Month 9 Plus

May 24, 2015
Post-operative day # 13 and I am pleased to report that our patient has recovered quite nicely. Sonja went back to school last week, continues to improve upon her brownie recipe and is back to tormenting her brother in the kindest sisterly way possible. We were fortunate to have experienced her emergency surgery, complete with general anesthesia, head surgeon attending, medications and a two night stay in the hospital for a total of 300 birr. 160 birr for the hospitalization and surgery and 140 birr for medications. That equals $15. 15 dollars! Hmmmm, shall we submit the bill to our insurance company?

Today is Election Day in Ethiopia. We are staying home. From my discussions, it appears that most people are staying home. Many people tell me there is no point in voting, as there will be no change in the ruling party. There is no viable opposition party in Ethiopia. Many people disagree with the current party’s governing, but a mobilized opposition party has not taken hold. Local people keep trying to explain to me that theirs is not a true election, not like an American election.

The current prime minister is an engineer by training. Hailemariam Desalegn is from the Southern Ethiopian states. He came to power after the elected prime minister, Meles Zenawi, died a sudden death (of natural causes) a couple of years ago. Hailemariam’s wife, Roman Tesfaye, is a champion of health care promotion in Ethiopia, including cervical cancer screening and treatment. I met her a few times this year. Well, I and a few hundred other people attending the same events.

The police presence increased this last week. There were more checkpoints as we drove to different cities during our cervical cancer screening outreach efforts. The cryotherapy “gun” was checked a few times, but it was given a pass. I don’t know what my Ethiopian doctor colleagues told the police, but I imagine that the words for “cervix” and “vaginal” cancer screening and treatment are deterrents for extended conversations.

Prior to Sonja’s appendectomy I went with Dr Desalegn, hospital CEO, to visit the Zonal Health Bureau and Regional Health Bureau. We discussed a plan to assist the implementation and sustainability of the cervical cancer screening program in the Gondar region. The Ministry of Health (MIH) has a plan to train local health workers to do cervical cancer screening. It is based on the cervical cancer training materials developed by Pathfinder International and Jhpiego (“Johns Hopkins Program for International Education in Gynecology and Obstetrics,” now referred to simply as Jhpiego, pronounced "ja-pie-go"). I have reviewed the 7 day training and will hopefully be involved in the official training if it can be organized within the next 4 weeks. Our proposal to the health bureaus is to continue a mentoring relationship with these local health centers beyond their initial training. During my 9 month tenure I have witnessed countless trainings. Health care providers receive trainings, often from international NGO’s, receive their certificates and accompanying pay raises, then go back to business as usual. Nothing changes. I think that the reason our cervical cancer screening program at hospital continued beyond the initial training is my continued presence and oversight. Dr. Desalegn, hospital CEO, agrees. The public health department director, Dr. Abebaw also agrees. They both understand the importance of a sustainability or mentoring program. Dr. Desalegn has offered to pay for the transportation and per diem costs for residents and the gynecology general practitioner (Gyn GP) to travel once a week to four sites, every month, indefinitely. Dr. Abebaw has also offered transportation assistance.

Our initial visit to the Zonal Health Bureau was met with a positive response. Drs. Desalegn, Semenawit and Birhanu came to this meeting. However, the zonal health bureau deputy thought we should meet with the Regional Health Bureau in Bahir Dar before proceeding. Dr. Desalegn offered to drive us in a University extended cab pickup truck. Mark, the kids and I piled into the back seat of the pickup for the 2 ½ hour drive and enjoyed a lovely weekend in Bahir Dar. Dr. Desalegn and I met with the Amhara region’s deputy health minister Sister Zebiduru and the director for medical training Sister Nigiste to discuss our sustainability plan. Again, very positive responses. However, they recommended we work with the Regional Bureau’s Gondar delegate, located on the Gondar hospital campus before proceeding. Back into the back seat of the extended cab pickup we piled and returned to Gondar.

Dr. Desalegn, Semenawit and I met with Tarakegn, Gondar’s medical education training director. He, too, received the proposal with positive response. However, he needed to talk to his supervisors, Sisters Nigiste and Zebiduru. He communicated with them, received instructions to organize the MIH approved training and told me to proceed with a schedule. I sent him a calendar outline detailing the training and follow up outreach plan. No response. For days. Sonja’s appendectomy then took precedence and I did not pursue the issue. During a hospital visit Semenawit told me that Tarakegn found her and said he had received new orders from the MIH Regional Bureau to delay any training. He didn’t know why. Semenawit thought he was too embarrassed to inform me, because he had been so confident just one week earlier.

I was not surprised. There is this interesting “yes” phenomenon that happens here. People will tell you “yes” in response to a request and then fail to deliver. We invite local people to join us for dinner. They tell us they will come, then don’t show up. Store merchants tell me they will have a desired item “tomorrow, so come back later.” Of course they don’t have it when I return. The head nurse tells me she will arrange an extra exam room. It doesn’t happen. The IT employee says he will prepare a computer program to enter our data. This doesn’t happen either. “Yes” does not mean yes here. I think “yes” means “I want to make you happy, so I will tell you what I think you want to hear, even though I have no intention to deliver.” And this appears to be culturally acceptable. The “yes” phenomenon may also be related to a culture of blame. People are afraid to make decisions without permission. They fear they will be blamed if someone later decides they made the wrong decision. Whatever the reason, the “yes” phenomenon is challenging. I cannot know if an affirmative response will produce the agreed action until said action actually occurs.

So Tarakegn thought he had permission to organize the initial MIH approved cervical cancer screening training. I would then proceed with the outreach mentorship program. But he was undermined and instructed to place initial training on hold. I get it now. 9 months ago this would have been frustrating. Now I accept it and move on. We were not told to place the outreach program on hold and so I proceeded. It was time to test Dr Desalegn and Abebaw’s “yes” responses. Would their “yes, we will provide transportation” commitments materialize? They did. Honestly, I was surprised. Pleasantly so, mind you, but surprised none the less. I was not surprised due to the involved individual’s personalities, they have shown great support in the past. I just don’t trust the word “yes” anymore. Cultural adaptation I suppose.

Dr Desalegn instructed his health administrative officer to find us a ride with the hospital’s HIV outreach program. This got us to Debark, a 2 hour drive from Gondar, and entrance to the Simien Mountains. Dr. Abebaw provided a car and driver to Chilga and Tikel Dingay, between 45 minutes and an hour drive from Gondar.

The visits this week were awesome. Two months ago several senior attending physicians, the chief resident and I discussed options to keep cervical cancer screening a sustainable part of the residency program. Together we decided to create a one month attachment or rotation for the fourth year residents. The responsibilities of this attachment include organizing the cervical cancer screening and treatments at the hospital, visiting the four selected outreach sites to do teaching and mentoring, and then presenting a report every month to the department. The outreach visits would also include discussion of obstetric emergencies. We replaced the residency’s outpatient infertility attachment with cervical cancer screening, hence the rotational schedule assigning residents to the attachment already existed. The infertility attachment had limited educational value, residents rarely saw more than 1 or 2 patients a week. I have not spoken to a single resident who is sad to see this attachment change. Dr. Chernet was assigned to start this attachment in May. Semenawit is still the Gyn GP. Therefore, Dr Chernet, Semanawit and I ventured out to do three of the four site visits this week.

Our visits had a routine. First, I discussed the purpose of our visit. I reviewed the Ethiopian government’s national strategy to start cervical cancer screening. I discussed the hospital’s goal to improve referral relationships with local health centers. And then I provided the last couple month’s data showing perinatal and maternal mortality rates. 25-30 babies die every month at the University of Gondar. 1-4 mothers die every month. 78-88% of the patients who suffered perinatal deaths had prenatal care in the local health centers. 40+% of the deaths were due to mechanical causes such as obstructed or prolonged labor and breech vaginal deliveries. Mechanical causes that are 100% preventable. I then showed the data specific for each health center we visited. Dr. Chernet followed with a discussion about obstetric emergencies using a health center case as an example. Dr. Semenawit then reviewed Pathfinder’s cervical cancer screening training manual. She has translated the training manual into Amharic. I believe it is the only Amharic version available.

We emphasized our goal to improve maternal health. We emphasized collaboration. We asked for feedback for the ob/gyn department. We were very well received. Health care providers understood we were not there to blame individuals. We were there to improve the system. These local health care providers are on the front lines. Some were quite old, uh, I mean experienced. They understood the Ethiopian health care system limitations and opportunities. We had open and constructive conversations. I was thrilled.

To top off each day, we tasted the local version of fried lamb and coffee. Chilga had very fresh injera, Debark had lamb that tasted like the thyme and wild rosemary the sheep eat from the mountain sides, Tikel Dingay loaded their fried lamb with garlic. The coffee from Debark bested them all. It was smooth, had a mahogany color, and was rich, not bitter. I will miss Ethiopian coffee upon our return. Mmmmmm.

Our driver to Debark picked up an extra passenger to and from Debark. She was a middle aged woman who climbed into the pickup bed with several bags. The bags were laden with market goods from Debark and then she returned with us to Gondar. On the way back she rode in the cab, joined in conversation, and before I knew what was happening, invited us to stop for local t’alla at her family’s home/bar. Sure, why not? T’alla is a homemade brewed beer. I have heard a Dutch foreigner describe it as peacock’s vomit. To be sure, I steeled myself and was able to drink ¾ a glass to show my appreciation for the family’s generous hospitality. A few photos were taken, showing us enjoying the brew and thanking our hostess. Truly, they were very kind. I then steeled myself for the remainder of our journey and tried not to get sick. I suggest Ethiopia continue exporting coffee.

The week ended with International Fistula Day yesterday, Saturday May 23. It was a nicely run celebration. Sister Zebiduru, the same deputy health minister we met in Bahir Dar appeared, as did the president of the University, a ministry of health representative, two of our primary fistula surgeons and members of the ob/gyn department. Dr. Mulu gave a passionate talk about her 30 years working with fistula patients. The respective leaders discussed their support to end obstetric fistulas. There was also a representative from Johnson & Johnson. Dennis had flown down from Scotland for the week, bringing a professional photographer with him. He worked with J&J’s corporate social responsibility department for 20 years, spending much of his time in Ethiopia. J&J has contributed much to the fistula campaigns over the years, and he was there to demonstrate continued commitment. I enjoyed my conversations with Dennis. Perhaps there is an opportunity to collaborate with J&J to expand cervical cancer screening. Fingers crossed.

Yesterday’s festivities ended with a wonderful lunch at a local hotel and restaurant. It was quite nice except for one thing. I ended up in two situations I have been trying to avoid during this election time. One, I somehow found myself talking to a reporter from a government controlled newspaper. And two, I sat down at a restaurant table and then was joined by many locals who wanted to talk politics…the day before the election! Criminy! I tried to use the interview as an opportunity and managed to discuss cervical cancer screening. I reviewed the program’s successful screening of over 540 patients at the University of Gondar since mid-October. I reviewed some statistics documented in Ethiopia’s official cervical cancer strategy booklet. 20.7 million Ethiopian woman at risk for cervical cancer. Leading cause of death from cancer in Ethiopia. 30% of all cancers diagnosed in an Ethiopian hospital were cervical cancer cases. The reporter seemed interested, but kept asking me what challenges we faced. I was suspicious, so talked about the strength of the individuals working to help and other positive aspects. She kept hammering me for challenges and so I finally said that the medical community faces the same challenges as the rest of the country, lack of consistent power and water. This seemed like the least controversial statement I could make, and it is something everyone knows to be true. It still made me nervous though. We only have four more weeks in Ethiopia. I would like those weeks to progress smoothly.