Desalegn Hotel

View from my balcony at sunset

My room!

Crystal chandeliers, ultra chic

Wrecked

Within two hours of leaving my hotel this morning, I found myself on the side of the road, down $20 US, and having been in a car wreck. A fairly typical morning for Addis I would say.

The morning started lazily as I somehow managed to pull myself out of bed and shower before heading down to breakfast. My plan was to go to St. Paul’s to check in on my clinic there. I had high hopes that this one would have fared better given that they already had the infrastructure in place, having an already running screening program for HIV positive women. Although that clinic is run by Pathfinder and funded by PEPFAR, I figured that ours would at least be chugging along at a semi decent pace.

             After breakfast, I hunted around for a taxi to take me over to the hospital. Usually getting a cab in front of the hotel means paying 200% more than you normally would and when you can take the minibus for not even 50cents, it’s hard to justify paying US prices. However, the mini bus station was a good 45minute walk away and I was already pushing the time (who am I kidding, there is no such thing as being late when you are on habesha time), so I asked the first taxi how much to St. Paul’s. Normally the ride is about 120birr (or at least that’s the lowest I’ve ever been able to bargain), but this guy was asking for 300birr! No way. He wouldn’t budge so I moved on. The next guy wanted 200birr, nothing less. I thought it was little odd that all of them were quoting me so high but kept on moving. Finally I found a taxi driver who would take me for 150birr. Sold. When we finally got there, I found out why everyone had been so firm in their prices. The whole road in front of the hospital was completely torn up, big piles of dirt and blocks of concrete hurled about. The driver couldn’t even take me all the way because there was no way a car could go down it. I felt so bad about my earlier haggling and wanted to pay him more, but with only 200birr left in my wallet, I knew I would need everything I had to get home!

            When I got to St. Paul’s, I went immediately to the clinic. I was so relieved to see at least 5 women sitting on the bench outside waiting to be seen. I knocked on the door and waited and waited, but no one came. That’s odd. I tried the door handle, very slowly in case the nurse was in with a patient, but it was locked. By this point, it was over an hour past when the clinic was supposed to start and I was getting worried. So, in an effort to waste time and give the clinic a chance to open, I decided to head over to the HIV screening program to visit Zewdu and Nigussu. They were the first people I met in Ethiopia and let me sit in on their clinic when I was first learning about how to utilize VIA and cryotherapy. They even helped us in our training by being site leaders at St. Paul’s. I was greeted with a big hug from Zewdu and the traditional Ethiopian greeting (handshake with 4 kisses on the cheek, alternating each time) from Nigussu. It was so nice to see them well and happy. They told me that their clinic was doing great and they had seen 200 new patients since August. After catching up, I bid them goodbye and promised to stop by again before I left at the end of this week.

            On my way back to my clinic, I passed by a sign that stopped me cold. The sign read, “UCSD Cervical Cancer Screening Training Nov. 12-23, 2012.” Apparently, UCSD has decided to run their own training session at St. Paul’s. UCSD is part of the MEPI (Medical Education Partnership Initiative) grant that Emory, John Hopkins, and University of Wisconsin has with Addis Ababa University, so its not surprising that they would be doing work down here. It was just frustrating to feel like my turf was being pounced on. But really, if I were St. Paul’s, and another big time university was offering to come train my employees for free and give me invaluable resources, I would jump at the chance. I guess that’s global health for you. I wonder though if it would be better for one organization to tackle one issue. It seems as if it would be much more organized and allow for better implementation of lasting infrastructure. Wouldn’t it get confusing if 20 different NGOs, universities, and religious mission groups came in and tried to tackle the same issue? Seems a little muddled if you ask me.

            Anyway, I finally got access to the clinic and grabbed the patient information forms and surveys I needed. Unfortunately the clinic wasn’t seeing patients today, but I was happy to grab my data and be on my way. I found a cab to take me home, thinking I would be generous with me 200birr offer. Nope. He wanted 300birr, no less. I opened my wallet to show him that I literally had nothing more than 205birr and finally he begrudgingly agreed to take me. As we passed by Piazza, in the midst of a daydream as is often the case while I am driving through the city, I suddenly heard the squeal of rubber on road and then a crash as my body hurled forward. Apparently, my taxi’s breaks didn’t work well enough to stop us from slamming into the car in front of us that was parked at a light. Both drivers hopped out, rubbing their foreheads in disbelief, as a local traffic officer came over to investigate. As did about 15 other bystanders, might I add. Luckily, no one was hurt and I walked away with only swollen and bruised shins, repercussions from slamming into the driver’s seat in front of me. I gathered my items, slapped 100birr into my cab driver’s hand and started to walk away. He tried to argue with me, but I kept on walking. I was close enough to Black Lion that I was able to catch a minibus and soon was careening down the roads again on my way home. 

           

Days Go By

Yesterday, I traveled to Black Lion to meet with the graduating residents we trained in August. They had agreed to take a break from studying for their OB/GYN boards to talk with me about how they felt the training went and their hopes for utilizing VIA/Cryotherapy in the future. I was nervous that they would not feel comfortable being honest with me present in the room given the fact that I had organized and run the training, but they were delightfully candid. Originally, all of these focus groups were supposed to be organized and run by Melesse, an Ethiopian man with a Ph.D. in behavioral sciences that we had been paying a stipend to help us with surveys and data analysis. He had proven himself to be less than helpful despite the large salary we were paying him and eventually it came out that he had been suspended due to some disciplinary issues and now was no longer allowed to be associated with the department. So it was up to Dr. Dawit and I to run the show!

The residents had many positive things to say about the clinic, which was good, but did lament that the hands on experience was too short. We had anticipated that this would be a problem since the training was only 5 days and we had lots of material to get through, but it was difficult enough to get them such time off from their clinical duties. Due to reasons explained in my last post, very few had done additional VIA screening and only 3 out of the 9 present had done cyrotherapy, with the majority of these done by the two nurses we trained as their sole job was to run the clinic. Yet despite their lack of experience, all felt confident in their ability to screen and treat women in the future, which I think demonstrates how simple and easily implementable the method is. Our plan is to hopefully give one of the graduating residents a cryotherapy machine so that they can continue to screen for and treat precancerous lesions when they become practicing physicians in their hometowns. In other plans for the future, Dr. Dawit is hoping to integrate teaching VIA/cryotherapy into the OB/GYN curriculum and have all residents rotate through the clinic. This way, we don’t need to hold formal trainings and all of the OB/GYN residents will be exposed year after year. Of course the main problem is that we don’t have the funds to provide every resident with cryotherapy machines for when they graduate, but I’m hoping my search for a grant to cover the costs will be fruitful. After the discussion, I had each participant fill out a modified KAP survey so we could see if their knowledge and views of cervical cancer had changed after the training and also to assess their comfort with VIA/cryotherapy. While I haven’t formally analyzed the data yet, it looks like there was great knowledge retention between our training and now and that most people feel comfortable with VIA and cryotherapy. Hopefully I find the same thing at St. Paul’s next week!

As for the rest of my time, I have spent the majority of it at the hotel inputting data onto our online database. Unfortunately, all of my work requires internet and the only place where the WIFI reliably works is at the hotel. I didn’t buy my own network USB stick because I didn’t find the cost worth it as I'm only here for two weeks, so I’m at the mercy of Ethiopian WIFI, which is frequently down or too weak to support the website I use. This means that I am either in my hotel room watching FOX movies as I type away on my bed, or am in the hotel lobby, sipping Chai tea or a macchiato.  It doesn’t help that today after a whopping 15 hours of sleep, I have awoken to a burning chest and a cough reminiscent of an elephant seal. But I am proud to say that I made myself walk to a coffee shop and enjoy the gorgeous weather we’ve had here. Not a lick of rain. I curled up on a tattered chair at La Pariesienne and read my book while treating myself to a croissant sandwich and Ambo. Overall a lovely afternoon. Tonight I have decided to venture out to dinner on my own. I generally don’t like the idea of walking by myself at night, but think that the extra expense of a taxi is worth getting a change of pace. I must say I miss the days of gathering up all of my roommates and heading to a fun dinner out! I guess our stateside reunions will just have to do for now.

Devastatingly Expected

Today was my first day to officially survey our clinic at Black Lion. I can’t really say I’m surprised that I found it in the state that it was in, but it didn’t make it any less frustrating. Several changes have happened within the administration of the hospital that have made it difficult for the clinic to function properly. First of all, the whole management of the hospital has changed. Instead of individual departments (OB/GYN, Medicine, Pediatrics, etc) running their own inpatient units and outpatient clinics, there is now one director of all inpatient care and one for outpatient care. Due to this, the work staff has been completely reorganized such that the departments didn’t necessarily maintain their own ancillary staff. So a nurse who has essentially specialized in OB/GYN may now be working in a gastrointestinal medicine clinic. The other major issue is that the outpatient clinics are currently devoid of any water or sewage system. Unfortunately for us, this has meant that the clinic has essentially not been running for the past four months. Without running water, we are unable to create sterilization buckets for speculums and other instruments and the autoclaves are not working. Without any way to clean our instruments, we can’t routinely exam patients. Because of the lack of water, amongst other suboptimal changes, the nursing staff has “revolted,” to use Dr. Hezkiel’s words, against the outpatient care director and are refusing to work until the piping system is put in place. Additionally, the whole outpatient floor is being redesigned such that our clinic will actually be moved to another location in the coming weeks. Hopefully once we are relocated and the water is back up we can really begin to screen in earnest, but I’m worried that we have lost the momentum of the training. We will have to start a serious advertising campaign in order to get the word out again as now very few patients are coming to clinic requesting the screening.

To add to these problems, the multitude of forms we left the clinics with are either not being filled out or are not being filled out properly. There are no patient surveys for the additional patients seen over the past four months, and some of the patients don’t have a clinic data form in the clinic binder, but instead the document was put in their hospital chart. Hospital charts at Black Lion are like ghosts. Somehow patients get their hands on them when they have appointments but tracking them down is nearly impossible especially given that we don’t have any of the patients’ names as they also weren’t logged in the clinic log book. Simply put—not only is the Black Lion clinic not running, but there is also no data. Luckily my work here over the summer has hardened me enough that I am not having a complete breakdown but it is so remarkably disheartening.  The one uplifting factor is that Dr. Dawit and Dr. Hezkiel still have such a passion for the project and continue to make efforts to incorporate VIA/Cryotherapy into the curriculum and to spread the method to rural areas, such as at Dr. Hezkiel’s clinic in Debre Markos. Now we just have to find a way to work around the issues we are struggling with right now. Unfortunately, these are issues endemic to low resource areas, so even if we fix it now, who’s to say the same problems won’t pop up a few months to years down the line.

As I mentioned yesterday, Dr. Dawit and Dr. Hezkiel want to hold a training in 2-3 weeks for the rising fourth year OB/GYN residents so that they are able to participate in our clinics during their final year. I brought up the idea with Dr. Hezkiel and he mentioned the need for incentives for the residents to participate in the training. He has told me this before and tried to explain that it is just part of the culture here, but it wasn’t any less grating. I would think that any training that can further your career and help your patients would be one you would gladly participate in. In the US, any conference or continuing medical education session offered generally comes at a price, yet here, we must pay for people to attend? It seems so backwards to me. I tried to explain that our budget was completely drained by the last training and that while I was in search of grants, acquiring those funds would take time; however, he continued to insist that we provide some sort of compensation. Hopefully they can still manage to conduct the training with departmental funding or just insist that the residents attend, otherwise I don’t think we can expect the expansion of knowledge we were hoping for.

While Dr. Hezkiel mentioned that a patient might come in the afternoon for screening, I decided it was a better use of my time and better for my sanity to leave and work on data entry. I took the mini bus to my old neighborhood, hoping to enjoy a macchiato from Kaldi’s and get some work done. On my walk from the mini bus drop to the coffee shop, I was joined by a young man who started asking me about what brought me to Addis, the election, and other things about my life. After a few minutes, he turns to me and asks if he can get my advice. Feeling a scheme come on, I agreed, but made sure my bag was secure and began walking a little faster to my destination. He started by telling me that everything he was about to say was top secret, which made me begin to think that he might have some mental issues. He then went on to explain that his parents were murdered by people within the government and that out of fear for their lives, he contracted a broker to help his little brother and little sister leave the country. However, now they were in Italy and he had no way of contacting them. He told me that he is a graduate of the history department at Bahir Dar University and that he wants to come to the US. At this point, I am expecting either a plead for money or a marriage proposal, but what I get instead is, “Can we be friends on Facebook?” It was one of the oddest conversations I have had here to date. I still have no idea if anything he said was true, but it was so out of left field and he was so endearing that it really could have been. It sort of reminds me of this patient I had on my psychiatry rotation at Grady. The patient had bipolar disorder and during my patient interview, told me all about his humanitarian efforts to rid this one tropical island of its massive infestation of coconut rhinoceros beetles. He kept going on and on about it while I nodded and tried to empathize as best I could. Well, when my assessment was done, out of curiosity, I did a quick Internet search. Much to my surprise, there indeed was a huge coconut rhinoceros beetle infestation at this one particular location right around the time my patient said he had been there. The man was definitely delusional and had a serious case of bipolar disorder, but still, maybe he was there. Maybe that was the one truth he could still tell. How can you really know?

Off With A Bang

My day in Addis started quite early this morning as I was awoken around 1am to the sounds of a wedding send off outside my bedroom window. There is no such thing as central heating or air in Addis and so a cracked window provides a nice breeze to the heat generated throughout the day. Startled awake, I heard Ethiopian chants, claps and cheers as the bride and groom were whisked away from the hotel. The party had been literally shaking the hotel all night with music and dancing and I was relieved that it had come to an end. However, as we all know, my insomnia can be a devilish thing, and I ended up tossing and turning and attempting to read until 2am before finally falling back asleep. A few hours later, I was up getting ready for the day and hurrying down for breakfast and my much needed macchiato. Dr. Dawit met Abed, the OB/GYN resident who is here as part of the MEPI grant Emory has with AAU, and I in the lobby and we hurried to Black Lion for morning report and Abed’s final lecture to the residents. 

On our way to the hospital this morning, I requested the Dr. Dawit put on Teddy Afro, my favorite Ethiopian pop star, as I often do when we are driving together. I think he finds it amusing how much I love the music and my bad white girl attempts to habesha dance. As we were talking about the concerts Teddy Afro had been holding in the area, Dr. Dawit mentioned that his next concert is a week from Saturday in Awasa, just south of here. Turns out the Dr. Dawit will be down in that area next week and has invited me to attend the concert! I could not be more excited. I’m not 100% sure it will work out, but I think it would be amazing.

After our academic responsibilities were done, Dr. Dawit and I met to go over the “to do” list for the trip. Unfortunately he is going out of town next week so we are cramming a lot of the work into this week. I think I grossly underestimated how much work there is to be done while I am here. There should be literally hundreds of patient data forms that I need to input into our online database in addition to whatever else needs to be done. One of our goals is to interview all of the residents and nurses we trained in an effort to get feedback regarding the usefulness of the training. The only issue is that all of the chief residents are on educational leave as their OB/GYN boards are coming up in December. Suboptimal, but I am confident it will work out. Also, Dr. Dawit suggested that I give a lecture to the medical students rotation through on OB/GYN so that they can potentially help in the VIA/Cryo clinic, which I think is a great idea although now I only have a few days to pull one together. Finally, we are hoping to set up Dr. Dawit and Dr. Hezkiel to hold another training in a few weeks with the rising chief residents so as to implement the training into the final year curriculum. In other news, Dr. Dawit is expanding our VIA/Cryo clinic to now run two days during the week at Black Lion instead of just one afternoon, and Dr. Hezkiel has brought one of the cryotherapy machines to his clinic in Debre Markos, a small town up north, to screen women from more rural villages. It’s so exciting to see so many efforts being put into place to maintain continuity and to sustain the program, and really gives me the confidence that we will have created a lasting impact at least in Addis.  Now I just need to find out how to fund it!

Back to Addis

It’s hard to believe I’m actually back. I wasn’t quite sure how I would feel stepping back into the world of Addis, especially given that this time I am here alone for the most part, but the second I was zipping through the city, surrounded by the distinct Ethiopian air, I had a visceral punch in the gut of nostalgia. With my first sip of chai tea, when the moment the words “salam” left my lips, everything came racing back, all of the memories, good and bad. Not much has changed here to be honest.  Addis is perpetually in construction and many of the projects that were being undertaken are still haphazardly in various states of completion. Bole road, the main road that was being repaved last time I was here, is still not finished, leaving a huge strip of dirt that is continually washed with water from the sewers (another construction project). The biggest initial change was that the security rules are no longer in place so instead of entering the fairly calm international airport, there were swarms of people pushing and shoving, hoping to get a glimpse of their loved ones. Luckily, I was able to connect with my hotel shuttle fairly quickly and was soon on my way, although I was half expecting to turn into Bole homes and be greeted by the sweet voices of my habesha sisters. It definitely feels a little emptier here without the whole real world Addis clan.

Throughout the city, signs have been erected memorializing the recently deceased Prime Minister and Ethiopian flags cover almost every window. Nothing like some good old Ethiopian national pride. I am also happy to report that the Edna Mall movie theater is now officially 7D! Not sure how they accomplished that one but will definitely have to check it out. I also ran into some of the children we knew during our stay here this summer. One of the boys can’t be older than 4 years old and has this wild curly hair and a smile that could melt any heart. He runs around in front of Kaldi’s, one of the coffee shops here that mimics Starbucks quite impressively, and sells gum. Sure enough, he came running up to me and with teeth gleaming, asked, “Gum?” Even though it’s stale and tastes horrible, I always pay him double.

Now I am sitting here at the German Bakery, sipping my macchiato, which is even more delicious than I remembered, and trying to organize my plan of attack for this trip. The goals are to assess how our clinics are doing at Black and St. Paul’s by analyzing their clinical records and patient surveys. We left them with a lot of forms to fill out and to be honest, I’m a little wary that it got done. That is our only source of data though, so I’m keeping my fingers crossed! I am also hoping to survey the residents we trained to see if they have utilized VIA/Cryo and if they thought the training was adequate now that we are 4 months out. Finally, and most importantly, I am hoping to address some of the sustainability issues that I foresee and that Dr. Dawit and Dr. Hezkiel anticipate. PEPFAR provides 5 years of funding for and VIA/Cryo clinics for HIV infected patients, but we unfortunately don’t have the resources to do that and really want to reach the general population, so funding will definitely be a major issue. Many things to think about!

The more I think about and talk about this project, the more driven I am to see it through and to expand our clinics to make a bigger national impact. I know it would take a lot of follow up and work, but I think it could make such a difference here. Now that I am pursuing a residency in the southeast, maybe even at Emory, I am hoping that this will be a possibility! Who knows, the future is such a tricky thing.

The Last Hurrah

For our second to last day of training, we spent all day in the clinic and I have to be honest I was kind of dreading it. It is literally the most exhausting thing to try to manage trainees. I am at St. Paul’s essentially by myself with two clinics seeing patients at the same time. I have nurses who know how to do VIA/Cryotherapy in each of the clinics but neither of them know our study protocols so I have to be watching everyone like a hawk to make sure that the consent forms and surveys are done, plus making sure that they fill out the forms correctly. I also need to watch them do the screening to ensure they do all the steps adequately.
            Although I had less trainees with me today, Alisa wasn’t able to help me out in the other clinic so I had to run back and forth between the two ensuring that all the paperwork was done and that everyone had enough copies of all of the forms.  Luckily the other room was completely on top of it, but it was still really stressful. Then I had women again pounding and pushing on the door and on me to be screened as I pushed them back. It’s great that everyone is so enthusiastic, but it makes me immensely stressed out to physical force patients away. One woman was particularly persistent that her 63 year old mother be seen and would not listen to me when I tried to explain that we are only seeing women up to age 45; however, she barker her way into the room telling me that she was a doctor with the ministry of health and proceeded to question me on the details of the study. Of course, this caused me to be a little flustered and a little irritated that a so called professional would be so aggressive with me right off the bat. I quickly stepped out and called Dr. Goedken asking her to ensure that a head physician of the project be here at all times in order to help me keep the peace since no one really listens to the white girl. We aren’t really sure if this woman was actually with the ministry of health, but we screened her mother anyway. I felt a little guilty that I had treated her a little brusquely since all she wanted was help for her mother, but her first reaction to me was so hostile that I couldn’t help but respond with a little force behind my words. Maybe not the best way to have handled it, but I was trying to juggle fifty other things that my stress got the best of me.

Ethiopian physicians have literally no concept of IRB or patient awareness. It was a point actually brought up at the MEPI workshop I attended Thursday morning, but in a slightly different context. The leaders of the conference said that in recent years, the IRB process here has become more stringent (my roommates and I can attest to that!) out of a very real fear that developed countries doing research in low resource areas often take advantage of African patients. However, they have become so strict in their policies that it is almost impossible to get any project approved and the committee nit picks over minor details in order to exact some sort of control. Even though they continue to stone wall research and tout the idea that “policies” must be followed, the physicians here have no idea what they are even upholding. There is no such thing as privacy here and a woman’s medical information is discussed openly in front of others. They do not understand that patients need to be the final decision makers in their medical care and sweep patients into treatment fast tracks without stopping and really discussing options with them. For example, the woman from the ministry of health was furious that I was denying her mother care and questioned my IRB approval, but when I explained to her that I didn’t have approval to screen her mother because she didn’t fall into the appropriate age range, she didn’t seem to care so much about the IRB approval then. The patients here are denied so much due to lack of resources that when they become available, it’s a mad dash to the clinic door regardless of protocols or patient rights.

Somehow I survived the day and spent the evening with Dr. Goedken, Alisa, and Sunyiat, an OB/GYN from Michigan and Ethiopian ex-pat, at Dr. Dawit’s house as he had invited us over to dinner to meet his wife, Tigi, and their newborn son. Barkau (no idea how to spell it, but it means “blessings” in Amharic) was the sweetest little baby and made the most hysterical faces. Definitely gave me some baby fever. We had a wonderful dinner of Ethiopian food, fish, and vegetables, and we eagerly stuffed our faces because by the time we actually ate it was almost 9:30pm. Dr. Dawit kept the wine flowing and was a little over generous with my glasses if I do say so myself. We were all getting a little louder and a little looser as the night went on and the rainstorm outside pounded down on top of us. By 12am we decided it was time to head back to the hotel as we still needed to write the exams for the participant testing in the morning. Finally by 1:45am, I was on my way home, but not without some aggressive habesha bargaining with the cab driver on my part. Unfortunately the power was out in our house and my phone was dying so I was slightly panicked that I wouldn’t wake up in 4 hours. I lay in bed and mentally repeated my wake up time in my head hoping that I wouldn’t sleep in, but luckily my phone lasted the night and I was off to the Desalegn Hotel yet again at 6:45am.

When Dr. Goedken and I met up over breakfast, we realized we had some last minute details we needed to tie up so I headed over to St. Paul’s to have our training certificates signed by Dr. Abdulfetah and buzzed back as quickly as I could given the Lada taxis here don’t go much about 15mph, and made it back in time for the testing. Everyone did very well on all of the assessments and passed with flying colors! We handed out the official training certificates and sadly said our goodbyes. I am proud to say that we have officially trained 15 new healthcare professionals how to screen for cervical cancer using VIA! I can’t believe it’s all actually over. I have spent the past two months dedicating my life to this project and it’s unreal that the largest part is done! I still have the “data” to review, the papers to write, and possibly the return trip in December if we get funding, but my training “baby” as I refer to it, is all said and done. Thank goodness. 

The whole group! From the left: Fikirte, Hussen, Mesfin, Terafeyuw, Zeleke, Jalel, Tilahun, Sherangizaw, Dr. Goedken, Abebe, Fikre, Dr. Hezkiel, Me, Nigussu, Dr. Dawit, Genet, and Betre

Dr. Hezkiel, me, and Dr. Goedken. Yes, Dr. Hezkiel is holding my hand. All Ethiopian friends, whether its two men or two women or a man and a woman, are very affectionate and always hold hands. So habesha.

Dr. Dawit, ladies man.

The whole group!

The certificate of training. So official looking!