Medical mission in Ethiopia - week 6

November 07, 2014

Sunday, October 26, 2014

Facebook is a wonderful thing. My birthday was a couple of days ago and I felt that I received more birthday greetings than I ever have before. Several people sent personal emails, and my parents even called on the phone. I send everyone a HUGE thank you for your well wishes. Life is challenging, and every encouraging remark helps.

Mark went a little crazy and organized a party at our apartment guest house with Josh, Sonja, Janis and Stephan, the other ex-pats living here. We had traditional Ethiopian food, delivered to the door, a couple bottles of wine, and a real birthday cake with candles. Mark decorated the room with a string of holiday lights and frilly banners. Nuru, our most trusted Bajaj driver, apparently drove Mark all around town to find candles at one shop, the cake at another, lights somewhere else, the banners yet another. Josh and Sonja made decorative and artistic birthday cards. Mark’s big present was fixing BOTH toilets in our apartment. He was a little disappointed that I did not show more excitement when his gift was unveiled, because apparently it took several more trips with Nur and many hours to accomplish. I was appreciative, but chocolate and good wine from Janis and Stephan provided more immediate gratification. I think the initial pounds that I lost have been reestablished over the last couple of days of cake and left over injera, tibes, and shiro.

Yesterday was a sad day, as we bid Janis farewell. She finished her six month stay, and has gone back to the UK. Now it is just Stephan and us. We will miss Janis’s enthusiasm, and easy laugh. She was such a help as we oriented ourselves to Gondar. Hopefully we will reconnect again at the end of our year away, as we hope to travel on our way back to Seattle. The only positive aspect of Janis leaving is that we have now inherited a slew of stuff that gets passed from one ex-pat to the next. We now have a small AND large fry pan, a tea pot, a cutting board, 2 sharp knives, balsalmic vinegar, several spices, some movies on DVD including “SuperSize Me” and “Godzilla,” and extra hand sanitizer. Sweet.

Today we went to Walleka, a village near Gonder. We took a mini-bus to the piazza, and then walked to Walleka, just a few kilometers away. Walleka was a Falasha village until all of the Jewish people were airlifted away to Israel during the Dirg, or Red Reign of Terror. Now it is known for an NGO that trains single mothers to do crafts so they can support themselves. On the way, Josh became upset again. I don’t know if it is the stress of school, other differences in Gonder and Ethiopia, or puberty. After an hour or more of sullen sulking, he returned to his normal happy self. But those down times are tough. We talked about the school situation again. After meeting with the school directors a few times, we had decided to try going to the community school again. Josh and Sonja have also started after school tutoring in Amharic on Mondays, Wednesdays and Fridays. Every day Josh writes a page report about the differences he notices at school here compared to Kimball Elementary. He has been giving these reports to the school director. One effect of these reports is that Mark and I had a parent/teacher/school director conference last Thursday morning to discuss hitting children. Although much of the conversation was in Amharic, it was clear that the director would not tolerate the teacher hitting the children. We will see how long this lasts. Our current plan includes a new (but very cheap) cell phone for Josh so he can call us whenever he or Sonja needs us, frequent conversations with the school director, and tutoring with Sam, an Ethiopian-American. Sam was born and raised in Maryland, and just moved back to Ethiopia last year to teach English. We will try another couple of weeks and see how it goes.

Monday, November 3, 2014

It has been hard to write this last week, because I have not been in a very positive mood. Several days went by and I asked myself, “What could I write about today?” My answer was a blank page. This morning I walked to work with Stephan, the German anesthesiologist, and discussed some of my frustrations. His reply, “That is the normal cycle, isn’t it? You get frustrated and eventually lower your expectations so that eventually you can feel successful again.” As far as work goes, yes, that seems to be the cycle.

The moods with the family and at home have been in continuous oscillation. The lows are very low, and the highs are a relief. Although I realize that even when everyone in the family is in a good mood, I only tentatively enjoy the moment, bracing myself for the next trough. Josh has the deepest troughs. He has always had more sympathy for those who are suffering and this characteristic currently seems more a burden than an asset. We are all triggered by even small challenges. It is as if our cup is full of small stressors, and that one additional stress factor aggravates the whole cup into a tempest.

School is still a challenge. The kids are getting used to the physical interactions of students and teachers. Josh continues to be invited to fight, and he continues to decline the invitations. I wonder if this is the kids’ way of trying to make friends, I don’t think that this fighting invitation has any malicious intent. Or perhaps this is what I wish. The teachers still use thin branches to stike the students as they line up for class, the flag ceremony and whenever a student is a disruption. The behavior reminds me of the sheep goat herders, trying to keep their flocks out of harm’s way. These things will not change. Sam, the American of Ethiopian descent who is tutoring the kids, tried to explain that the kids expect this kind of discipline. He said that after his first year teaching English he was evaluated by the students and students complained that he did not discipline them enough. He does not use any form of corporal punishment. He also tried to explain that the school is like a giant family, and the teachers act like parents, and sometimes students, like children, need discipline. Although Josh and Sonja are becoming more accustomed to this behavior, it still bothers them. We have encouraged them to keep talking about it and we continue to evaluate whether or not we can stay at the community school. Josh and Sonja are in good spirits 90% of the time, but that unhappy 10% is challenging.

I wonder if this physical aggression is beneficial in some way that we don’t understand? A few weeks ago we read the internet news and reports about the Marysville high school student who shot his friends and then himself. Apparently he was a fairly popular kid, recently elected homecoming prince for his class. The news reported that several weeks earlier he was suspended for engaging in a physical fight after another student made a racial slur against him. I wonder if allowing, and even encouraging physical interaction could be healthier in the long run. Are humans programmed to express anger with physical interaction? If this high school shooter had been allowed to physically fight without significant punishment, would he have resorted to more extreme measures? I don’t know. On the other hand, there are many gunshot victims who come to the Gondar hospital emergency department. So maybe allowing physical aggression in school doesn’t have any benefits. Usually the gunshot patients are from rural areas where everyone has a shotgun. We don’t hear about shootings in the media, so it is difficult to know where the truth lies. The only Ethiopian “news” is the government channel, Ethiopian Broadcasting Service, and everything is wonderful in Ethiopia. I don’t know. I just don’t know.

This weekend we decided to go to Bahir Dar and stay in a nice hotel, relax, and support each other as a family. Bahir Dar is known as the Cote d’Azur, the Riviera, of Ethiopia. It is a more developed city on the coast of Lake Tana. Lake Tana is the third largest lake in Africa, and the source of the Blue Nile. The Blue Nile joins the White Nile to form The Nile. The Blue Nile supplies about 85% of the water to the Nile. We only planned this weekend trip to Bahir Dar a few days prior to the weekend, so the nicest resort hotel with a pool only had availability on Friday night. Kurifu Resort and Spa was indeed a treat. Unfortunately we were not stress free, because Mark had scheduled a couple of Skype meetings and the internet access at the resort was inadequate. So, Mark was stressed. The kids and I enjoyed the pool, swimming both Friday night and Saturday morning. Mark and I also enjoyed the king size bed, quite luxurious compared to our full size bed at the Guest House. We decided to do touristy things, visited a couple of island monasteries on Lake Tana, saw the mouth of the Blue Nile, some hippopotamuses (hippopotami?), huge pelicans, ate at a nice restaurant overlooking the lake, and then went to see Blue Nile Falls. I enjoyed a massage and Josh had a leg/foot massage. Our second night’s stay was at a more mundane hotel, it was old and musty. Our initial room didn’t have working plumbing, so they moved us. The people were all very kind which made up for some of the inadequacies of the hotel. The weekend was overall quite pleasant. Other than the bugs. There were many more mosquitos by Lake Tana, and the kids served as fresh hosts for those Bahir Dar mosquitos. Poor kids were covered with big red welts from mosquito bites. I just hope the malaria prophylaxis that they have been taking works!

Wednesday, November 5, 2014

Last night Josh had a high fever, felt sick and delirious. The fever came down with some acetaminophen and he felt better this morning. I stayed home with him this morning until he was certain that he felt better and then we took him to school. We took the opportunity to prepare for Sonja’s birthday tomorrow. Josh wrapped some presents, and I acquired some ingredients for Sonja’s requested meal, Aunt Joan’s Mountain Man Soup. Later this morning I took him to school. The deputy school director, Ato Zenebe, met me at the school gate and said he has been talking to Josh about his mood. Zenebe has some training in psychology and told us he would try to help Josh and his sad feelings. I hope this helps.

I arrived at the hospital shortly after the residents started to see patients. There are no appointment times here. Patients just wait until they can be seen. Clinic starts after morning report and teaching session, which ends at variable times. This morning I asked the residents about malaria symptoms – fever within a week of infection is common. Hmmm. They all thought it was very unlikely Josh would have contracted malaria while on prophylaxis. Although they also suggested that if the fever were to recur we should have Josh’s blood sampled for malaria. I think I am reassured…

Dr Semenawit and I continue to train the interns and junior residents to do VIA cervical cancer screening and cryotherapy. Dr Semenawit told me that during this morning’s teaching session there was a discussion about cervical cancer in pregnancy. The chief resident mentioned that we were doing cervical cancer screening and the residents actually applauded! Feedback! Wow. I wish I could have been there. But at least I know that there is some appreciation for what we are doing.

There is so much uncertainty in my daily work. Some days feel they have potential, and other days are just stagnant. I keep hoping that perhaps I just cannot see or have yet to comprehend even the minute achievements on those seemingly stagnant days. I try not to stress about these days. I try to open my eyes of awareness. What is it that God is showing me today? The Amharic word for small is “tannish.” I feel that my life is full of tannish moments, and I only see those tannish moments if I am vigilant in observation. Observation is our primary way of being. We don’t speak Amharic, so we don’t understand the conversations. We don’t understand nuances of the bureaucracy and politics in which we are immersed. Life continues on around us, and if I am lucky, I appreciate that which I observe. Today I was thankful to receive some definitive feedback.

Friday, November 7, 2014

Yesterday Sonja turned 8.; This was her first birthday away from home. Mark rigged up the streamers and blinking lights from my birthday a couple weeks ago. I prepared her requested birthday meal, Aunt Joan’s Mountain Man soup. Thanks to Janis’ going-away donations of crushed chili peppers, cayenne pepper, dried parsley, basil, cheese grater and large fry pan it actually turned out fairly well.  Sonja invited Stephan, the German anesthesiologist, and Nuru, our favorite Bajaj driver. Nuru was instrumental in providing for the party, having carted me around throughout the city to get minced meat at the butcher, cake and ice cream at the coffee house, fresh bread at the bakers, canned corn for the soup at Best Supermarket, and birthday candles at the candle shop. Sonja proudly sat between Nuru and Stephan and enjoyed their attention and gifts. Janis was present in many ways throughout the evening, not just due to her donations to the soup. She also left many art supplies that will eventually go to some local orphans. In the meantime she suggested giving the art supplies to Sonja for her birthday. Sonja was thrilled. She loves art. Mark and I brought the Laura Ingalls Wilder “Little House on the Prairie” series from the U.S., so she has some new books to read. Josh gave her a beautiful butterfly batik made by single moms at a Women’s training center. The party was complete with a resounding chorus of “Happy Birthday” and a smiling Sonja. Phew!

We have been without reliable internet access for almost three weeks. There was a small window of opportunity yesterday morning at the hospital, and I was able to send one email. This has been frustrating for everyone, but especially Mark. Mark has projects he is trying to complete both for Gondar University Hospital and for his contacts in the U.S. Several nights he has tried to Skype. He has not yet been successful due to lack of internet access. Apparently there are emails that people are waiting for him to answer. The phone is more reliable, but even the phone service will be out of commission for several hours at a time. Ethiotel is the government run and sole provider of telephone and internet access. The service representatives are very nice, they try to help as best they can, but when the entire system is not functioning they can really only ask for patience in as kind a manner as possible. I think Mark has always been able to fix things, and this is something he cannot fix. This morning I saw someone trying to use the WiFi at the hospital. I asked how the WiFi was working, and he said, “Well, about 15 kilobits/second, it’s very slow. But, I have no choice, I need to download something, so I must be patient.” 15 kilobits. The U.S. hasn’t operated at 15 kilobits for the last thirty years.

Patience is the practice here. I have noticed that very few people seem anxious or are outwardly depressed. People also do not complain. Patience and tolerance. Tolerance for intermittently functioning electricity, water, internet, phone service. Tolerance for life’s pain and discomforts. Tolerance for medical complications. Tolerance of course has its role. Despite life’s difficulties, I see more open smiles here than back in the U.S. People are truly grateful for what [little] they have. However tolerance is not all good. This week four patients presented to the hospital with uterine ruptures. Prior to working here I had seen four uterine ruptures in my 15 year Ob/Gyn career, including residency. All the cases this week presented to the hospital from community health centers. Some patients had been followed during their labors at a health center. Other patients labored at home and eventually went to a health center. One woman had complete rectal-sigmoid prolapse and a uterine rupture after protracted labor. Only one of the four had a previous cesarean section scar. I asked the four senior residents how many uterine ruptures they have seen during their four year residency. They all answered, “oh, about 50.” Fifty!?! And of those, how many had previous uterine scars? “Maybe 3 or 4.” Almost all cases are associated with prolonged, protracted labor. A culture of tolerance allows labor to persist beyond a normal length. The woman who presented with uterine rupture and complete rectal and sigmoid prolapse presented after 15 hours of prolapse. I asked the surgical resident who helped reduce the rectal-sigmoid prolapse if this were common. “Oh yes. Unfortunately people will tolerate rectal prolapse for a long time. They are embarrassed to tell their family and come to the medical centers. We often do not see patients with rectal prolapse until it is gangrenous.” Whoa.