Medical Mission in Ethiopia Month 8 Part 2

May 11, 2015

kulshanIt has been an emotional week. Quite likely the most difficult emotional week since our arrival. On Thursday we received an email from my Dad. The email heading was, “Kulshan 1999-2015.” My heart became a ball of aluminum foil. Oh no. Our beloved family golden retriever dog of 15 1/2 years. The kids were in their room, playing, laughing, giggling. Mark was on a Skype call with the U.S., I was catching up on emails. I saw the headline and said, “Oh no…. Josh. Sonja. Please come.” I did not say another word. Together we read Dad’s artful recount of Kulshan’s last few days. And the tears started to flow.

This is what the email said:

Kulshan: 1999-2015

Yesterday, around 3 o’ clock, Kulshan stretched out on the floor with his head in my lap and his paw in Margaret’s. I was on his right. Margaret was on his left. There were just the three of us: three of us with our backs against the wall sitting on a mattress covered with warm blankets and a pillow.

His favorite vet, Terry Tomchick, although “off duty” came into her office, squatted on the floor with him, listened to the fluids in his lungs and in his belly then hugged him to hide her tears.

“I’m sorry...Buddy …It’s time…This time…it’s time”, she said before recomposing her professional demeanor.

Lizzie, her vet nurse, started to ask if she should take him back to insert the catheter. “No,” said Terry.

“Leave him here in comfort and let’s do it here.”

Margaret took off his collar. Kulshan watched the procedure with calm and composure.

Five minutes later Dr. T. and Lizzie left quietly and slowly closing the door behind them. Kulshan had already left.

Margaret and I stayed for a few more minutes, his head between my hands and his paw still in firm grip by Margaret. You could feel the temperature drop.

Just an hour earlier I had been sitting on the bridge between the carport and the house when Lisa Austin sent Mr. K. a message. It was a simple message. I thought it would cheer him up. It just let him know his friend Jake, Lisa’s faithful dog who was part of her scene long before Paul made an impression, would be there to greet him. I tried to read it. I couldn’t. I ran my fingers around the black dog collar that matched Jake’s. It was a wedding present and reminder that they both took part in Paul and Lisa’s wedding. I still couldn’t read it. I tried six times and I failed six times.

But Kulshan knows.

He knew a lot.

Yesterday morning Margaret was up first and gave him a little breakfast of fried chicken liver and fresh bread. He didn’t want to eat. He didn’t even want to get up.

Immediately after she pulled out of the driveway to go to her 8:30 dental appointment, he let me know he wanted me to come and sit with him -- or at least have me in view. He whimpered when I stepped into the kitchen to make coffee. He whimpered when I went to answer the phone. He whimpered when I went to the bathroom. By 3 o’ clock I had still not made time to brush my teeth.

Twice he tried to get up. Twice he failed.

He wanted to go outside but even with my supporting his rear end we could make it no further than the bridge. There we sat, next to each other, for the next several hours. His belly looked and felt bloated and he would try to cough. A couple of times he barked for no apparent reason. Perhaps it was a call to his Dog Almighty: a realization that it was time to give up this earthly life. Perhaps he was already talking to his friend Jake.

Just a week ago we were going to the Mirrormont Park at least once every day and having a half-hour walk. He would let me know that anything shorter was not acceptable. But that’s when he started to refuse his Iam’s dog food. He got canned dog food and fresh chicken liver (of which I bought some 20 lbs. and put in the freezer). A couple of days later he tired of all dog food, canned dried or biscuit.

On Saturday he went with us to Seattle. On Sunday he spent the day outside. He was inspecting a new trail I have been building then decided to stretch out in the sun right in the middle of it. He didn’t want to go to the park so we put away the tools and talked.

That night I had a dream. Unlike Margaret, I seldom dream – or can remember of what I dreamt. I was looking on Google for Chicken-Liver Pâté recipes. I can’t remember if I found any. Chicken-Liver Pâté?

By Monday, however, Kulshan could not make it to the lane without Margaret’s help. He could not even do a #2 without falling over. However, being Kulshan, he merely adapted and did what he had to do on his side. He was able to stretch out on the dry leaves and relax.

If only we could adapt with such ease to take advantage of the moment.

Then yesterday…Tuesday….

So quickly everything changed.

He knew he needed us.

Unlike the animals of wild, he didn’t want solitude in his last hours. He wanted company. He wanted his Master and Mistress. He wanted us.

The grin that had been a permanent fixture on his face for 15 years gave way to those meaningful glances.

I now know what he was saying…

It’s time…Buddy….This time….It’s time.

This time, it was time.

We love you and we miss you….

Buddy.”

Tewodros, a trusted bajaj driver, asked me why I appeared sad on Friday. He looked at me quizzically when I told him our family dog had just died. This is a foreign concept. “Family” dog? How could a dog be a part of one’s family? Several weeks ago I heard an Ethiopian say that dogs and children are genetically predisposed to hate and fear each other. And indeed, the way that dogs and children interact supports this theory. True, most dogs have rabies, and there is good reason to fear them. The usual dog greeting on the street encompasses hurling a large rock as the dog jumps and runs away, tail down. The expression, “treated like a dog,” could have originated here. So, local empathy, there is not.

Our ex-pat friends understand. Pascale and Ingrid, our apartment neighbors from London completely understand. Even if Pascale is a cat person, she gets it. I thank the well timed email from Deb Chaplin back at home, understanding and compassionate. Our American family friends living in Gondar understand, they are moving mountains to bring back their adopted Ethiopian dog to the states. We share our feelings with those who understand. The others allow us to just be.

A few other stressors are circling around us. One is our visa status. After my last visa extension experience we decided to ask the University of Gondar to take care of this process for us. Accordingly, we sent our passports to the customs liaison representative in Addis three weeks ago. Yesterday we learned the passports had returned to Gondar sans visa extension, sans resident permit. I spoke to the University of Gondar customs liaison representative. The resident permit process has changed. Now we need to obtain an official work permit (signed and stamped) from one Ministry. We then should bring this work permit, photos, fingerprints and completed application to the immigration department who will decide whether or not to grant us temporary residency status. I don’t know why we were not informed of these requirements three weeks ago. Argghhh. We were told if we apply for another visa extension, we may receive 15 to 30 days maximum. Meanwhile, our current visa expires in three weeks. Over the past 8 months we have learned that every single step in every single process takes an inordinate amount of time and patience. Mark and I are running out of both.

Our ex-pat friend and colleague has it far worse. Liz, the British anesthesiologist, arrived 2 months ago for a three month assignment. She was only granted a one month visa prior to her arrival. Her one-month visa extension was not granted until a week after her first visa expired, despite the fact that the immigration office had her passport and paperwork a week prior to the expiration. Liz was told she would not be granted another visa extension and she needed to apply for a resident permit. The University of Gondar ex-pat liaison thought the resident permit process should be started immediately, so he did not return her passport to her. This occurred one month ago and now her visa is again expired. However, she has still not received the official application or fingerprint forms despite multiple inquiries. Last Monday she needed to go to Addis for the week and was able to use her British driver’s license as identification to enter the airport. On Friday, the Addis customs officer denied her entrance to the airport without her passport. She was unable to board the plane to visit Lalibela on her return to Gondar. Despite official letters and passport photocopies the Addis custom’s officer would not allow her through. Liz is a conscientious person, she has anesthetists to train at the hospital and she cares about the patients who need surgery. Today she recounted the story of her 16 hour bus ride back to Gondar, sitting in the center of the back row, next to the smelly woman, and vomiting into her plastic bag due to motion sickness. To top it off, the university ex-pat liaison now wants her to pay the expired visa fine, required before proceeding with any additional visa or residency permit applications. The fine that the University incurred due to inaction. Criminy. She just hopes she will be able to collect her passport and leave the country in a couple of weeks, at the end of her three month stay.

Today we met the liaison representative in Gondar and collected our passports. Mark feels much more relaxed, because we at least have our passports back in our own hands, albeit without visa extensions or residency permits. I am still anxious. Are we leaving in 3 weeks? Should we buy our airline tickets? Where are we going? Purgatory is indeed unpleasant.

The problems we have here revolve around the lack of planning and communicating in order to prevent said problems. These are the same issues that plague the health care system. Cervical cancer screening is all about planning and communication to prevent cervical cancer. Preventive maintenance would ensure the power generators continued to work. Anticipation of a problem does not lead to action. People wait for the problem to materialize then react. Local health center patients are not referred to a higher level of care prior to obstructed labor and a fetal death or uterine rupture, but after. Ok, Kristen. Breathe in, breathe out.

I did not present my hospital referral study to the dean of medicine or the academic commission this week. There were text messaging exchanges confirming the plan to present the study, but late in the week one of the public health directors informed me the dean had flown to the U.S. for a couple of weeks and all meetings were postponed. At least the public health folks seem to understand the practical applications of communication. I thank them. Breathe in. Breathe out.

My new deep breathing mantra started after an altercation with the ob/gyn department head. I have invited her no less than a half dozen times to meet with me, only to be dismissed. A few times she has accepted an invitation, and even proposed meeting times, only to no-show. One Tuesday she appeared during morning session and proceeded to ask interns and residents questions in a way that can only be meant to humiliate. I have sat for months during these sessions and tried not to judge. But on Tuesday my patience snapped. She asked an intern a question, he gave an appropriate answer, and then she continued to hammer him with the same question, as if asking for another answer. I eventually turned to her and said, “Doctor, would you please answer the question? I would really like to know the answer.” She responded, “Why don’t you ask the student?” And then we moved on to discuss the next patient. Later that morning she gathered the labor ward resident team to the office to discuss her displeasure regarding their patient care and documentation. The two junior senior attending physicians were also present. I joined the meeting and near the end of the discussion one of the junior attending physicians asked me what I recommended to improve care. I said that at my training institution in the U.S., the senior attending physicians are present every day, around the same time every day, and that they make regular patient rounds with the residents. I described the practice of sign-out from the outgoing team to the incoming team, and that the team included the attending physician. I also said that I did not think showing up once every few weeks and reprimanding the residents was effective. I recommended the attending physicians (including myself) be present on the labor ward at least once a day during sign-out. Well, she did not like my comments and said as much. 12 days have elapsed since this altercation, and I have not seen her once.

This altercation upset me. I questioned why we were trying so hard to extend our visas and stay in Gondar. Fortunately, there are some kind, wise folks around here. One is the chief resident. I asked him for guidance in dealing with the department head. He asked me why I cared about what she thought. He told me that the residents and the other attending physicians truly appreciate and recognize my ideas and work. Why should I care about one person’s opinion? And then he said I should do what everyone else does, just ignore her. And so I began my new mantra, “Breathe in. Breathe out. And move on.”

April 26, 2015

These issues seem trivial now in light of recent world events. Last week ISIL released a video that showed the beheading and shooting of 28 Ethiopian Christians in Libya. Executed because they were Christians. The entire country of Ethiopia is in mourning. Flags are at half-mast. People wore black for three days. There were demonstrations in the major cities, some which turned violent. Many people have changed their Facebook profile picture to a simple black box. Social media content is predominantly filled with story after story of the execution. People are sad. Very sad. They are outraged. They feel powerless. Thousands protested in Addis Ababa. Mark is in Addis Ababa to extend our visas and witnessed the crowds. He texted, “OMG. There are so many people.” I texted him back, reminding him of the Ethiopian people’s exuberance during happy celebrations, “Please stay safe!” During a later phone call he recounted watching thousands of people marching up Bole Road, the main road through down town Addis. They neared a police barricade, police started beating people with sticks. Pandemonium ensued. Mark was watching events unfold from a restaurant balcony. He said people started running everywhere, including up the stairs and through the restaurant trying to escape. Within a few hours the crowds dispersed. Businesses were not looted. Order returned.

I asked some people why they are upset at the government, when the beheading obviously took place by ISIL in Libya. “The government should do something.” “These people [who were executed] were fleeing Ethiopia to find a better life. If life were better in Ethiopia, then they would not be fleeing, and would not have been captured and executed.” Some said that Ethiopia is now a target, because the Ethiopian government worked with the United States to subdue Al Shahab in Somalia. This coordinated military strategy has been largely successful. Al Shahab is weak. But Al Shahab joined ISIL and now they are retaliating. Some Facebook postings linked American news reports that state the U.S. supports ISIS, because the U.S. supports Libyan rebel forces fighting the Illegitimate Libyan government, and ISIS is fighting the illegitimate Libyan government. Other postings questioned why the U.S. is maintaining silence. Why have U.S. leaders not condemned this execution? Why should Ethiopia help the U.S. fight against Al Shahab, a subsidiary of Al Quada, if the U.S. does not help Ethiopia in their time of need? Still others say that they expect the U.S. will help, because the U.S. was the first country to be truly attacked by terrorists, and Americans understand terrorism. I did a Google search and found a news release that a spokeswoman for the White House condemned the attacks. The report did not mention the spokeswoman’s name.

A Muslim bajaj driver told me that ISIL and ISIS are not true Muslims. Many people are saying this. Several people told me it is written in the Koran that Ethiopia shall remain safe from Islamic aggression, because long ago Ethiopian Christians protected Mohammad’s family from persecution. In fact, the Ethiopian king at that time apparently converted to Islam, thus establishing early Islamic roots in Ethiopia. This may be why a Christian Ethiopia has remained relatively untouched amidst several Islamic countries, maintaining its strong Christian identity. The Koran deems it be so.

Relationships between Christians and Muslims in Gondar appear relatively stable on the ground. Social media is a bit conflicting. People say horrid things on social media outlets that they would never say face to face. Christians accuse Muslims. Muslims defend their religion. On the other hand, a recurring post is of the Ethiopian Muslim who chose to be executed by ISIL with his Ethiopian Christian brothers, rather than denounce their Christian religion. Damn. That is courage.

Bickering and squabbling cannot upset me. ISIL execution of Ethiopian Christians upsets me. I am also tired of eating cabbage, onions, and potatoes as my only vegetable source for the past couple of months, but how dare I complain of that?

Prior to the ISIL event, Mark went to Addis to try and secure visa extensions. His experience was similar to my immigration experience, except he did not surrender the horrendous job to a local. Instead, he persevered. Initially he was told we could not have visa extensions, because we had already received one visa extension, and the rules only allow one visa extension, try a residency permit. He was dismissed with the wave of a hand. He returned, and was told we could not have residency permits, because our contracts only continue for another three months, residency permits are for those staying at least six months to a year. Hand wave dismissal. That was Tuesday. Each attempt takes hours of waiting in lines, going to one office, then being sent to another, and then another, some officials are not in their offices, so then it is back to the previous office. Wednesday morning he returned. This was the day of protests, roads were closed, police barricaded. Mark and a local colleague walked to the immigration bureau. A fortunate outcome of the protests was that most people were unable to reach downtown. The immigration bureau was relatively empty. Again, Mark was sent from one office to another to another. By the end of Wednesday morning, the officials had agreed to give Mark and me visa extensions, but not the children. They wanted original notarized birth certificates, not just the copies that Mark brought. The argument that notarized birth certificates were unnecessary for the first nine months of our stay fell on deaf ears. Hand wave dismissal. Wednesday afternoon Mark returned to once again argue our case. This time someone actually looked at our current visas and decided that we have been in the country illegally since our return from Kenya. We had single entry visas, obtained a day before Mark returned to the U.S., and two weeks before we all went to Kenya for our one week safari with my mom and dad. Our single entry visas were dutifully stamped by the customs official when we re-entered the country. The immigration official said those single entry visas were invalid the moment we left the country, and that we were responsible for the fines and other penalties (Imprisonment?). At this point Mark left the office, sat on the immigration office steps, put his head in his hands. Breathe in. Breathe out.

Our colleague, who had not been allowed into the inner offices, found Mark and inquired about the process. Mark explained. Our colleague then went to the outside office and asked to see a supervisor, a director. He then proceeded to shame them. “These people are here helping the Ethiopian people! Mark is fixing hospital equipment, his wife is a doctor training other doctors! And we are not helping them! This is embarrassing. I am ashamed of my country! We are the ones who made the mistakes! They were just doing as they have been told. This is humiliating. You must make it right!” Or at least this is the translated version as I understood it. The supervisor decided to make a decision. We were granted three month visa extensions. All of us. The penalty? Mark needed to apologize for causing such a problem and profusely thank him for his help.

Today is Sunday. Mark is still in Addis. The passports with visas were promised to be ready Friday. The kids’ and my passports with visas were prepared, but Mark’s was still sitting in the unprocessed pile. “Come back Monday,” he was told. Mark changed his Saturday flight to Tuesday. Breathe in. Breathe out.

Through all of these challenges there has been a constant positive bright spot. There has always been someone there to help us. I met an Ethiopian-Canadian last week at the hospital. She invited us over for dinner on Sunday and then she was the one who went with Mark on Tuesday to the immigration office. She helped him navigate and translated when necessary. Another Addis colleague helped Mark on Wednesday and Friday. Dr. Semenawit has constantly helped me, and also gone the extra step to ask our whole family to her place for the holiday dinners. I will not forget how her face lit up with a relieved and truly happy smile when I told her our visas had been extended. Dr. Chernet lent an open ear and gave me some sage advice at one of my most frustrating points. Just now Tewodros, our trusted bajaj driver, walked Josh home from the local bar after watching a Premiere League football (soccer) game. Last week, Dr. Desalegn, hospital CEO, surprised me by taking the time to go to the zonal health bureau with me and pitch our idea to expand cervical cancer screening and improve referrals for the hospital. A couple of weeks ago Josh called me after school to say he could not find Sonja. Within ten minutes Sam the American English teacher and after school Amharic tutor, Sammy the vice principal and John our American friend were searching the school and neighborhood. Josh found Sonja near the bathroom, she was sick. Our Seattle friend Laila, who was working in Gondar for three months to improve patient awareness regarding prenatal care, babysat Josh and Sonja two weeks ago to allow Mark and me a date night…our first date in Gondar without the kids.

Yesterday our American friends invited us to a tourist guide-book launching event. John had helped edit the book to make it more readable. I bought a copy, it is in English. This event was quite an event. We were there for five hours. Five hours of traditional music, dancing, recitations, poetry readings, monologues, staged Ethiopian history re-enactments, and a live auction for a signed copy of his book. Sonja was not impressed and demanded we leave for about 4 of the 5 hours. She did not get her wish until the event’s end. Perseverance is not her weak point. Laura helped me out with her I-pad movie and Reece’s pieces. Movie for Sonja, chocolate and peanut butter gems for me. Again, I thank the Lord for helpful friends.

My other comfort is baking. Baking is a stress relief, and fortunately we have an oven. I think it is the batter beating which is most therapeutic. We discovered we can make banana bread and brownies. Neither requires butter, and there is no butter in Gondar…for four weeks now, but who’s counting? Real chocolate does not exist here, either. But hot chocolate cocoa mix does! Sonja quickly took to brownie making. I think she made 3 batches of brownies last week, by herself. Each batch is getting better.

Friends and brownies. What else is life truly about? By the grace of brownies and helpful friends we will continue our journey. Three more months. Breathe in. Breathe out.