Lalibela, Axum, and Tigray

This past weekend, we spent four days in Lalibela, Axum, and Eastern Tigray, which are all part of the northern historical circuit and considered the root of Christianity here in Ethiopia. For the most part, Ethiopia is deeply Orthodox Christian. Women and men roam the city with white shawls covering their heads and shoulders heading to and from daily mass. Much of Ethiopian history is rooted within this context, focusing on saints and Christian dynasties. For example, Ethiopian texts state that Queen of Sheba was Ethiopian originally, not from Yemen, and traveled to Jerusalem where she had a child with King Solomon. This male descendent of King Solomon then returned to Ethiopia and ruled the country to uphold Christianity. When he returned to Ethiopia, he brought with him the Ark of the Covenant, now said to reside in Axum. None of this is supported by any western or European historical texts, but the Ethiopians are absolutely convinced that they hold the Ark of the Covenant and are the true center of Christianity. Ethiopians have a tendency to rewrite history to fit their own understanding, even when refuted by direct evidence, which can be quite amusing at times.

            To start our trip, we flew from Addis into Lalibela and headed into town. We stayed at the Asheton Hotel which was a small place recommended by one of our guidebooks. The beds were warm, the sheets were clean, and although a little dusty, the bathrooms actually functioned, so overall for $6/night, not too shabby! The hotel arranged for a guide to take us on a tour of the famous churches so that we could take in the history as well as the scenery. The churches are divided into two areas, the northern and southern groups, and we were fortunate to see pretty much see all of them. The thing that makes these churches so spectacular is that all of them were carved out of the mountains and rocks in Lalibela. Some are still connected to the original rock walls from which they were created and clearly demonstrate what an undertaking building each church was. Tunnels through the rocks connect them, and our guide said that the passageways were created so that the royal family could escape if the churches were ever attacked. We even traveled through a 30m underground stretch of pure darkness poignantly called Hell. Most of the structures were created during the Zagwe dynasty under King Lalibela whose goal was to create a new Jerusalem, or center of Christianity, in northern Ethiopia. All of the churches are named after important Ethiopian saints including St. Mary (as in mother of Christ) and St. George.  Apparently, St. George’s church was constructed after he visited Lalibela and was angry that he didn’t have a church built in his honor, so his masterpiece is a little separate from the original churches. St. George is a huge iconic figure here in Ethiopia (he even has his own beer, which happens to be one of our favorites). The story goes that a giant dragon was guarding the water supply in one village such that every time the villagers wanted water, they had to sacrifice a goat or often a maiden. One day, the dragon requested the princess be sent to him. Luckily St. George sweeped in, slayed the dragon, and rescued the princess. Due to his bravery, the villagers abandoned paganism and adopted Christianity. So a lot of religious paintings in the churches show St. George on his horse, spear through a dragon, upholding the morals of Christianity. Like I said, Ethiopians have an interesting view of history!

            In the afternoon, we were directed by our guide to a khat (pronounced “chaw-t”) house. Khat is a plant that acts as a stimulant when you chew and swallow it’s leaves. It’s the equivalent of having a large cup of strong coffee and gives you a little bit of a buzz if you eat enough. Medical students use it here when its time to study for exams and it’s a common pastime for men (think going and grabbing a drink with your friend but instead you eat leaves). So we sat in this small hut on the floor, watching Teddy Afro music videos, chewing khat and drinking Coca-Cola, while the men around us smoked shisha (flavored tobacco) out of hookahs and talked with us about America. At one point, they wanted to hear some American music and while our selection included Miley Cyrus’ Party in the USA, the theme song to the Fresh Prince of Bel Are, and 99 bottles of beer on the wall, our singing was not well received. As usual, Chris dominated his khat bag and the girls and I just nibbled on a few leaves, feeling very much like farm animals. Somehow, two hours of time passed and after Christian, Karen’s friend from college who is visiting, was propositioned by a “lady of the night” we decided it was time to head out. Overall a very interesting time in Lalibela!

Going down into the tunnels

St. George's church

St. Mary's church

         

Karen and I enjoying the khat

The next morning, we headed back to the airport to fly to Axum. There we were meeting Eddie, a recently graduated infectious disease fellow from Emory who is living with us, to see the sights. Throughout my flying experience, I have noticed that the pacemaker is not well received here. They continue to ask for “medical papers” and stare me down with such skepticism it’s unnerving. Even when I physically show them my pacemaker and scar, they continue to berate me for papers. Eventually they give in and proceed to give me a “pat down.” This pat down is unlike anything I have ever experience in the US. One of the women even put her hands in my bra and then patted me on the back and said that it was important to be safe. Um, excuse me? Seems a little aggressive considering my boarding pass is literally a piece of paper with a number written on it. When you have to go through four security checks to get to your gate, it can get a little tiring but still pretty humorous.

            When we arrived in Axum, we had five hours to tour the city before driving on to Gheralta Lodge in Eastern Tigray. After seeing Axum, five hours was plenty. The main attraction there was giant obelisks erected to represent the power of the surrounding kings. The largest obelisk standing over 300m, the largest building to be erected by manpower alone, was placed here and promptly fell over. It still lies there in ruins on the rubble of the buildings it crushed. We also saw a giant water reservoir, once natural and now preserved with concrete, that they believe was Queen of Sheba’s bath. Now the villagers use it for laundry, although it was once their drinking source. Walking along, we traveled up a mountain to view a tablet containing Sabean, Greek, and Ge’ez writings (similar to the rosetta stone) found in Axum, and some tombs built for the kings who ruled the area. There was also a nice view of the Ethiopian/Eritrea border. Eritrea used to be part of Ethiopia but formerly applied for independence in the 1970’s. It is a source of contention among the population here, resulting in the inability for Ethiopian citizens to cross the border.

            Arguable the best part of Axum was Bruce, my camel. Many of you may not know this, but ever since I left Morocco last year, I have been dying to ride a camel. Much to my delight, right outside of the park with the obelisks, there was a man offering camel rides for 50birr (about $3 US). Yes please! So, after touring around Axum, we returned to Bruce who was foaming and gurgling, slightly mimicking a rabies infection, and we hopped on. Sandy and I had a delightful ride up and down the street, looking absolutely ridiculous, getting stares from all of the locals. We may have looked like the most absurd farenji tourists, but we had a great time. After completing that life goal, we wandered off in search of lunch. It was at this time that I met Philly. Philly was a local Axum boy who decided he really wanted to be my friend. He grabbed my hand and off we went, hand-in-hand, roaming the streets. He told me he was 10years old but I’m fairly sure he was much younger, either that or he had some growth issues due to malnutrition. We went over how to count to ten, the ABC’s, and told each other we loved each other. I thought he would leave after I gave him some birr (most kids here greet you with, “Hello! Give me birr!”), but he persisted, never letting my hand leave his. He followed us all the way to lunch and then waited outside of the restaurant for me. What started off as cute was quickly becoming sad and anxiety producing. It was clear that he wanted me to buy him food, but I knew I couldn’t at the restaurant (the owners repeatedly tried to chase him off). It broke my heart and nearly brought me to tears at the table. When we left, Eddie was kind enough to buy him a donut, Philly skipped away happy, and off to Eastern Tigray we went.

The tallest obelisk in Axum that toppled over as soon as it was erected

Philly and I walking through Axum

Bruce, Sandy and I

 It took us around 3 hours by truck and the scenery was gorgeous. There were mountains and stone formations everywhere reminiscent of Arizona orBruce , and when we pulled up to Gheralta Lodge we could hardly believe our eyes. The lodge was like a nice desert resort you would find in the US with wooden floors, stonewalls, and giant windows looking out over the mountains. There were lounge chairs outside where we sat and gazed at the stars every night, praying we didn’t have to leave. The two biggest draws by far were the showers and the food. The shower was literally the best shower I have had since leaving the US and was a welcome relief after trudging through the dust all day. Additionally every night, we had a four course Italian or Ethiopian meal, which was phenomenal, as well as a full breakfast the next day. For $18/night, it was a little slice of heaven.

            The next morning we had a leisurely morning and headed out to hike the rock churches of Tigray. These churches are similar to those of Lalibela in that they are carved directly from rocks, but in Tigray, this means most are on cliff faces and at the very tops of the mountains. The first church was a good 1.5 hour, mostly up a steep incline, hike. The views were amazing and a little vertigo inducing for those of us (including myself) with height issues. We arrived upon the first church, which had two separate entrances for men and women and required us to take off our shoes to enter (as did the churches in Lalibela). Inside, the rock was painted with stories of Christ, Mary, and St. George, very similar to ones we had seen before. The church was cool and quiet and felt refreshing after our big hike. We then rounded the corner of the mountain, traveling along a narrow ledge to reach another church. This church was literally carved into the mountain face and provided incredible views of how far we had come.

The group getting ready to hike

On the border of Ethiopia and Eritrea

Chris, Sandy, Karen and I enjoying the views

Karen, Sandy and I

Eddie enjoying the view

A priest in one of the rock churches

            After lunch we drove to our final church. This hike was said to be short but technically difficult and we all were curious as to what was in store. What we got was definitely nerve rattling but spectacular. The first portion of the hike was very simple but then the priest of the church met us and instructed us to remove our shoes. From this point on we would hike without them. We started with a completely vertical face of rock that had small hand and foot holes eroded into it by constant hiking and chiseling. We had an Ethiopian guide who was behind us literally pushing us up the wall by our backsides. Of course the priest demonstrated that he could do this part with no hands as we struggled up the rock. From there we continued up vertical stints, which were slightly easier and then came upon a rock that was literally surrounding by drop offs. It was at this point that I began my love affair with the surrounding the rock and hugged them for dear life. I either remained on all fours or face planting the wall as I tried to still my beating heart. The pictures don’t do it justice, but I will say that there is no way that climbing this mountain without any equipment, as we were doing, would be allowed in the US! From the rock surrounded by abyss, we moved on to a ledge that took us to the other side of the rock face to the church entrance. This ledge was literally 1m wide before dropping dramatically into a ravine, and we shuffled along pressing our bodies against the rock wall and grabbing at the holds. Honestly, it was the most terrifying thing I have ever done. The church inside was beautiful and had been repainted in the 17^th centuries so the images were bright and colorful. As I sat in the cool church, looking out at the views, I was overcome by the beauty of it all even as I was constantly dreading the hike back. 

Climbing up the rock face

The priest climbing with no hands

Chris scaling the wall

Holy texts in the church

            On our way back, we decided to sit on the 1m ledge, take some pictures and drink in the scenery. At this point, most people were relaxed but I continued to have my back glued to the rock face, trying to force a smile. It didn’t help that the guide continued to admonish us for moving because if we went over the ledge, we would “destruct” as he liked to call it. Finally we made it down and my heart stopped racing just enough for me to realize that while terrifying, I would do it again in a second. Nothing like the adrenaline rush of pushing one’s self to the limit!

The 1m ledge leading to "destruct"

Heading down

Heading down from the rock with the abyss on either side

Enjoying the view

Eddie and I

Holding onto the tree for dear life

Group shot!

            Overall the weekend was incredible, easily the best in Ethiopia to date. I was so unaware of how beautiful this country is outside of the city and am surprised it isn’t a bigger tourist destination. There are literally no tourists here and every white person we see has been here for some time working on a project of some sort. Most are working with the hospitals or with the government to improve infrastructure. Even we consider ourselves more habesha than farenji although the locals would beg to differ. Hopefully as the country improves and advances, it can draw in more visitors who can also enjoy the wonders here that we have enjoyed so much. 

Discovery Woes

Many of you may be wondering why I have yet to really write anything about my project. Well in truth, things are going along very slowly. The first week I was here, I spent two mornings at St. Paul’s Hospital observing Pathfinder’s reproductive health clinic for women infected with HIV. Every morning, men and women gather outside of the clinic and receive counseling about opportunistic infections seen in patients with HIV/AIDs, STDs and cervical cancer. Once the women were done with their regularly scheduled primary care visit, those that were recommended for screening headed on over to us. The VIA/cryotherapy clinic is in one room (I posted the picture earlier) run by three nurses. I became friends with two of them—Zewdu and Nisussu—as they walked me through the day-to-day schedule. Both thought I was hysterical because I kept writing things down and were even more amused by the way I hold my pen. Although they routinely laughed at my Farenji-ness, Zewdu was particularly sweet and regularly gave me hugs, telling me to stay in Addis. One thing is for sure, people here are amazingly friendly and welcoming even if they think you are ridiculous. Although the clinic at St. Paul’s has been up and running for two years, they just recently saw their 1000^th patient, which is a very small patient load considering the need. A big reason for this is due to the difficulty in advertising these services and having to rely on word of mouth. 

            The screening process takes about 15-30min per patient and is actually really simple. The whole idea of the project I’m working on is to provide a cost effective and acceptable method of screening for cervical cancer in low resource areas. Cervical cancer remains the second most common type of cancer and the leading cause of cancer related death in Ethiopia even though it is easily preventable and treatable when caught early. The US used to have similar statistics, but when the Pap smear was invented and we could screen for potential precancerous lesions, incidence rates of cervical cancer dramatically dropped. The method that we are implementing here is called VIA or visual inspection with acetic acid. It involves swabbing the cervix with regular table vinegar (read very cheap and easy to get) and to look for precancerous lesions that show up as white spots on the cervix. If lesions are present, you can utilize cryotherapy (what you use to remove a mole or wart on your skin) to freeze the lesion and kill the cells. VIA/cryo has been proven to be just as effective as the Pap smear in a study done by John Hopkins in Thailand and now several international reproductive health organizations, such as Pathfinder, JHPIEGO, and RHO, are doing implementation and feasibility studies around the world in low resource areas including Uganda and Kenya.

            What I am trying to do is facilitate the creation of a similar clinic as St. Paul’s at Black Lion, Addis’ largest public hospital and the main hospital affiliated with AAU (Addis Ababa University).  I am attempting to have this clinic in working shape and fully stocked by the time we try to start training the two OB/GYN physicians in charge of running the clinic in early August. I am confident that I can find the space and staff in that time, but my concerns include the duration of training warranted by JHPIEGO (the organization we are modeling after) and the availability of patients on which to train. The JHPIEGO manual dictates that training should either take place on a 7 or 10-day course with each day involving up to 7hrs of training. In Addis, doctors work maybe 2 hrs in the morning (not including the mandatory macchiato breaks), take a 2hr lunch, and then usually take the afternoon off or work another job, so I’m not sure how amenable they will be to sitting in a classroom for 7 hours. Additionally, we need patients to be regularly coming to the clinic from the start so that the physicians can practice the method and gain competency within a reasonable period of time. However, advertising, as I said before, is a really difficult concept here and takes awhile to really have a significant effect on patient numbers.

            This morning I met with Dr. Hezkiel Petros, one of the OB/GYN physicians that will be in charge of the clinic at Black Lion, to discuss these challenges. Our meeting was scheduled for 10am, but he did not show up until almost noon and had to leave after 20min. The sad thing is that I am not surprised in the least. The problem with the culture here is that punctuality nor accountability exists. No one answers their emails and no one has a voicemail so getting in touch with people is near impossible. I now understand why foreign medical students who come to Emory are the way they are. I used to laugh that my Egyptian medical student on my surgery rotation would take a two hour lunch break (lunch breaks are nonexistent at Emory for the most part), but now that I see surgeons heading for coffee rather than to the OR when they have two emergent cases, it makes a little more sense. The system is also entirely dominated by the idea of paternalism and the patients are seen as little more than cases to fix. Needless to say, we are all getting a little frustrated here. The struggle of working within this system every day is exhausting and wearing on us all. There is so much to be done but every minor advancement is met with such resistance and stonewalling that it can be easy to want to give up. Luckily, we are all in the same boat and can offer support to one another, but overall, the days are getting pretty long here in Addis. 

More Pictures!

Sandy, Katie, and I out for a group dinner at Aladdin, a high end Middle Eastern restaurant in Addis. This was the day I spent in bed, with a pounding headache and febrile, convinced I had the plaque, so I'm looking a little worse for wear, but happy to say that it was short lived! 

Eddie, me, Sofia, Chris, Sandy, and Katie out at Chinese Ten Ten Restaurant in Addis. This place is definitely better than any Chinese found in Atlanta and I have made the group return on several occasions. They seem to think my California upbringing is the reasoning behind my absolute love of any type of Asian cuisine. 

Million, Katie, me, Chris, and Sandy about to dive in to fresh fried tilapia in Awassa. This was plate one of three we devoured. 

Me and my monkey friend at our lodge in Awassa. These little guys were everywhere and were not afraid of humans at all. In fact, they usually tried to steal your things or get in your room. 

Katie, Chris, me, Karen, and Sandy in front of the fishermans' boats in Awassa. 

Tales from the OR

Yesterday I spent the morning at St. Paul’s in the OR with the general surgery residents. One of them, named Brihan which means “light” in Amharic, was kind enough to take me under his wing. Of course this meant he took me on as his medical student and pimped me throughout the case but that’s ok. For those of you non medical students, “pimping” refers to when residents and attendings ask you questions on rounds or during an operation to test your knowledge and get you thinking and is nicely coupled with anxiety and pressure. Think the Socrates method of learning.

I have noticed that everyone hear focuses a lot on the meaning of names. Most names have some sort of underlying definition in Amharic. People are also very curious to know what your name means. It’s kind of hard to explain that your parents just liked the name “Katherine” and that it doesn’t really mean anything, so I go with that it’s a biblical name. People seem to be okay with that. They do get a kick out of “Tennis” though. Another interesting thing about names here is that no one has a surname. Their last name is their father’s first name. So Dr. Engeda Abebe is the son of Abebe, and his son will be named something Engeda. It makes it kind of hard to figure out who is related to whom!

Ok back to the OR—after I changed in the “locker rooms” I went to check the OR schedule which is written on a piece of paper pasted on the hallway wall and hunt down a scrub cap and mask. The locker rooms are divided for surgeons and nurses not by gender, which makes it quite interesting. For a culture so concerned with modesty, it was a little shocking to see a female attending start taking off her clothing in front of all the other male attendings. No one else seemed to care so I just went with it. 

Our first case was an open cholecystectomy for cholelithiasis (gallbladder removal for gallstones).  I headed with Brihan to go scrub in. The OR suites are arranged as three rooms off of a central “core.” Like I said before there really is no observation of US sterilization techniques. Patients kind of hang out in the core on black stretchers, semi reminiscent of a morgue actually, and all the OR room doors are kept wide open so anyone can wander in and out. You don’t have to wear a mask unless you are actually involved with the operation and even then, they only wear masks over their mouths and don’t cover their noses. Scrubbing in involves semi vigorous hand washing with regular soap. Once your hands are clean, you head to a little room next to the sinks where they have bundles of gowns and towels wrapped up in sheets tied with string. Usually one of these bundles is left open on a table (read not sterile) so you can grab a towel to dry your hands and a gown. The gowns are folded a new way each time so it’s kind of impossible to make sure the “sterile” part doesn’t touch you. In the US, this is all done by the scrub tech and is kept very, very sterile. Once gowned, you hunt down gloves and try to put them on without contaminating them or yourself. They only had size eight gloves and I am a size six so it was a little interesting. As I was clearly struggling to get suited up one of the residents asked me if this was my first time gowning and gloving. I tried to explain in the most PC way possible that we do things differently in the states but I’m pretty sure he just figured I was incompetent.

Then it was off to the OR! The patient lies on a black stretcher with no sheets and no one really talks to them. Their blood pressure is monitored by a manual cuff once before the operation and once after, and no one uses a stethoscope to check tube placement or if they are breathing ok. The only thing they have is a heart monitor. Once under, the operation gets started really quickly. There is not much time spent draping, cleaning the patient, and there is no call to order.

We started with a transverse approach and then were stalled by the fact that the bovie didn’t work. It took about 10min with the patient open in a non-sterile environment to find one that did. We dissected through the tissue and visualized the gallbladder. The main difference I noticed at this point was that these surgeons didn’t take their time to dissect thoroughly, visualize the anatomy, or practice good tissue handling. Honestly, I don’t think any of that was due to their ability as surgeons. They are working with old tools that are bulky and hard to handle (although they have definitely mastered how to use dull scissors) and I’m sure they try to reduce how long the patient is under as much as possible. The gallbladder was removed fairly quickly, though I was pretty terrified that they were cutting the common bile duct but what do I know, with only a minor spillage of bile into the peritoneal cavity…Then we worked on closing and they let me cut some suture and close the subcutaneous tissue. They thought I was ridiculous because I could not for the life of me work the stupid dull scissors and I realized how nice we have it back in the OR’s at Emory.

The next case was a right total and left partial thyroidectomy on a 65 year old woman who had a physiological goiter due to an iodine deficiency. She was from the highlands of Ethiopia where they have a huge iodine deficiency causing the thyroid to have to work overtime to make enough hormone. Her neck looked like she had swallowed a softball. Normally in the US you never do a partial thyroidectomy but in Addis, they don’t have enough money to place a patient on Synthroid for life so they have to leave a part of the thyroid in the patient. This operation would normally take 3-4 hours in the US (depending on the surgeon, you Emory B people know what I’m talking about!), but we did it in 1.5 hours. This was mostly because we never once looked for the recurrent laryngeal nerve or the parathyroid glands, and we didn’t identify each artery supplying the thyroid gland. We merely sectioned off chunks of tissue attaching itself to the gland and ligated it en mass.  For this operation, Brihan let me close. We actually closed the skin with subcuticular suturing which was surprising. I figured we’d do interrupted stitches due to lack of suture. It was a little difficult to suture using giant forceps as pickups but I somehow managed. As I was closing, all of these medical students started hovering around me, commenting on my technique. It was ridiculously awkward. Considering I haven’t sutured anything in a good three months, I was pretty rusty, and struggled a bit to find my rhythm. I was a little surprised I was allowed to due anything at all, but was grateful for the opportunity, even if it was slightly embarrassing.

Today I am taking a breather and relaxing at my Farenji mecca. It’s beginning to cool down here and the rainy season is settling in. It took me 2 hours to get home yesterday by mini bus with a good 30min of it spent hovering under my small umbrella with an Ethiopian woman as we waiting for a bus to Bole. When they are infrequent like yesterday, you have to charge the bus and push your way on, so my new Ethiopian friend and I had to become a dynamic force to secure our seats!

Tomorrow I am hoping for more OR time and more observing. There is always more to learn!

Gum Thieves

Tonight I fell victim to the gum thieves. We spent the early evening at the travel agency booking our upcoming trip to Lalibela, Axum, and Tigray, and it looks like we have a great long weekend ahead of us. Once we were set with our plane tickets, Sandy and Chris headed to the gym while Eddie, the infectious disease fellow living with us, Karen and I ambled along pseudo-Bole (one of the main roads here) and headed home. A few blocks from our place, we were bombarded with young children trying to sell us gum. Normally, you can wave them off and say a stern "no" but tonight they were rather persistent, pushing me up against a car parked on the side of the road and overall surrounding us. We continued to push back and say "no" as we all clutched our bags. Unfortunately, their small quick hands prevailed and once we got home, I realized my local phone was missing. I was lucky enough that my passport and the large amount of cash I was carrying was spared, but I definitely took a hit since I had literally just added money to my phone. Hopefully those kids will pawn that phone and use it to buy food for themselves and their families. Helping the Ethiopian economy--one quick fingered child thief at a time! As we were warned, all children who sell gum are thieves. Until tomorrow my friends, email is the way to go!

A rude awakening

Although my time spent in the Ethiopian hospitals has been short as of yet, I have been pretty blown away by the conditions here. I have really only seen St. Paul's, which is one of the nicer hospitals, but it's hard to imagine that this is what health care in low resource countries is like. It seems totally unjust and unfair. I never particularly felt strongly that health care is a natural human right but I'm beginning to think it is. It especially hits home as I hear stories of twenty year olds with pulmonary hypertension and cardiac failure due to an atrial septal defect that was never closed, something that is so simple to do in the US. As one of the pharmacists at the clinic told me, it is merely chance that we are born where we are.

Outside of Pathfinder's HIV/Reproductive Health Clinic at St. Paul's

The VIA/Cryo clinic room

The entrance to the ER at St. Paul's. It is packed with people carrying their family to the entrance trying to get in. 

I spent this past Friday morning with Dr. Engeda Abebe, a general surgeon at St. Paul's. After morning report, we headed up to the ORs. There are three working ORs and most look like they have never been cleaned. There is no concept of a sterile core and most people wander around with all of the OR doors open. Scrubs are not regularly laundered and there are barely enough scrub caps and masks to go around. There is only one glove size, limited suture, and limited gauze because all of their surgical supplies are donated from other countries. The length and extent of surgeries and closure type are based mostly on how much suture they have. Apparently 80% of hospital acquired infections here stem from surgical wound infections and I can definitely see why.

An OR at St. Paul's. It looks a lot cleaner in this picture than it really is. Note the open window.

After changing into scrubs and finally hunting down a surgical mask, I was informed that all of the ORs were down due to an equipment malfunction. We waited for an over an hour before the surgeons called off the entire day. Luckily all of the cases were elective (thyroidectomies, cholecystectomies, etc) but I could not believe that the ORs are shut down on a regular basis due to equipment issues. As I was leaving, I saw one man undergoing a procedure just there in the hallway with no sterilization of the incision site and bare bones equipment. It was pretty shocking. 

I spent the rest of the morning rounding with Dr. Engeda, the surgical residents and medical students. It is definitely different than the US. There is no clear hierarchy or structure and it is not evident who really is in charge of the patient. Charts were left empty and films were scattered around with no patient labels, and the patients were in beds covered in blankets that looked like they hadn't been cleaned for weeks. The resources are so scarce here that this is the best care that they can give. Dr. Engeda himself works very hard to implement structure and adopt more Western standards of care but he is working within a system that gives him little room to grow. 

While it is often painful to see, I am hoping to spend more time with the surgical team and learn as much as I can and to observe how to feasibly improve the system. I think the patients here deserve so much more. 

Awasa, Hawassa, Awassa

For a little getaway, we spent this past weekend in Awassa! It’s a beautiful lake side town in the Rift Valley (said to be the cradle of mankind) which is filled with six giant natural lakes. We spent most of the time at Lake Awassa known for its birds and fish market. We traveled there by bus with our new local tour guide friend, Million, who was one of the adopted children of Dr. Dollar the cardiologist I mentioned previously. In case you were wondering, he does indeed go by the full name Million Dollar. The trip took about 6 hours as we stopped along the way for macchiatos and to avoid cows and goats wandering the roads. The drive was a bit long but a good chance to see rural Ethiopia. It definitely demonstrated the dependence on an agricultural economy that Ethiopia has. There were large expanses of crops sprinkled with huts and children running around after the lifestock and each other. If they happened to spot us traveling by, we frequently heard shouts of “You, you, you!” or “Farenji, Farenji, Farenji!” or my personal favorite “China, China, China!” There happens to be a huge Chinese population here in Ethiopia as they attempt to industrialize the country so we get roped in with them.

The group on the bus

We stayed at a lodge, the name of which has changed about three times so we are unsure of what it is currently called, at the edge of Lake Awassa. The grounds were beautiful, filled with trees covered in bright orange blossoms, and the highlight turned somewhat infestation, grivet monkeys. They were everywhere, rolling around, jumping from the trees, and stealing guests’ Fanta bottles. Overall, it was a beautiful place and a nice respite from bustling Addis!

The lodge

Sandy, Karen, and I

Grivet monkey

The afternoon was spent having a delicious Ethiopian lunch with juice and wandering the edge of the lake taking in the sights and wildlife. There are several different species of indigenous birds, the most notable and arguable the ugliest bird alive is the Marabou kingfisher. These birds were everywhere, stood almost up to our shoulders, and lurked around the fisherman trying to steal their daily catch. We also saw many swimmers, fisherman, and honeymooning couples cuddling by the lakeside with their macchiatos and Coca Colas. After an afternoon of lounging and exploring, we settled in for dinner at Dolce Vita, an Italian restaurant run by an Italian ex-pat. The food was delicious and much to Sandy and Katie’s delight, they even had Pineapple and Strawberry Fanta!

The ugly Marabou Kingfisher

Colorful birds

The next morning we woke up early to grab our breakfast before heading to the fish market. After less than successful bargaining by our very own 80% habbishat, otherwise known as Karen, we headed down to the waters edge to watch the fisherman pick through their nets. Every morning they bring in their nets and work through them, pulling the tilapia and other fish free. The fish then go straight to the beach where others gut them, scale them, and trim them to be ready for sale and frying. Several shanties line the top of the beaches where locals have giant pots filled with piping hot oil for fish frying. We devoured 7 fish and they were probably the best food we have had yet in Ethiopia. As with everything here, you eat them with your hands which can get messy but is definitely fun.

The fishermen picking through their nets

Cleaning the fish

Fish fry

The finished product!

On our way home we blasted Teddy Afro, our favorite, hippest Ethiopian pop star and political truant, and stopped at Lake Langano. We treated ourselves to some cocktails on the beach at the swankiest resort before continuing our long drive home.

Now we are settling in at home, our stomachs filled to the brim, eagerly awaiting our next big adventure!

13 months of sunshine

Ethiopia has lots of little oddities that have taken some getting used to. For instance, there are twelve 30 day months in the year and one 13th month with 5-6 days in it. Due to this difference in calendars, it's actually the 7th day of the 10th month of the year 2004. It can get a little confusing! Also, they do the time differently where our 12am/12pm is their 6am/6pm respectively. So if a meeting starts at 8:30am our time, it's actually 2:30 Ethiopian time. I have to second check all of my meeting times for fear of showing up at the wrong time! Not that it really matters--no one is on time and everything just sort of does things whenever they so desire. Lucky for me I have no particular agenda so it works out!

One great thing about Ethiopia is the coffee. The country used to be an Italian colony so they still have lots of espresso machines and coffee is huge in their culture (see past post for talk about the coffee ceremony). I am pretty much obsessed with the macchiato's and have been scoping out each cafe for the best ones.

Macchiato from Lime Tree, my little Farenji (Amharic for foreigner) mecca

In other news, I joined a gym! Sandy and Chris have been going to this gym on Bole and I figured with  all of the amazing food here and free time it would be good to try to get in shape. The gym is actually pretty nice and has lots of treadmills, bikes, and weight machines. There is also an hourly aerobics class that looks amazing and I can't wait to do jumping jacks with the locals. One of the trainers at the gym has really taken to us and helps us with our training and stretches our legs afterwards. Talk about good customer service!

Our gym!

So far, this city has been amazing and I am having the best time exploring it. I am hoping to take more time next week to visit the museums (one of which holds Lucy's skeleton!), the steps where Olympic runners train, and other sights and sounds of Addis. Every day is something new. Well until tomorrow, salam!

Bole Bole Bole

Today was my first real day at the hospital. I went by mini bus to St. Paul’s, which is about an hour or so away. The mini buses are quite the unique experience. There is a station with dozens of buses and people yelling at you as to which bus is going where. They whip around the city like crazy but are definitely the best mode of transportation here.

Mini Bus Station 

When I got to St. Paul’s, I sat in on surgical morning report, which lasted all of 10 minutes and was impossible to understand. I think the morning reports somewhat substitute for any sort of rounds they would have here. Afterwards, I got to listen to a presentation on hand washing which is part of Karen’s project. Apparently the compliance rate at St. Paul’s is 1% before seeing the patient and 3% after seeing the patient. Compare this to Emory’s compliance rate, which is around 60%! No wonder Karen needed us to bring over so many bottles of hand sanitizer!

View from St. Paul's

Room where morning report is held

After morning report, Yanothan, a member of Karen’s team, was nice enough to introduce me to Dr. Abdulfetah who I believe is the head of OB/GYN at St. Paul’s. From there I was lead to the Pathfinder clinic which specializes in reproductive health for women infected with HIV/AIDs. This clinic already utilizes the VIA/Cryotherapy method that I am trying to implement at Black Lion, the main hospital associated with Addis Ababa University, or AAU. Apparently, Pathfinder wanted to train AAU OB/GYN’s in this method but due politics and some negative attitudes within AAU, this never came to light. So, my goal is to observe the Pathfinder clinic at St. Paul’s to recreate the same idea at Black Lion.

My first day was very informative and it is so interesting to see how things are done here. The clinic and visit itself is very chaotic and scattered. There is no emphasis on patient directed care or forming any sort of relationship with the patient. Sterilization of equipment and beds between patients is fairly bare bones. I am curious to see how the rest of the hospital is run! I have also been in contact with Dr. Engida, a surgery attending  at St. Paul’s, and I am hoping to scrub in on a few cases with him. I hear the cases you see are unbelievable and am very eager to get started!

In other news, yesterday Sandy got in touch with an Emory cardiologist who apparently funds housing for orphans and children with medical issues here in Addis. Yesterday afternoon we visited this house and were the guests of Bayelgne and the other “children” staying there. Bayelgne was taken to be a child soldier at 9 years of age after his mother died. Once free from the fighting, he met an American cardiologist who helped rehabilitate him into society and provided him with tuition for schooling. He now works with similarly situated children, such as those living in this house. Most of the children were in their teens or early 20s and finishing up school to take national exams before the summer begins. There were a total of 2 girls and 3 boys living in the house and two of the children had very significant scoliosis. Apparently, they can’t do spinal surgery in Ethiopia and have to send these children to Ghana to be operated on.

They welcomed us with a huge feast of injera, shiro, spinach with garlic, pasta, salad, and vegetables along with bottled Coke. They mix Coke with water here, which is interesting but actually pretty tasty. They also preformed a traditional coffee ceremony where they hand roast coffee beans over a fire in the house along with incense providing such an amazing smell. Part of the ceremony also involves making and eating popcorn. We sat around talking for hours about travel, marriage, children, and most of all India. Bayelgne loves India apparently. We also met a man named Million who is a travel guide and said he would help us plan a few upcoming trips we are working on to Awasa and Lalibela. Overall it was a really fun experience, and we are hoping to have them over to our house for pizza sometime in the near future!

Enjoy the pictures below!

Bole Road, the main road in Addis

Construction in Addis

My street! And donkey friends