal temperatures and feeding problems was not. I really wish I had brought a neonatology book although I have realised that my books are of limited use as most of the investigations and the treatments they describe are not available here. Fortunately I have managed to find a very basic reference book and look up antibiotic doses and feed volumes, we are not talking very high tech management since the limit of treatment is intramuscular antibiotics, feeding through an naso-gastric tube and nasal oxygen therapy. One of the other visitors is a neonatal nurse from America and she has been a great source of reassurance and advice.

There is so much that I could tell you about like the attitude of women to pain and to the loss of their babies (which sadly is a daily occurrence). There is also plenty to tell you about the nurse-midwives attitude to the same that, at times can be pretty shocking but I need to save something for future blogs as there are ten weeks ahead of me in Gimbi!

Sorry about the lack of pictures but unfortunately the dial-up is unable to cope with the file sizes so I will try to send some back mid-term when Mark comes out to visit.

Now it starts to get interesting.............

2010-01-12T08:02:00.001-08:00

12th January

Did my first night as 1^st on call for obstetrics (& gynaecology) last night and finally feel as though I might be earning my keep. The night was busy with not much sleep opportunity and I was rather "wired" in the bits were I did get back to my room so sleep was fitfull even then- hence the short blog entry as I need to catch-up as the on-call is at best 1:2. It all feels a bit like being a junior doctor again as this is a whole new way of doing things. I am gradually adjusting to the reality of trying to manage things without any investigations and with none of the usual medications. Add to this the fact that they use the American version of many of the drugs that I am familiar with and you can begin to imagine the issues. Managed not to need to call on the local doctor (who definitely deserves a night off as he works a 1:1) but there were some moments of uncertainty.

I did a caesarean section this afternoon on a woman who came in from an external clinic and had been trying to push a baby out in a breech position for 12hours with a foot (and scrotum) visible. Amazingly when she arrived the baby was still alive and he doing well on the ward after delivery.

As I expected the feelings of homesickness are abating as I get to know everyone and find my niche. There is a lot that could be done here but many basic resources are lacking (medical comment- we can't even dip stick urine for protein as there are no reagents!) and I am very certain I am not going to be bored!

Many of the other "faringe" have worked in Africa for a while or before and so there is plenty of support and advice (the Orthopaedic surgeon from Canada worked in Burundi where they regularly ran out of sutures to allow caesarean to be done and knows all sorts of ways out of trouble). Everyone is also very sociable and they have also come up with creating cooking solutions for the limited ingredients here (there is no dairy produce of any kind and aonly a small selection of seasonal vegetables) with someone making a delicious carrot cake yesterday. There is one problem I foresee, is that as I am surrounded by North Americans-you may have to forgive me if the occasional non- English syntax slips in!

Still struggling with the dial-up.................

2010-01-10T23:07:00.000-08:00

11th January

The blog entry below was intended to be sent yesterday but had problems with dial-up (the blog entries are sent to the site by email).

(would like to blame Ethiopian internet but it turned out to be a "blonde moment" technical problem on my part- I will spare you all the details but needless to say I know now!).

10^th January

Settling in is more difficult than I expected- I thought that I was too old to get home sick but that doesn't appear to be the case. It is getting easier with each day but it is not a feeling that you have a lot of control over which is very frustrating. I think about the fact that I came here not expecting mobile phone signal and wonder how I would have got through without the ability to send/make occasional texts and calls.

Everyone is very welcoming. There are a number of other long and short term ex-pats working here (we are collectively know as "Faringe" by the Ethiopians which appears to be a term that is descriptive rather than derogatory in any way). Many though not all are Seventh Day Adventist missionaries as Gimbi hospital is an NGO run by their church. Perhaps it is a reflection on the type of people who do this sort of work long-term but I have been overwhelmed by the time people have taken to explain things and to help me to find my feet for aspects of day-day living.

Overall I have nothing to complain about as I have far more than I expected in the way of creature comforts and as promised we have electricity "most of the time" and water "most of the time". It can stop out at inconvenient times like this morning – getting going in the morning (afternoon/evening person) is a challenge for me any day but without coffee it is particularly difficult!

I've already had feedback about too much medical detail for the non-medic readers- apologies I will try to keep it sanitised and minimal but it is what I am here for after all. Things are a bit quieter than I was expecting. No one really understands the statistics here and certainly they are unable to make any future predictions but for some reason the delivery rate has fallen from 200/month to around 150/month in recent months. There is a brand new Government Hospital just opened in Gimbi, this is not seen by the Adventist Hospital as competition but a desirable alternative especially for people too poor to afford to pay for their care in medicine and surgery. The new hospital may be part of the reduced activity but it is not the whole story as the birth rate fall began a few months ago and Maternity Worldwide provides a "safe Birth" fund so that there is care available to all women here (additionally ex-pats from here visited the new hospital yesterday and found one inpatient in a 50-bedded hospital- can you imagine). Anyway this means an average delivery rate of 5 babies day here. The section rate is about 20% as the aim is still for SVB if at all possible, the midwives do all the suturing and also do straight forward vacuum deliveries (the re-use Kiwis here- sorry a very medical comment). The other thing is that unlike the UK, women are not in labour in the hospital for prolonged periods as they only come to hospital after they have been in labour for a long time at home with labours that are clearly obstructed and beyond the help of the ubiquitous syntocinon we use for slow labour in the UK. Thus review and action (usually caesarean) are swift. Overall what this means is that there is a lot of time waiting around for things to happen so I will have plenty of time for other things such as teaching or organisation once I find my feet.

Hope the cold in the UK is abating slightly. I won't gloat about the 30degree sunshine outside, as there are downsides to other supplies in Gimbi to make up for this!

Wow I had forgotten just how slow dail-up is.......................

2010-01-07T05:07:00.000-08:00

7^th January 2010

I am now in Gimbi and due to the fact that unlike the rest of the world the Ethiopians never officially converted from the Julian to the Gregorian calendar it is Christmas day again. I have to tell you that unlike the UK it doesn't look much like Christmas as it is warm, sunny and very green outside.

The journey (yesterday) to Gimbi as promised was "long and hard" 440km taking 10hours. Two thirds of the road is fantastic (provided by the Chinese) but the middle third is truly terrible, although a fleet of brand new Chinese lorries and diggers is in evidence standing by to commence work on this section later this year. The driving here is some of the worst I have ever seen: the roads have little traffic but what is on the roads is either travelling very slowly or very fast. The belief that there will be nothing coming the other way results in some risky overtaking. Add to this the need to weave around paedestrians, dogs, goats, cows and donkeys in large numbers all with no apparent road sense and you begin to understand the tally of 7 over-turned vehicles on or near the road and 7 canine fatalities (assuming a hyena count in this category) that we saw on the journey here, thankfully non-witnessed.

Arrival was a big culture shock and I experienced my first pangs of severe homesickness and that "do I know what I'm doing" feeling was particularly strong. In fact a cup of tea brought it all into perspective: the accommodation is much better than I was expecting (rather like the hospital accommodation I stayed in as a junior), there is a hot shower, the cook had left me a more than edible supper and there is a mobile phone signal (so if O2 don't cut me off I can at least phone home when desperate). I put on some music (thanks to my ipod and portable speaker) and busied myself making it feel more like home (i.e. spreading my stuff everywhere). I also took solace from the good advice of a work colleague who has worked abroad and warned me that the 1^st few days would be dreadful but that it would soon get better (if you are reading this-thanks Asha).

I did my first round with the local obstetrician (Tekle) this morning and assisted him with a caesarean. Amazingly the threshold for LSCS seems very low- which many of you know goes against the grain for me so we will see how it goes. The differences with care in the UK are huge. Everything is done on the minimum resources, issues like patient confidentiality and privacy are considered luxuries beyond the most basic level, the neonate is secondary with little resuscitation possible, infection control is considered but limited by resources (beds are maximum 3-feet apart in the ward). This lists but a few however overall the sense of all staff trying their best (often working 1:1 on-call) given these constraints is obvious. I just need a bit of time to see if there are things that can be done that will make the staff's lives easier and/or help the women they care for.

As it is Christmas here are no clinics so I am now on-call for the labour ward with Tekle and hence have time for a blog update. Well that really is more than enough to expect any of you to read and I will try to keep it shorter in future but at the moment everything is very new and different. Keep warm in the snow-bound UK!

And so it begins..................

2010-01-05T02:52:00.001-08:00

So I've arrived in Addis Ababa and now have to start to work out exactly what I am meant to write in a blog. I suspect I am best to keep it short so as to make it more likely I will get around to doing it and that people may feel inclined to read it.

I managed a dignified farewell to Mark at Heathrow (we've not been apart for more than about ten days in 18 years) and he waved me off over a prolonged period as I waited whilst they squeezed an impossibly large child's buggy through the xray machine ahead of me.

Bole airport was a surprise as it is bright, modern and apparently lacking the chaos that is typical of most African airports. It was all very efficient immigration, baggage (all arrived safe and sound), customs (a short discussion about the nature of a sonicaid required), bank (fortunate to get a wad of newish birr notes that have not yet been handled by half the population of Addis) and hotel transport located in under an hour without a single offer of a dodgy taxi.

I'm now checked into a hotel for a 24-hour stay before the 10 hour drive to Gimbi tomorrow and will do the boring Embassy registration and provision shopping today with hopefully time for a swim later. I think I need to make the most of these last moments of the creature comforts I am used to as for the next few week it will be back to basics.

Well that seems about enough for the first addition and besides it is starting to feel like breakfast time (currently 06.45 in the UK and I have been up for 3 hours).

So much to do!

2009-12-07T03:15:00.000-08:00

Many of you will have heard that I am taking a three-month "career break" (NHS terminology) - leaving on 4th January - to go to Ethiopia to work in maternity a hospital in a remote town called Gimbi, 500km (and 10 hours by road) west of Addis Ababa. The hospital is funded by a small charity called Maternity Worldwide and takes volunteer doctors from Europe to provide direct hands-on care and to train local healthcare workers.

One of the WHO's Millennium Development Goals is to reduce maternal mortality worldwide by 75% by 2015. This is a laudable aim but sadly seems unlikely to be achieved. Maternal mortality in large parts of Africa is unbelievably high. Ethiopia has good rates by African standards but the statistic is still 670 per 100,000 pregnancies compared to 7 per 100,000 in the UK. In Ethiopia this means a woman has 1 in 27 risk of dying in relation to pregnancy (five or six babies) in her lifetime. The risks in rural areas such as those around Gimbi are much higher than the rates for Ethiopia as a whole. Furthermore, in common with much of the rest of Africa, Ethiopia also has very high infant death rates.

Many people have asked me why I am doing this: I am realistic that as a contribution to reducing maternal mortality it will be a drop in a very large ocean but every little must help. More than anything it is to be reminded of just how lucky I am to have the healthcare system we do in the UK (for all its challenges) both as a provider and a receiver of medical care.

There is so much to do before I depart to Addis Adaba on 4th January- should of thought about the challenge that preparing for christmas, finishing things that are essential at work and getting ready for 3-months away would present!

This message is a test really as I'm a blogging novice so I just wanted to check it worked. I'm not sure how easy to blog it will be from Ethiopia as internet connections are all dial-up in Gimbie where the hospital is and I am told ruinously expensive but I will try to find a way to keep up with occasional postings.