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

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.................

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.............

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..............

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..............

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...............

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................

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.