Medical mission in Ethiopia - week 3

October 04, 2014

Tuesday, September 30, 2014

Today was our first “normal” day. The kids went to school and I went to the hospital. Josh and Sonja already knew which classroom they were in, and we didn’t need to wait to be told to wait some more. I am beginning to note a behavior that has repeated itself several times. I am calling it, “Please sit down and wait.” It sounds nice, as if someone is going to take care of us, but sometimes doesn’t. For instance, yesterday I brought the kids to school, but I did not know which classroom they were assigned. So, I asked a teacher where 2nd and 6th grade children were supposed to go. He asked if we had been assigned a classroom yet, I told him I didn’t know. I had also been told last week that the school needed another official document stating Mark and I were working at the University of Gondar and our children could therefore attend the University community school. I had never been told if this paperwork had been completed. So, he showed us to the school director (the Principal). The director was very nice and asked us to please take a seat and wait. And so we did. After about 20 minutes I interrupted and asked if he could just tell me where the 2nd and 6th grade classrooms were. “Please have a seat, and I will be right with you.” Okay. Not wanting to upset the status quo, Josh, Sonja, and I had a seat and waited for 1 ½ hours. We met two other foreigner families, both Indian. They were waiting as well. However, one of them decided to go find the 4th grade class for her daughter by herself. She then came back to the office and said she had put her daughter in a class and would come back later to talk to the director. So, I followed suit. Josh, Sonja and I went out of the office and found some high school students who spoke English well and asked where the 2nd grade and 6th grade classrooms were. We then walked into those classrooms and introduced Josh and Sonja to the teachers and students.

Josh’s first period teacher is American. He is from Maryland. He teaches English and Josh was very pleased to show me his A+ from his first English assignment today. So, even American English must qualify as English. Sonja’s English teacher is from Doncaster, England. When I told her teacher, that yes, I knew where Doncaster was, she nearly keeled over. It happens to be one of the few English cities I know, because that is where my Dad’s aunt and uncle lived with their dog, Tyson, and we would visit them when we visited England.

Sonja has already made a friend, Soriana. She is a very nice girl who was the top of her class last year. Hopefully this friendship will last! Josh has made a friend as well, named Adam. Adam is quite good in English and is teaching Josh some Amharic.

So today we did not wait for the director. The kids were dropped off and found some friends and off they went. Nur, our favorite Bajaj driver, then took me to the hospital. Today I went to the fistula clinic. They had 2 surgeries – both vaginal hysterectomies with anterior colporrhaphy. The senior resident, Dr. Johannes, primarily did the case with the 3rd year resident. I was the only “attending” on the premises, but I didn’t need to be there. The senior resident was a very good surgeon. He honestly knew some techniques that I did not know. We did some parts of the surgery differently, but I felt that he was definitely the primary surgeon and I was assisting with occasional questions and comments. Part of the residents’ training includes a rotation in Germany. And, there are some German gynecologists who come to Gondar every year and teach the residents for a month or so. There were also some French gynecologists who came and taught for a few months. Dr. Johannes has learned well. Residents complete an intern year and then practice medicine as a General Practitioner for 2+ years prior to starting a 4 year OB/GYN residency. So, the 4th year senior residents are very experienced. They have been in training and/or practicing medicine for at least 7 years.

We spoke about some of the social difficulties these women with prolapse have. Several of them come for surgery, not because the prolapse itself is preventing them from doing their daily activities, but because it is difficult to have intercourse with significant prolapse, and their husbands will leave them for another woman who has a functional vagina. The other “social” problem some women have is that they feel it is necessary to keep their uterus and continue having children. It is not uncommon for some rural women to have 10+ children. I was told that they think that if they have more children there is a better chance that one of them will do well and be able to help the others. The concept that having fewer children increases opportunity for those children to thrive is not recognized in some of these rural areas. So, many women do not want hysterectomies, even with significant uterine prolapse. They are also worried their husbands will leave them if they are no longer able to have children. I asked if this concern were realistic. “Yes, it is, unfortunately.”

Several months ago, the Fistula Hospital in Gondar decided to take care of women with significant prolapse as well as fistulas. Community health workers will identify women in remote rural villages with prolapse as well as fistulas. However, whereas a fistula is something that must be repaired, prolapse is more elective. Dr. Johannes was explaining that one educational piece they are now trying to communicate to the community outreach workers is that patients need to have a desire for prolapse repair, and that every woman with a cystocele, rectocele, or some utero-vaginal prolapse does not need to be herded into the Fistula clinic. There have been women recruited to the fistula hospital who decide they really don’t want surgery after consultation with the gynecologists. It’s sometimes several days journey to get here, so some pre-emptive education for the community workers will be welcomed.

Wednesday October 1, 2014

The dates continue to confuse me. Apparently it is October today. This Ethiopian calendar being 7 years and 10 days behind our calendar is tricky.

The kids woke up this morning and informed me they didn’t want to go to school. School is not what they are used to. They were hoping that they would be able to blend in more with the school kids and would not be treated differently from everyone else. Well, today was only the 3rd day of school, and they are both still attracting loads of attention, hair patting, hand holding, and other physical contact types of interactions. Also, there appears to be a shortage of teachers, as one teacher will have 2 classes. The teachers are almost all male. While the teacher is teaching one class, the teacherless class gets extremely rambunctious. Josh says that kids are jumping on tables, wrestling each other, hitting each other, chasing each other and running in and out of the classrooms. Josh calculated that about 3 of the 7 hours at school are complete chaos. Sonja reports similar activities in her room, although jumping on the tables does not happen in the 2nd grade quite yet. Sonja does not like the culturally accepted practice of teachers using a switch to swat kids. She says about 8 or 9 kids in her class are hit by the teacher every day. I asked about this practice when at the hospital today, and the interns and residents assured me that not only is it culturally accepted for teachers to swat their students, but it is also the norm for parents to hit their kids. When told Josh and Sonja this, Josh said, “oh, well that explains why the kids hit each other, too.”

Yesterday I learned that Dr. Johannes had been assigned the project to find a school in Gondar for Josh and Sonja. Last February/March I had been in communication with Solomon. Solomon has many titles, and one of them is “coordinator for international faculty.” I had told Solomon that I had 2 kids and he assured me that the kids could go to a community school. However, I had not heard much else. Little did I know that one of the senior residents had researched several schools for us and decided that Gondar University Community School (GUCS) was the only school in Gondar with acceptable and similar standards as U.S. schools. GUCS also happens to be the school that Dr. Shitaye started several years ago. Dr. Shitaye is an internal medicine physician who appears to be in her 60’s. She has a wonderfully open and warm personality, quite outgoing, with a very British accent. In fact, on the kids first day, I received a phone call from Dr. Shitaye. She had stopped by the school and noted that Sonja was very upset, crying, because she could not understand the teacher (even when he was speaking English). Dr. Shitaye called me and handed the phone off to Sonja. This was such a kind gesture, it reassured me that there are people looking out for the kids. This phone call made me realize we have not filled out any paperwork with contact numbers to reach parents, or medical problems the kids could have. Fortunately Dr. Shitaye had my number from previous phone conversations. The school wanted documentation that Josh and Sonja were good students, but had no requirements for emergency preparedness. Hmmmm. I should make sure Josh and Sonja have our phone numbers!

Saturday, October 4, 2014

The kids’ school has consumed much of my attention this week. I don’t know why I had this idea that school would be very strict here. I had imagined students sitting at attention, dutifully copying down what the teachers wrote on chalkboards, answering questions when asked, coming to the front of the class to recite lessons. The only foreign school I have experience was high school in France, and I now realize I had made this assumption that all foreign schools would be similar. This was a silly assumption.

Children here are very free. Often children ages 4-10 will join me on my walk to the hospital (about a 2.5 mile walk). Some of them want money, some want to practice their English, and some just seem to want to walk next to a white person. Sometimes it turns out they are actually going somewhere, because they will suddenly turn down a muddy dirt road and cheerfully yell “Ciao” or “Bye Bye!!” But they are definitely far from their homes. One day I met a 13 year old on my way home from the hospital and a couple of hours later I saw him about 3 miles away near the kids’ school. On our initial encounter he wanted money, on our second encounter he was joking around with friends and on their way to the town square (again on the opposite side of this sprawled out city). Kids play in the streets, yelling, running, wrestling, carrying the smaller kids around. There are no helicopter parents in Gondar.

I think this freedom extends to the classroom. This is a cultural shift for us. This week Josh has been very frustrated that the kids run wild when the teacher leaves the room. Sonja was initially bothered, but seems to be adjusting. Also, Adam and Soriana are turning out to be very good friends indeed. Josh credits Adam with continuously protecting him from invitations to fight the other kids. I have personally witnessed Soriana grasping Sonja’s hand and helping to lead her through throngs of excited kids to get to their classroom. Angels come in all ages. I think Josh and Sonja will adapt to this Ethiopian kid freedom fairly quickly. This weekend they are exhibiting signs of feeling free to run wild in our apartment complex, and it is only a matter of time before they are running crazy outside the apartment gates.

The other cultural adaptation is that the teachers use sticks to hit the students. Josh and Sonja are both bothered by this. Sometimes, they don’t know what the student did to deserve a whack, and this scares them. Fortunately, neither one has been whacked, yet. I spoke to the school director and the founder of the school, Dr. Shitaye, to tell them that this corporal punishment is making Josh and Sonja scared to come to school. We’ll see if anything changes. Maybe the change will be that Josh and Sonja adapt to this as well. A part of me feels for the teachers. It must be extremely difficult to establish any order with these students.

The final part of this week of school that has made things difficult is that there is not a full complement of teachers. I asked the school director, Mr. Mengistu, why the teachers leave the classes for so many hours during the day (about half of the day there are no teachers in the classroom). As I suspected, the teaching positions are not filled, so the current teachers will teach one of the classes in each grade, then leave that class to go teach the other class. Sometimes teachers don’t seem to be present. Josh did not have computer class on Tuesday because the computer teacher was not available. Sonja did have computer class on Thursday, because there was a teacher present. The school director assured me that within 1-2 weeks new teachers would be hired. Again, we will see. In the meantime, I have started inquiring about tutors. And fortunately, we were hoping for a cultural educational experience, and that we are definitely getting!

Meanwhile, Mark was away in Tanzania, and I have continued to go to the hospital every day. I am impressed with the academic knowledge of the interns and residents. These are very bright people. They are also compassionate people. The labor ward is 10 cots (beds) lined up end to end, arranged in a long rectangular hallway. The other side of the hallway is postpartum, another 20 beds lined up end to end. They deliver about 15 patients a day. The average postpartum stay is 6 hours. During the day, there are about 10 interns on the labor ward and 6 interns on the postpartum ward. So, every laboring patient during the day has 1 to 3 interns sitting at their bedside for their entire labor. At night, there are 3 interns. The interns do everything. They palpate every contraction. They listen for the fetal heart rate every 30 minutes with a fetoscope (a little wooden trumpet-like instrument). They start the IV lines, calculate the drip rates for oxytocin infusions and eventually deliver the babies in the delivery ward. I see women grasping at the interns’ jackets, arms, hands during their contractions. There are no family members present, there really isn’t any space. So the interns are the only support that the laboring patients have. There are also no Labor and Delivery RN nurses. I have met five midwives. They help with neonatal resuscitation, c-sections, difficult IV line starts, and general assistance for the interns and residents. They also do deliveries when interns or residents are not available.

Some of the patients have prenatal care, but many do not. Even patients with prenatal care do not usually have ultrasounds during their pregnancy because there is only one (ancient) ultrasound in the department, so due dates are calculated by LMP, and many patients have unknown LMPs. There are no NST’s, but more than half the patients I have seen would qualify as “high risk” back home. About 2-3% of the patients are HIV positive. Another delivered breech with an open spinal bifida and hydrocephalus and then died. I saw two patients with intrauterine fetal demises last week. A patient with severe pre-eclampsia with elevated liver function tests at 28 weeks gestation was given misoprostol for termination. Neonatal survival is less than 5% at 28 weeks. They once had a baby survive who was 1000 grams at birth. Another patient had a fetal heart rate in the 200’s for a few hours, then it resolved to the 150’s after IV fluids. I was asked what I would do with this patient. Seriously? I would have an MFM (Maternal Fetal Medicine) consult, a fetal echo, and of course a continuous NST. I feel that practically every patient would be seen by MFM at home. What can I do here? I am still trying to figure this out.