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.