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!

Designated Wrangler

We are officially beyond the halfway point! It’s hard to believe that the training is almost over and we are well on our way to celebrating a successful week! This morning Dr. Goedken was nice enough to invite me to a Medical Education Writing Workshop at the Sheraton Hotel sponsored by MEPI (Medical Education Partnership Initiative) before heading into training this morning. It actually was very useful and really broke down how to take an aim or question and translate it into a publishable work. Both Dr. Goedken and I agreed that the course would be a great addition to Socrates, our medical research weeklong course at Emory, which definitely left something to be desired. While I was thinking about future medical research and how useful this information was, the course also made me think about my own personal writing and how to move forward with it in the future. My goal has always been to write a novel and I’m hoping that my time here gives me the experience and the opportunity to pursue that! I keep telling my roommates that if surgery doesn’t work out, maybe I’ll just go with my original idea to be a writer. Sounds a lot easier these days especially as I work on my residency applications and begin to face the reality of moving on from the safety of school and into life as an intern.

            After the workshop, we were picked up by Dr. Dawit and headed to Black Lion. On the agenda this morning was a debriefing session from yesterday’s clinical experience and then more practice with cryotherapy and VIA images. Also worked in there was my lecture about infection prevention practices in the healthcare setting and in the VIA clinic. It was a pretty bland lecture, but I think it went well! I also showed a video from MAF or Medical Aid Films which showed the necessary steps for decontamination and disinfection in the VIA clinic. It was actually a really clear and useful video, even though it took a bit to load given the tricky internet situation in the hospital.

Me giving my lecture. Everyone is obviously riveted. I tried to make a joke and heard crickets. 

            Right before lunch, the chief resident Samson kindly let us know that none of the residents would be able to attend tomorrow or Friday due to having to administer medical student exams. It seems like the medical students have exams every other week and the whole hospital literally shuts down when they do. No one rounds because the medical student is the one who collects the patient history and no operations are done because all of the residents and attendings are administering exams. I understand that everyone needs to be a little more patient in teaching hospitals but the idea that the hospital slows to a halt during exams is a little odd to me. Anyway, luckily we rearranged the schedule so the residents can complete the training and attend the testing, but that little hiccup almost gave me an ulcer.

            The afternoon was again spent in the clinics having the residents practicing VIA on participating patients. We finished around noon so I took my time with lunch as I figured most of the residents would. At around 12:45 I looked around for my group and they were all gone! I was supposed to pay for the residents to take a taxi cab to St.Paul’s, but apparently they left without me. So Alisa and I made our way over. On the way, my cab driver quizzed me in my Amharic knowledge and I am now proud to say that my vocabulary has greatly expanded. I can now count to 30, ask a man or a woman their name, how they are, etc, and know various other words. Anytime we stopped talking, he would take it upon himself to ensure my understanding and randomly test me on a number or phrase. It was hysterical. I can’t say I did very well, but I tried!

            When we arrived at St. Paul’s, the residents were nowhere in sight and I began to get a little panicked. I also was unable to get in touch with Dr. Abdulfetah who was supposed to be overseeing the clinic. Finally, the residents strolled in already to go and started setting up the clinic. The patient charts started stacking up and it looked like it was going to be a very productive day! Unfortunately we were beginning to run low on consent forms, the VIA exam forms, and the surveys so I ran across the street to make copies, which worked surprisingly well, and hurried back. Initially the residents were doing so well—counseling the women, ensuring they had filled out the forms, and doing thorough exams, but about an hour into the day everything just fell apart. The charts piled way high and women were literally trying to push their way into the exam room while I pushed back to barricade the door. In their attempts to move things along quickly, the residents shuffled all of the charts and all of the paperwork I had organized by patient number. They forgot to go over the consent forms before the patient got undressed and up on the exam table and didn’t have the patient leave the room to fill out the surveys. The surveys are supposed to have the patient rating the services they received so if filled out in front of the residents, there is a huge potential for bias. Plus, the patients don’t even understand the first question because the Amharic translation is off and makes it a double negative, which not surprisingly patients find very confusing. My data may be totally bogus, but oh well!

            Finally the day wrapped up and we got ready to head home. We had to send away 4 patients and tell them to come tomorrow because we were so swamped. When all was said and done, I headed over to Desalegn hotel to meet with Dr. Goedken and make some changes to the forms we are using and our schedule. Both of us were slumped in our chairs, barely forming sentences out of pure exhaustion. She had to head to a MEPI dinner at Yod Abyssinia right after while I thankfully got to go home. At home, we started to clean the house and get organized as Karen, Chris, and I are all leaving this weekend. As much as I miss home, my family and friends, I am unbelievably sad to be leaving. This place, as loud and chaotic and often frustrating as it is, has become to feel like a second home and I will be really heartbroken to leave it. But there is hope that I will be coming back in December to see how the clinics are running and to collect more data, so maybe my Ethiopia and I will be reunited again. 

From Pork to Patients

            Another day done! The morning started with me rolling out of bed, still exhausted, and heading to the Desalegn Hotel. Luckily, there were no en route panicked phone calls and I relaxed for a little with my macchiato before Dr. Goedken came down in her usual blaze of bubbly energy. We chatted over eggs and toast and came up with a reasonable to do list and amendments to our schedule given our participants inability to be on time. Then we headed down to the lobby to meet Dr. Dawit who has been giving us rides to Black Lion. Dr. Dawit’s family actually owns the hotel, and he works there as a supplement to his income as a physician. Around 45minutes later, he pulled up in his car, sporting his Prada sunglasses, and off we went!

            Per usual, Dr. Goedken and Dr. Dawit worked on higher up details and talking with faculty while I ran around like a mad woman setting up the room, printing schedules and sign in sheets, and setting up the lectures. Luckily, we only ran 30minutes late this morning so I didn’t have to hassle people too much on time. We reviewed the steps of VIA and cryotherapy and then spent the rest of the morning practicing the two. We brought over two ZOE pelvic models and bought hot dogs, as I mentioned yesterday, to be used as pretend cervices to cryo. It actually worked remarkably well and the residents thought it was hilarious that we had little hot dogs on sticks stuck in the pelvic models. We had each resident walk through the whole process and spend extra time counseling the “patient.” Physicians here don’t really take the time to counsel or to make any sort of connection with the patient. Generally the patients are ignored and told what to do, so we spent a lot of time talking about choice, privacy and confidentiality. If you think things doctors have bad bedside manner in the U.S., you would be shocked here. I have seen doctors completely ignore crying women who have just been told they have cancer as they sign paperwork, so a little extra emphasis on how to talk to patients was definitely needed!

Hot dog's on a stick make excellent cervices apparently. Unfortunately, Dr. Dawit left them in his car over night so they smelled a little ripe. 

Dr. Goedken helping Mesfin adjust the speculum to show the hot dog cervix. 

            As the residents counseled, screened, and treated the hot dog cervices and rubber pelvic models, I was busy making copies of all the forms we would need for that afternoon. There were consent forms, patient follow up cards, education sheets, surveys, and VIA/Cryotherapy forms that all needed to be printed, copied and stapled. I’m telling you, I am mastering the art of being an assistant. Oh and the Ethiopian photocopy machine, which is finicky beyond belief. All of these forms have to be in Amharic, which can sometimes prove difficult with formatting. I’m not sure how to read it so can’t tell if the lines are in the appropriate place or what and was definitely admonished today by the attendings for my sloppy forms. Oh well!

Mesfin practicing VIA on Samson, OB/GYN Chief resident pretending to be the patient/obligatory hot dog in pelvic model holder. 

Practicing cryotherapy

Dr. Abdulfetah watching as Jalel practices cryotherapy.

            When the mini training and demonstration was over, the group heading to St. Paul’s, made up of 4 residents, one nurse, and one attending, quickly grabbed sandwiches and hopped in a cab. Well, really they all grabbed sandwiches, sat down and took their time eating, while I was standing, taking my lunch to go, tapping my foot and glaring at my watch. Oh habesha time…We eventually got there about 1pm and Nigussu, one of the nurses, and I, busied ourselves with setting up the clinic. It is even more noticeable to me how hierarchical the medical system is here. I am asked by everyone to do the most minor things simply because I am lowest on the totem pole. When asked something absurd, I tend to stand my ground, which the attendings don’t appreciate, but what can I say, my stubbornness usually wins out. Luckily, the clinic came together pretty quickly and we began to see patients within 30minutes or so. Half of the residents spent time in HIV VIA clinic that St. Paul’s already runs and the other half were with me in the non-HIV clinic. The hospitals here don’t really understand HIV transmission nor do they have good decontamination techniques so the HIV population is still heavily segregated in terms of procedural rooms where blood or bodily fluids could be involved.

Our little table filled with forms and patient charts. The OB/GYN residents would sit here and talk with the patients before performing the screening test. 

The other side of the clinic showing the patient table and our decontamination buckets. 

            Over the course of two hours we saw a total of 14 patients in the two clinics and all of the women tested negative for any precancerous lesions. As Dr. Abdulfetah, the OB/GYN residents and other trainees talked to the women and performed the screening, I was nagging everyone to obtain consent forms (preferably PRIOR to the woman undressing and putting her legs up in stirrups. This proved to be a difficult concept) and in my broken Amharic trying to have the women sign surveys. Of course, half of them didn’t understand the form, so I’m pretty sure my data will be horrendously skewed, but it all got done! We are surveying the women to assess the overall acceptability of VIA and cryotherapy. We basically want to see if women will tell others about it and view it as a positive experience, which is one of the ways we can hope to assure sustainability of the program.

            While we were busy at St. Paul’s, Dr. Goedken, Dr. Dawit, Dr. Hezkiel, and 5 OB/GYN residents were over at our other clinic in Black Lion Hospital seeing patients as well. Unfortunately, they only saw 4 patients over the course of the afternoon but were able to utilize cryotherapy to treat a precancerous lesion found. The rate of dysplasia in women is usually around 10-15% so unfortunately for the training, the residents won’t gain the experience in utilizing cryotherapy (the treatment modality) as often as they will the steps of VIA (the screening modality), which is done on everyone.

            Tonight I am busy preparing my lecture for tomorrow on infection prevention practices, which I am a little nervous about. Hopefully I don’t bore them to death and hopefully they take me seriously. I guess we will find out more tomorrow!

600 Condoms and A Pack of Hot Dogs

Well it’s official! Day one of the training has come and gone and I am happy to say that despite a late start, everything went off perfectly. Dr. Goedken arrived early yesterday morning so we met all afternoon to arrange last minute details with Dr. Dawit and Dr. Hezkiel. Dr. Dawit, the principal investigator on this project, has been traveling all over for the past few months and MIA in terms of the project (why I have been working exclusively with Dr. Hezkiel). Dr. Dawit was initially in London on vacation, followed by Canada conducting a training session, and then in Colorado as his expectant wife was awaiting delivery of their first child, so we had a lot to catch up on. Of course, despite the fact that I had sent out schedules and lectures almost three weeks ago, begging for approval and feedback, this was the meeting in which they wanted me to rearrange everything. So I busied myself with a to do list, being the good administrative assistant that I am, and tried to calculate in my head just how little sleep I would get in order to finish all of this work. After a quick coffee, we headed to Black Lion to set up the simulation lab with all of our materials. The lab where we are holding the training is a surgical skills lab donated by Johnson & Johnson and is absolutely gorgeous. It bears no resemblance to the dilapidated facilities it’s contained within and is constructed entirely of marble. Even the tables are marble topped! It contains projectors and screens, flat screen TVs, and laparoscopic equipment. It’s hard to believe this exists in Ethiopia, but thankfully for us, it does. At a small fee of course. 

The simulation lab where we are holding the training

Our training materials.

Our visual aides for learning VIA. Every participant got one of these to put in their respective clinics.

            Once we had set up our pelvic models, notebooks and charts, we headed to the grocery store to buy some extra supplies to outfit our clinics. Since we are trying to treat this VIA screening as a portion of an overall reproductive health checkup, we wanted to supply the women with condoms and sanitary napkins. Luckily, our budget is pretty extensive so we felt comfortable outfitting the hospitals with a substantial number to utilize after we leave. Not so comfortably, at least on my part anyway, we bought 600 condoms and almost 500 sanitary napkins. So here I am, being my awkward white girl self in Ethiopia, strolling the supermarket with a shopping cart filled with multiple economy sized boxes of Sensation condoms, ribbed for extra pleasure of course. I got a few stares as did Dr. Dawit and Dr. Goedken who were with me. As Dr. Goedken said, they probably wanted to know how this Ethiopian man scored two Farenji women. That of course, made it even more awkward.

            I spent the evening at Lime Tree, with Dr. Goedken and Alisa, the PGY-4 OB/GYN resident, catching up, and I, stuffing my face with pizza and chocolate cake to soothe my nerves and frustrated anxieties. All the while, I am praying that Friendship supermarket doesn’t close so I can run to and buy multiple packages of hot dogs that we will use tomorrow to train the residents in cryotherapy. Apparently the end of a hot dog looks like a cervix and mimics the consistency of human tissue, who knew? Luckily, my amazing roommates were able to grab some for me and I could breathe easy knowing one of my tasks was done.

            I finally got home at around 9:30pm and quickly got to work creating two new lectures, amended two old ones, re-writing the schedules, going over my presentations, and resending all of this material to those involved in the training. Of course during all of this, my internet wireless stick ran out of money and stopped working and I almost fell asleep multiple times, but finally around 1:30am, I finished my list. I wish I could say I crashed into bed, but my nervous energy kept me bouncing around until my alarm blared at 5:30am. Off to the Desalegn Hotel I went to meet Dr. Goedken for breakfast and to discuss other concerns we had. On the way, I received a phone call from Dr. Goedken telling me about even more changes that I needed to make, so I busied myself on my computer in the cab ride over. My driver told me I work too hard and wanted to know when I was going to focus on having babies instead. Oh dear. 

            I’ve had a lot of time to reflect on Discovery over the past couple of months and have realized that my project really has nothing to do with medical research despite what our curriculum says. In reality, I have spent this summer experimenting as a glorified administrative assistant. I have made schedules upon schedules, set up meetings and canceled meetings, facilitated purchases and deliveries, printed literally thousands of sheets of paper just so that when my attendings meet, I can literally redo it all again to their liking. I have dealt with people being unreachable, with people talking down to me because I am a medical student, and simply put a smile on my face to get the job done, but even now that it is almost over, I can’t say that I’m relieved. It could be the lack of sleep talking, but I am pretty frustrated that I almost feel as if my role in this project has been viewed as inconsequential. Regardless, the project is not about me and is really about the women here, but still, it’s hard not to feel a little let down after all this struggle and so little recognition.

            Dr. Goedken and I quickly ate our breakfast and met with Dr. Dawit in the lobby. Of course, even though it was 7:30am and we needed to be at the hospital at 8:00am, he insisted we could have coffee and still be on time. Sure. At 8:20am we arrive at the hospital and I run up the stairs as our training is scheduled to begin in 10minutes during which I need to set up the projector, print the schedules, set up the room, and overall prepare everyone for the day ahead. Of course this entire time, I am being admonished for my lack of flexibility and inability to conform to “habesha time,” but I find the whole idea so ridiculous, I can’t budge unless in a completely disgenuine way with a strained smile on my face. I understand the need to assimilate to another’s culture when trying to enact change, but the idea that you have to budget an extra hour into a training, a training that you have spent literally thousands of dollars on to give free medical training to residents, because they will all be late (for no good reason either, mind you) is absurd to me. Also, when planning yesterday, we were told we needed to buy notebooks, pens, and bottles of water for every participant as this was expected from presenters. I think they forgot to note that this is what is expected from white presenters. Anyway, I digress.

            At 9:30am, the residents begin rolling in and much to my amazement, all nine senior OB/GYN residents, 3 nurses, and two attendings were present, meaning we that we are training a total of fifteen people. We began our day with introductions and lectures, discussing the pathophysiology of cervical cancer, counseling women, and even doing role-play (with me as the Ethiopian woman of course) so that the residents could practice answering common questions. We even had two tea breaks with coffee and cookies and a wonderful lunch catered to us! I couldn’t believe that so many different components came together so nicely. Despite our late start, we finished a whole hour early, much to the joy of the residents.

Dr. Goedken giving the first lecture

Dr. Hezkiel lecturing about HPV and cervical cancer

Dr. Dawit lecturing about the pathophysiology of cervical cancer

The afternoon was spent freezing hot dogs as practice and more grocery shopping. Tomorrow we are starting the clinical practice portion of the training, which is the last big hurdle of this week. Hopefully all will go smoothly and we will have patients actually show up to clinic! Keep your fingers crossed. 

            As my eyes are sagging and my stomach is in knots, I am having trouble balancing my thoughts of pride in the success of the first day and the frustration I feel as I am used as a menial laborer. I know it’s the role of the medical student, but it’s hard to swallow at the end of today. Despite my best efforts, this project has become really ingrained in me and to feel as if I no longer have control is difficult. I guess it’s a good lesson to learn as I continue on in my training, but today I am feeling a little worn out. 

            

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!