There Are Clouds Ahead

So yesterday, I was orienting Alisa Kachikis, the PGY-4 OB/GYN resident who just arrived a few days ago, to Black Lion. We were talking with a few attendings about my project here when one informed me that my project does not have IRB approval nor has it been approved by the Department of OB/GYN. When I questioned him about it (big mistake), he proceeded to give me a lecture about how you can’t just come to a country and do whatever you want—that there are standards, protocols, and my personal favorite “nice-ities” that you have to follow. Further investigation with others in the department yielded some interesting information. Despite having submitted the proposal almost 6 months ago, despite being reassured by the dean of AAU that everything was on schedule one month ago, we do not have IRB approval for my training project. My training that is scheduled to take place in 4 days.

            IRB stands for the Institutional Review Board, and is an ethical review board that reviews all studies involving human subjects to ensure that basic human rights and principles are upheld. It was born to uphold the Belmont Report, a product of the Tuskegee incident in the 70's where several African American men were experimented on in an inhumane way. The aim is to allow for an appropriate balance between risk and benefit to the participant. My project is an implementation project meaning that we are implementing a screening method that has already been proven effective and safe with minimal risk in other studies. Because of this, we are exempt from having to submit our proposal to the IRB in the US; however, the standards here in Ethiopia are very different. They are very particular about any research that comes through the university especially if it’s not the standard of care in the US. Several of the other students here have had major problems getting projects approved and have had to amend their projects or move to other institutions in order to even get started.

            While I understand the need to regulate experiments, especially in low resource areas where people could easily be taken advantage of, it is so unbelievably frustrating to be treated like a child and to be accused of having some sort of paternalistic attitude. I have worked so hard to balance the ridiculous political games the health administrators play with each other, to navigate all the bureaucratic BS as a white female medical student, and now to be told that it was all for nothing really has me aggravated. We have the best intentions with our project and this program we are trying to start, yet the university is not willing to budge. What’s even more irritating is that every two seconds, attendings are telling me what they need me to buy for them, essentially using me as a giant ATM. I am beginning to see the difficulty in being white and coming to a low resource area. Despite your best intentions, often you are nothing more than a walking dollar sign, and when you try to reign in unrealistic goals and promote real change, you are brutally rebuked for not providing the “standard of care.”

            Physicians here are obsessed with the US standard of care, as if they don’t understand how broken our own system is, how in debt we are due to unnecessary testing and outrageous insurance costs. They beg for laparoscopic equipment that they can’t maintain, when what they really need are surgical masks and gloves so that they can reduce the 40% surgical wound infection rate. They want the resources to provide Pap smears when it already takes one month (it takes maybe one day in the US FYI) to get the results back because they don’t have any pathologists here or the lab facilities to process tissue samples. Even when given the resources to follow WHO guidelines, their healthcare workers don’t follow through. For instance, HIV patients with cough who show up to clinic are supposed to get AFB sputum cultures to rule out TB, and if negative, given medications to prevent infection. Despite the high burden of HIV and TB, especially the high rate of co-infection here, no one does this and patients die from a disease that could have easily been prevented or at least caught earlier and treated. The other day, Karen was telling us that at St. Paul’s, they have dug a pit outside of the hospital where they throw all of the placentas after a delivery. Because of the high volume of rain this season, it has started to overflow which is a huge sanitation issue (not that it wasn’t to begin with). Their solution? Dig another pit. They want me to buy them thousands of dollars worth of equipment they don’t have the resources to maintain or fully utilize when they throw body parts into a giant pit? Are you kidding me?

            I think this place is grating away at me. The country itself, the people, are so beautiful and wonderful, but the healthcare system is an absolute nightmare. At first I could laugh about the ridiculous things done or said, but now as my project is dying a slow, agonizing death, I’m just beginning to see it as sad. 

Discovery Habesha Style

Yesterday Dr. Hezkiel and I planned to meet at 8:30am to pick up some items we need for the VIA/cryotherapy clinic and training. I had finally managed to take out 20,000Birr I needed from various ATMs around the city (not without the bank putting a teensy hold on my debit card first) so we were all set to go. Everything here is paid for in cash so if you are buying something expensive, say $700 worth of compressed gas, you have to carry around quite a bit of money with you. Luckily I have learned since my gum thieves experience and have found nifty ways of hiding money in my bag so I was feeling ok, but definitely a little nervous with all of that cash on me. 

When I got to Black Lion, I had my morning macchiato with Sandy, and then headed to Dr. Dawit’s office to grab a cryotherapy machine. These machines are similar to those used in the states for little skin lesions but we are using them to kill precancerous cells on the cervix to prevent the development of cancer. I wanted to take one of the machines with me to ensure that it hooked up correctly with the tanks before purchasing them. This particular piece of machinery is worth about $1500 USD and is conveniently packed away in a black briefcase that looks like it could possible carry $1million USD, a bomb, or a semi automatic. Nice.

So here I am sitting in the lobby of Black Lion waiting for Dr. Hezkiel to show up. It’s 9am. I call and he tells me he will arrive at the hospital in 10 minutes. Ok great except that time goes by and now it’s 10am. He finally casually strolls into the hospital and talks with some colleagues before heading up to his office, walking right past me. I chase after him with my black briefcase and at this point he informs me that we really should go run our errands at 2pm and with that, he is off. Trying to calm my boiling blood I walk away and decide to head home to take a little breather. At this point it has started to rain (sigh) and I am carrying roughly $1200 USD in cash plus $1500 USD worth of medical machinery, so I decide that it’s worth the $6 USD to take a cab home. In the cab, sailing towards home, I begin to feel a little bit better and start to re-plan my day with the change in schedule. That is until the cab breaks down in the middle of the road. What was even better is that the cab driver got out and started to just pump random pedals, refusing to let me leave the car, insisting that everything was fine. Ultimately, I had him drop me off 15min from home to avoid another break down and then prayed that I didn’t get robbed on the way. Luckily, the gum thieves weren’t out in drones so I was safe as I sped walked home.

When I got there, Freye, our housekeeper was busy sweeping and mopping. She had been sick over the weekend so I tried to ask her how she was feeling. We weren’t really communicating well so I just smiled and headed to the living room to do work on the couch. Next thing I know, she sets a cup of tea down in front of me! I guess she had thought I had said I was sick and had been sweet enough to try to take care of me. Despite our dumping multiple pounds of laundry on her, I guess she really does care about us. Also during my little hiatus from the day, I tried to remove my nail polish from my manicure we had gotten for Karen’s birthday (more on that lovely experience later). I decided that neon purple wasn’t exactly professional and busied myself with removing it. Funny thing about Ethiopian nail polish remover is that it turns your nails blue. So while the purple was gone, my nails now looked like a strange combination of cyanosis and a bad dye attempt. Vigorous hand washing was in effect from that point on until my nails started to look semi normal again.

By 2pm I was back at Black Lion and much to my amazement, Dr. Hezkiel was there on time! It was wonderful and off we went in his Toyota to purchase the items for the clinic. We went to the CO2 cylinder-filling center and tested our cryotherapy machine on the tanks and were delighted when it worked. It was really fun to see all of the employees of the company crowded around the machine watching in awe as a little ice ball formed on the tip. Dr. Hezkiel excitedly explained to them how this machine could help prevent cervical cancer and everyone was smiling and cheering. It was really inspiring and fun to be a part of. Satisfied, we headed to the office to work out the details of payment and delivery. Well, of course the filling machine was broken and we would have to wait until later that week to grab the tanks, but still, all around good times.

Again off we went to pay the medical supplies distributor for a trolley we had purchased a few weeks back and my worries began to drift away with our productivity and as each 100Birr bill left my bag and made me feel less like a walking ATM. Then Dr. Hezkiel got a phone call. He had a patient to see! A lot of the physicians here work in the hospitals in the morning and then work in private clinics in the afternoon to boost their salaries, which are disgustingly low ($200 USD per month). So after some coffee, I waited in the car, and he saw the patient. Luckily for me, but not so much for the patient, the visit only took 10minutes so soon we were on our way again to the printers to pick up the training manuals we had ordered when Dr. Goedken was here. Well, of course the printer was broken, so we would have to pick up the manuals later this week, but we paid the remaining money owed and got everything squared away. The print shop owner even invited me to see his workshop and offered to make me an Emory Med t-shirt!

As I walked home at the end of the day in the pouring rain, of course, I realized that no matter how frustrated I get with dealing with the healthcare system or any sort of business here, meeting the people, seeing their love of life and love of connecting with others is so uplifting. Yes there are mentally ill people who spit on you in the streets, little children who may rob you blind, and mini buses that may try to scam you, but overall the people here are so remarkably friendly. I have been invited to graduation ceremonies, coffee ceremonies, and family homes just because. I have had a little girl, no more than 6, run up to me and hug me because she saw me tear up on a bad day. I have had women offer to help me carry my bags and lighten my load, even if just for a block. This is definitely a country of smiles and despite the challenges I face on a regular basis here, I usually have one on my face at the end of the day too.

A Comedy of Errors and 43 Spectacular Views

We have finally arrived home from Gondar and our excursions in the Simien Mountains! It was a wonderful trip on the whole but one ripe with misadventures and entertainment. A good week for highs, lows, and challenges if you will.

            We started the trip sipping macchiatos in the Addis domestic airport waiting to go through security to board our flight. As we were sleepily gazing around the lobby, a fellow traveler called for a doctor. Since we had a third year medicine resident, Sara, with us, we volunteered to check it out. The girls stayed behind while Ira, Steven, Chris, and Sara went to check on the situation developing in the men’s bathroom. Sure that someone had a syncopal episode or was suffering from a habesha GI virus we weren’t too concerned. Once we saw Steven’s face as he returned from the restroom, we knew it was more serious. We followed him in and there lying on the floor, was a large German man, covered in his own urine, ashen, unresponsive and pulseless. Immediately we started helping with chest compressions. At this point, the men had already cracked his sternum and broken most of his ribs in their efforts so we were spared the gut twisting sound of a man’s ribs breaking in efforts to save his life. Sandy, Ira, Chris, Steven, and I all took turns doing CPR as Sara lead and coached us on our depth and speed. We continued to check femoral pulses and continued to find no response. All the while, Ira continued to beg airport employees to call some sort of emergency response team and Karen tried desperately to find and contact anyone who knew the man lying on the floor. We are told again and again that the emergency response was coming although no one really seemed to care that a man was dying in the bathroom. Men continued to amble along in and out of the restroom, using the facilities, and walking out after staring at us for a bit. 25 minutes later, as we were all sweating and tiring from pumping this man’s chest, a nurse shows up with a green bag containing medical equipment.

            Let me take a break for a moment and describe what this would look like in America. A man collapses to the floor due to a massive heart attack in the bathroom. Immediately someone notifies airport staff and an emergency response team is called. Around the corner, someone grabs an AED (a defibrillator), begins CPR and attempts to shock the man into a life sustaining rhythm. Within minutes, an emergency response unit is there ready to continue resuscitation and transport the man to the nearest hospital. While the prognosis is probably not great, there is a chance that the man may survive. Now back to our story.

            The nurse who showed up ruffled through the kit she had dragged with her, took out a blood pressure cuff and stethoscope and attempted to take the man’s blood pressure. At this moment, the only reason this man was perfusing his brain and the rest of his body wass due to our compressions. Thus his only measurable blood pressure is a direct result of our efforts. However, she doesn’t understand this as I tried to explain it to her and she continued to get in the way of us doing compressions to check his pressure. Exasperated, I ripped the blood pressure cuff out of her hands and threw it on the other side of the room, so that Sandy could continue CPR. Searching through the bag, we finally found some epinephrine that was in glass bottles that snap off at the top. I tried to open the bottles in order to push the drug through the peripheral IV access that Sara was working on, but the bottle was so old, it literally disintegrated in my hand the second I tried to open it. The second bottle did the same. The remaining items in the kit included some gauze and tape. At this point we realized that there was nothing else we could do for this man. We felt horrible walking away, but with no additional medical response, we were too limited to do anything else. Almost 40 minutes into the ordeal, a man shows up wearing an orange construction vest with a wheelchair. Hello “emergency response.” We were assured that an ambulance was waiting for this man right outside, but not a single one of us believed it. We helped lift this poor man’s body into the wheelchair and they rolled him through the airport with absolute no sense of shame or urgency and out the door he went. No one in the terminal lobby even gave them a second look.

            It was 7:00am and 1 hour into our trip.

            Even though I am beginning my fourth year of medical school, I have never seen a code. I have never done CPR on an actually person, and I have only seen someone actively die once or twice, but here I was on the floor of an Ethiopian bathroom, covered in a man’s urine, desperately trying to do anything, immensely limited by my lack of experience and our lack of medical support. I still see his face sometimes—his ashen skin, blue glazed eyes, mouth bloodied. His lungs had continued to breathe for him despite his lack of cardiac activity. I think the thing that made it that much harder, was the amazing indifference demonstrated by everyone else in the airport. A man lost his life, alone, in the least dignified way possible, and no one cared. Only one women, whose job it was to perform a traditional coffee ceremony, wet her eyes with tears. It was something I will never forget.

            Remarkably, we made our flight to Gondar and our trip was ripe with talk of what we all had just experienced. As we landed, we were picked up by our guides who would drive us to Debark to start our trek through the mountains. The drive was over two hours and as we neared our destination, it began to rain. Not mild feathered rain, mind you, but all consuming rain. However, due to the massive changes in altitude we would be experiencing, our guide, Tesfy, decided we needed to hike into camp to acclimate. Luckily the hike in was only two hours, but it was spent sliding in mud, huddled in rain jackets, and eyes glued to the ground as we carefully navigated every step. Our view was obscured with a misty fog so heavy that we could barely see those in front of us. As we finally pulled into camp, soaked from head to toe, we were relieved to see that our camp was already set up and waiting for us was warm, salty popcorn and thermoses of tea and coffee set up on a long table covered in a gold table cloth. A fire was built and we busied ourselves drying our clothes as the rain continued to pour down outside. Our spirits slowly lifted as we regained feeling in our fingers and toes and as we filled ourselves with warm tea. The rest of our guides were busily chopping to the side of the hut and soon the tent was filled with the smell of onion, garlic, and spices. Little did we know that our chef, Alem, was famous for his culinary masterpieces. He soon approached us, dressed in a traditional chef’s uniform (hat included) and announced to us that dinner was ready. As with each remaining night of our trip, we were treated to a four course meal including freshly made soup, pasta, chicken, four to five different vegetable dishes, and dessert of cookies and pineapple. He eagerly watched us scarf down our food and like our mothers back at home, made sure we cleared each plate. Now this is camping.

Our campsite. To the right is the hut where we would have our meals and stay dry by the fire

Our living quarters

Karen and I enjoying the spectacular views 

              The next day we were lucky enough that the sun was shining and we headed out on our first big six-hour trek. We passed through hoards of Gelada baboons, who are completely docile and have no fear of humans, caught views of incredible waterfalls and giant cliffs emptying into lush green valleys, and forged rivers cold as ice. It was a perfect hiking day, except for the fact that I was suffering from the habesha GI virus. That day definitely squelched any shame I had remaining in me. Talk about being one with nature. I was lucky enough that my body felt well enough to keep on trekking, but it was definitely suboptimal. This day we were led by our scout, as our guide Tesfy, was escorting Sara (who unfortunately was not feeling well) back to Gondar. According to park regulations, every group traveling through must have a scout escort them at all times and he must be armed with a gun. Our particular scout carried an AK-74 and was fond of singing to himself, making sheep noises, and habesha dancing early in the morning to the radio. He loved my repeated enthusiastic replies of “gobez” which I had been told meant “good” but actually means “clever.” Again, people here are fairly amused by my idiocy. Our scout had a warm place in all of our hearts. He watched over us protectively and guarded us each night from jackals that apparently like to steal shoes. It is still unclear as to whether they were referring to animals or people when they discussed the jackals surrounding us. Our scout even lovingly covered Sandy’s vomit with dirt when she too came down with the habesha GI virus. Needless to say, he received a very large tip at the end.

             Again that night we were treated to coffee and tea, a four-course dinner, warm fires, and much to our delight, ice cold St. George beer and Coca Cola. We played Yahtzee to our hearts content and retired for bed at a normal 7:30pm. When it gets dark and it begins to really freeze, there is no better place than cocooned in two sleeping bags in your tent with 5 layers of smokey clothing clinging to your body. Sleeping in the clothes you wear on a daily basis is incredibly convenient I’ve noticed, especially when hygiene only really consists of wiping your face with a moist toilette and brushing your teeth. I’m telling you, I made roughing it look good.

            Unfortunately, our luck of weather died with that night and we spent the remainder of our hike draped in foggy mist. While it wasn’t raining thankfully, it remained cold, and most of our views were obstructed by the fog. On the third day of our trek, we hiked 7 hours to the peak of Mama Mia (much Abba was sung on that mountain). The peak stands at 4100m and we were breathing quite heavily as we summited. Although our spectacular view (Tesfy was quite fond of this phrase, almost as much as he liked to sit us down to discuss our program for the next few hours) was blanketed in white, being up on top of that mountain felt incredible. It was the highest I have ever been and felt really proud and happy that I had made it. The wind began to blow in earnest on the peak and soon, we began to eagerly bound back down the mountain towards camp. As we approached our last night in the Simiens we anxiously awaited our sure to be amazing meal from Alem, our scout’s loving watch, and Tesfy’s reiteration of our program that lay ahead. That afternoon at camp, we even caught a glimpse of the elusive Ethiopian ibex—a huge beast with horns that were literally 2/3 of its body length. Although we spent the majority of the time cold and muddy, a good portion of the time completely wet, and all of the time short of breath from climbing and singing, trekking through those mountains was a trip we will all remember for a lifetime.

            The next morning we spent some time hiking around hoping the clouds would clear for some more views, but unfortunately, the mist persisted. So we loaded up our trucks and headed back to Debark and Gondar. Well some of us did. As I’m sure most of you can imagine, underdeveloped roads during rainy season tend to get a little muddy. The truck carrying Karen, Steven, and Emily plowed ahead and up the mountain, while our truck had some difficulties. We slide up and down on the muddy road, literally five feet from a cliff, trying to make our way up. I was desperately clutching Ira’s sunburned arm much to his chagrin, exclaiming that I had much more to give in this life fighting back a tear or two, while Tesfy laughed at my absurdity. Apparently, fearing that the tin vehicle you are in which the driver has no control over while in spitting distance of a cliff leading to sure destruction is very funny to Ethiopians. Finally we were ordered out of the car and all of us began to mentally prepare, as we stood in the pouring rain, for the guaranteed 4 day hike back to Debark, when out of nowhere, at least 30 Ethiopian men began to mobilize into action. A short, 4-foot rope was tied to the bumper of the car and a man chain was formed. Some men grabbed the rope but the majority of them were clinging on to each other as they began to literally pull the car up the mountain. It was one of the most ridiculous things I have ever seen.  Their strength and dedication paid off and soon enough our truck was out of the mud and up the mountain. We paid them generously for their efforts and off we went.

            I wish for time’s sake that I could say that our adventures stopped there, but much more ridiculousness was ahead for us. The four star service of our guide and his crew was again evident when we found out that our hotel in Gondar had been booked and paid for already so we were soon on our way to warm showers and clean beds. Our hotel was beautiful and when we arrived they prepared a traditional coffee ceremony for us. We wandered around the city of Gondar and then headed to dinner at The Four Sisters Restaurant. The restaurant was stunning, covered in traditional Ethiopian paintings, and we knew we were in for a delicious night. We ordered shiro, tibs, and the fasting plate and went to town. Unfortunately, as we were getting to leave, it began to rain (I can imagine you are getting the idea of rainy season in Ethiopia now), so we decided to wait out the storm before heading back to the hotel. At this time, Steven was already up making friends, and playing one of the traditional musical instruments. All of the sudden, the sisters started singing, and we were up in a dance circle as they tried to teach us how to habesha dance. We had a soul train line and we chanted and danced in circles as everyone else in the restaurant clapped and laughed at us. As the music and rain died down, we sadly said our goodbyes and headed home. There at the hotel, we resumed our dance party as we shimmied our shoulders, jutted out our chins, and flipped our hair to Teddy Afro much to the delight of the hotel staff. It was a great way to end our final night in Gondar.

            The next morning we got up early so we could visit the castles of Gondar before our afternoon flight. Gondar is part of the northern historical circuit as well and is known for castles that stand in the center of the city. We were delighted when a certified tour guide was there ready to take us through the history of the city and the kings that had ruled there. We had no idea what was to come ahead. I’m sure most of you have seen Ferris Bueller’s Day Off at some point in your lives. Most of you actually probably watched it due to my repeated insistence. Remember when Ben Stein gives that riveting lecture on voodoo economics? Got it? Now imagine sitting in that lecture for one and a half hours. Welcome to our tour of Gondar. I’m not quite sure how, since I was zoned out pretty much the entire time, but we somehow covered all of Ethiopian history, talked about psoriasis, the Empire State Building, the Sistine Chapel, and had a quiz in the history of water filtration. Of course, being the good medical students that they are, Sandy, Ira and Chris absorbed and enjoyed most of it, but the rest of us were slowly dying and losing our minds. Luckily, we were able to cut the tour short so we could catch our plane back home to Addis.    

Castles of Gondar. Most of them were destroyed during the various militant activity that has taken place over the years

Fasilides Castle built by Emperor Fasilides

     

One of the castles in Gondar

Sandy and Ira in the lover's window. 

            

Ira, Sandy, and Chris learning during the tour

I apologize for the lengthy entry, but these past five days were too riddled with ridiculousness, sadness, helplessness, discomfort and pure joy to leave out a single minute. As our last trip as a group in Ethiopia, it was a strong way to end. Stay tuned for more pictures!

More Simien Mountain and Gondar Pictures!

Getting warm and drying our clothes around the fire. By the end of the trip, we all smelled so horribly of firesmoke

After the first day of hiking freezing and wet but loving it--Karen, me, Sara, and Sandy

The crew! Our scout is on the left and Tesfy, our guide is on the right. 

Our cook Alem and his sous chef

Alem in his traditional chef outfit

Breakfast the first morning. Each day we had bread with nutella spread and peanut butter along with eggs, pancakes, and french toast.

Our first day of hiking! Luckily it was sunny

Dominant male Gelada baboon

Baby Gelada baboon

Sandy and I with the baboons!

The crew! From left to right: Emily Schmitz, me, Ira Leeds, Sandy Zaeh, Karen Schmitz, Steven Gerhard, Chris Smitson

On our way to the waterfall!

Steven and Karen

Chris in front of the waterfall

Me overlooking the cliff's edge at the waterfall

Our scout with his AK-74

Heading down into the valley. The mist would travel over the mountains from time to time. 

One of the many rivers that fed into the natural springs of the park

One of the rivers we had to cross on our hike

A child running through the village of Gich we passed through at the end of our first day of hiking

The village of Gich

One of the native birds in the park

Steven looking into the distance on the summit of Mama Mia

Me, Karen, Steven, and Emily at one of the many spectacular views

Me overlooking one of the edges of the cliff. Facing fears everyday

This is how the majority of the trip was--mist overlaying everything

Ethiopian villagers helping to pull our truck out of the mud and up the mountain

Karen, Emily, Sandy, and I with the four sisters who owned the restaurant

The Four Sisters in Gondar

Steven and Karen in the lovers window

The Emory Global Health Crew

From left to right: Janet Gross, Sara, Sandy Zaeh, Chris Smitson, Me, Dr. Carlos Del Rio, Karen Schmitz, Dr. Glass, Sophia, Dr. Goedken, Janette, Dr. Russell Kempker, Dr. Henry Blumberg, Chris Lawley, Dean Lawley

Pampering and Progress

It has been a busy week for the Real World Addis house members! This week all of our Emory faculty mentors decided to pay us a visit and see how we were getting along in our research. Additionally, the dean of the medical school, Dean Lawley, came along as part of Emory’s efforts to secure a global health partnership with Addis Ababa Unversity and the other surrounding hospitals and healthcare systems throughout the city. We are one of four universities (Emory University, University of Wisconsin, Johns Hopkins, and University of California, San Diego) included on a MEPI (Medical Education Partnership Initiative) grant awarded to Addis Ababa University and as such, serve as partners in global health projects and research both here and in the US. The crew included Dean Lawley and his wife Chris, Dr. Henry Blumberg (infectious disease attending), Dr. Russell Kempker (infectious disease attending), Dr. Carlos Del Rio (bigwig at the Rollins School of Public Health) and his wife Janette (a pathologist), Dr. Glass (a neurology attending and specialist in ALS) and his wife Dr. Gross (a psychology PhD and teacher on grant writing), and Dr. Goedken (my mentor and an OB/GYN attending).

On Tuesday in honor of our independence day, we hosted all of the mentors at our house for an American BBQ. We had to be creative but we managed to grill actual burgers, make coleslaw, heat up baked beans, slice watermelon, and I even pulled off vegetarian lasagna cooked in a wok! Overall the dinner was a success, though not without a few awkward pictures courtesy of Dr. Del Rio, and we ended the night lighting sparklers and bottle rockets. As house DJ, I ensured Bruce Springstein and John Mellencamp was playing on repeat.

The next day, Dr. Goedken and I went full speed ahead on our project. Unfortunately her flight had been delayed and she missed all of her connections (sounds familiar, huh?) so we were short on time with a long to do list. We met with Dr. Hezkiel Petros, the OB/GYN at Black Lion who is our main contact now that my main Ethiopian principal investigator, Dr. Dawit, is out of the country, and discussed lots of issues and potential challenges we saw. Through our discussions, we have designated a clinic space, have started advertising for staff within the pool of OB/GYN nurses at Black Lion, have run literally all over Addis buying examination lights, CO2 cylinders, and other medical supplies, and are brainstorming advertising for patient recruitment. Overall, I am exhausted but very happy that everything is working out! During this week I have also met the Dean of Addis Ababa University Medical School, Dr. Mahlet, and the Provost of Medical Education at St. Paul’s, Dr. Lea. The latter meeting was actually quite interesting because I somehow got dragged into what was supposed to be a meeting with Dean Lawley, and I was instructed by Dr. Del Rio to describe our medical school curriculum and share my thoughts on it. I was definitely not prepared in the slightest to discuss it in front of several bigwig people from Emory, but I think it went ok!

Last evening, Dean Lawley took all of the Emory faculty and Emory medical students currently here in Addis out to dinner at Shaheen, the Indian restaurant at the Sheraton. The Sheraton is a monstrous presence in Addis and takes up a large portion of the city. It is quite decadent, draped in marble, and dotted with crystal chandeliers. Even though it’s in Ethiopia, the rooms still run $400/night so only the very wealthy manage to stay there. Needless to say, nothing in my wardrobe was adequate for such an event! The Dean insisted we sit next to him and throughout the dinner (which was mouth wateringly delightful) he asked us a multitude of questions about our backgrounds, our projects, and where we wanted to go in the future. He particularly enjoyed my camel story. How can you not want to hear about a rabid, gurgling camel named Bruce? Even though the dinner was easily the culinary (and schmoozey) highlight of the trip, I was literally falling asleep at the table. I hadn’t been home since 8am and had been barreling through the city in a tin can with diesel fumes coating my lungs. By 11pm, my bed was sounding pretty amazing.

Tonight Dr. Goedken leaves and won’t return until our training, which will officially take place August 6^th-August 10^th. So it will be up to me to ensure that all of the materials we ordered are ready and delivered, and to re-work the JHPIEGO curriculum to fit our crash course training. Although it is a lot of organizational work, I am feeling very confident that this is going to be successful. Sustainability is another issue, but I continue to insist that nurses need to be trained and serve as the backbone of the clinic. The nurses I have met here are so passionate about this issue and I am sure that with their support, this clinic will really fly.

Throughout this week I have also encountered a lot of global health politics, which I find particularly interesting. One of the main organizations that has worked on bringing VIA/Cryo to Ethiopia is Pathfinder International. Pathfinder is a women’s health organization that focuses on a multitude of issues but since it is partially funded by PEPFAR, only caters to HIV+ women here in Ethiopia. This is the same group that trained and helped start the VIA/Cryo clinic at St. Paul’s that I shadowed my first week here. JHPIEGO (an affiliate of Johns Hopkins) is another international health organization that worked with Pathfinder to create materials for a universal training course that would allow for the method to be implemented anywhere. For some reason or another, JHPIEGO and Pathfinder have had a falling out, but we are continuing to use JHPIEGO materials for our project. We had been hoping to actually pay Pathfinder to run a training session for Addis Ababa University (AAU) physicians to start a non-HIV+ clinic, but one of the physicians we are working with (Dr. Hezkiel) irritated Dr. Shumet (the head of Pathfinder here) and they now will not work with us. Great. We also had been hoping to work further with St. Paul’s to utilize their facilities and nurses, but there is tension there as well because St. Paul’s is starting a residency program, which further depletes the academic resources for AAU students working there. Luckily, we have navigated the issue well and both programs seem to be ok with us working with them simultaneously, but there has been lots of bribing with examination lamps, gloves, and CO2 gas cylinders to make that possible. To further complicate matters, we were hoping to recruit patients from the Family Guidance Association (FGA) for the physicians to practice on during the training. The FGA actually performs pap smears for women here in Addis, but since the results take over a month to get back, the program has been less than successful. We just found out that Pathfinder is actually running a VIA/Cryo training session for them this week, so we doubt they will be willing to send patients from their clinic to us now that they can utilize the method. Oh well. We are still hopeful that with the help of both Black Lion and St. Paul clinics we can recruit enough women to make this project a success!

Now I am currently waiting around for Keyline Advertising to deliver a prototype of the manuals we are printing and then I am off to the US Embassy with my roommates for a happy hour/Farenji meet and greet. It should be fun to meet other potential non-Ethiopians here in Addis! Our public health friend, Katie, has left us sadly, as has Eddie, a recent graduate from the infectious disease fellowship program at Emory, so the house is feeling a little empty. But, in a week or so, Ira (Sandy’s fiancé), Steven (Karen’s boyfriend), and Emily (Karen’s sister) are joining us for our trip to Gonder and a big hiking and camping trip through the Simian Mountains. I hear there are baboons there and I can’t wait. 

Rain, Rain Go Away

Well we are officially in rainy season here in Addis! It rains every day for pretty much the entire day. Luckily it doesn’t storm too often but the mud and the cold is beginning to drag on us all. Getting anywhere is made infinitely more difficult as people are crammed on the mini buses or navigating the streets that are swollen with muddied water. All of us now have three times as much laundry to do on a regular basis—poor Fraye!—and it’s a struggle to look somewhat normal and clean. I have had particular issues since the only shoes I brought are canvas slip-ons, Danskos (glorified clogs for all you non medical people), and flip-flops. It looks like I’ll be buying some more shoes while I’m here!

For the first time since I’ve been here, we spent this weekend at home in Addis. Overall, we had a great time, and spent most of our afternoons having movie marathons. You can buy bootlegged movies on the street for 30 birr (about $1.50 US) so we stocked up on some new movies and classic favorites. Unfortunately we don’t have a DVD player so we all have to cuddle up around my laptop, but it works out for the most part. We also went to the Edna mall theater to see Snow White and the Huntsman, which was entertaining! I’ve decided that the movie theater is my new farenji mecca. At 40birr ($2.25 US) per movie and with cheap, delicious popcorn, it’s a nice break from the rain and the bustling city! The movie selection is somewhat limited (current titles include Abraham Lincoln: Vampire Slayer and Ice Age 4) but some good ones come through too.

On Saturday, we decided to head to Mercado, Ethiopia’s largest open-air market. Katie, our fellow Emory MPH student, is leaving today and wanted to see it before she went on to Germany to visit family and then home. We were also hoping to buy a grill for the 4^th of July party we are throwing for our Discovery mentors tomorrow. All of our mentors including the dean of the medical school, Dean Lawley, are visiting us this week so we wanted to treat them to a fun dinner at our place. 

After brunch, we were lucky enough to hop on a mini bus going exactly where we wanted with room for all 6 of us. At least, we thought we were lucky. We started to head towards Piazza but then the bus suddenly made a U-turn and went the opposite direction. We thought that it was a little odd, but figured the mini bus driver was just being crazy and confused as many are. The bus made the loop and finally started heading the right way but then turned suddenly again. All the while, Chris was being hassled by the money collector and his stuff was constantly being touched and moved. All in all it was very weird, but we continued to trust that we were just reading into things. Then the mini bus dropped us off saying we had to take another taxi to Piazza, which never happens. We all were frustrated and confused but delighted when another mini bus pulled up saying they could take us all to Piazza. Mistake. Again the mini bus took off in the wrong direction, we were shoved into the window seats, and Katie felt a hand on her purse. Suddenly, the bus pulled over and we were forced to get out again. This time, angry and tired of being hassled and scammed, we grabbed our money back from the collector guy and stormed off. All the while the people that remained in the bus were laughing at our abrupt reaction. Looking back, we really did ignore the signs of a scam.  We are pretty sure the buses were working in conjunction to rob us but luckily they were unsuccessful and we even walked away with a small profit as we took back 10birr bills to cover our 8birr fare. Unfortunately for us, we were now in the middle of nowhere Addis and absolutely none of us wanted to get back into another mini bus. So we got oriented and started the 1.5hr treck home. Of course it started to rain, so we were thrilled when we got home and were able to promptly curl up to a movie before heading out to the Indian restaurant across the way for dinner.

Getting scammed is definitely a part of daily living here. At first we all joked about the hustlers and hagglers, the gum thieves, and the pickpockets, but after a month of constantly dealing with these stressors we are beginning to wane in patience. When you come to a country to help the people, to improve medical care, it can feel demoralizing to be constantly taken advantage of and to be singled out as a foreigner. Even our sympathy for those less fortunate has diminished as we are continually pushed to our limits of kindness. I think we are all looking forward to our next trip away!