Ethiopia’s New Campaign to Stop Treating TB, posted by Daniel

One of the most frustrating things I’ve encountered while working here is the government’s multitudinous and varied ways of undermining efforts to treat the patients most in need of care.  I certainly expected challenges when trying to practice medicine in rural Ethiopia, but amongst the obstacles I imagined, government ineptitude was well below poverty, hunger, illiteracy and lack of clean water on the list. The prime example of this incompetence and betrayal (although there are so many examples) is the Federal Ministry of Health’s inability to provide enough anti-TB medication to its infected citizenry.  One third of the world’s population is infected with the bacteria that causes TB and this bacteria causes 25% of avoidable adult deaths in the developing world.^[1]  This is despite the fact that the bacteria that causes TB was identified in 1882, that in 1993 the WHO declared TB an international emergency and that in 2000 the Global Partnership to Stop TB was established.  The impact of the Stop TB campaign is difficult to discern as there are over 9 million new cases per year and 1.7 million deaths per year, mostly in the developing world  This is more than a bit bothersome as TB is thoroughly understood and entirely treatable. And when I say treatable, I mean that the curative medications are provided for free to the countries in need, countries like Ethiopia.  Somewhere, the supply chain breaks, and that is where the trouble begins.

            First, a little background on how we treat TB.  The TB treatment program at our clinic follows the WHO’s Directly Observed Treatment, Short Course (DOTS) program.  It is an internationally implemented program that is intended to identify people with TB, to treat them effectively, to prevent spread to the community and to prevent drug resistant TB.  A few times a week we diagnose patients in our clinic with TB, inform them of the results and enroll them in the 8 month DOTS program.  For the first two months of treatment, the “Intensive Phase,” each patient comes to the clinic every morning to take the daily dose of anti-TB medications.  In order to come to the clinic daily, patients who live outside of our village leave their homes and families to move the 6 or so hours to live in a rented room or relative’s house in Chiri.

            To ease the financial burden associated with moving near our clinic and giving up 2 months of income from farming or working at home, our clinic often fully subsidizes food and housing for Intensive Phase patients.  Not only is this the humane thing to do, it is also a pragmatic necessity if one is serious about reducing death from TB, transmission of TB and avoiding drug resistance to TB.  If patients cannot take anti-TB medications consistently and uninterrupted they will not only die of an entirely treatable disease.  While they are slowly consumed by TB they will also share the disease with their families and neighbors.  Worse yet, if they had the good fortune to start treatment but could not continue, the TB they spread will likely be drug resistant, fating their surviving friends and families to suffering and death from a mutant form of TB that is far more difficult to treat.

            Fortunately, nearly all of our patients complete the full course of treatment and make remarkable recoveries. Over the first two months of treatment, the Intensive Phase, we get to know many of the 30 or 40 patients who come to the clinic each morning for their Directly Observed Therapy.  Once they finish the Intensive Phase and return to their communities, it is a real source of satisfaction to see these formerly ill, bed-ridden and cachectic patients come back to the clinic once a month for a free check up and medications for the next month. Because we serve a large, rural area with a population of around 150,000 people, many of these patients hike over six hours to report to the clinic and get the next month’s prescription.  Rather than exhausted and complaining, they arrive smiling and proud of their diminishing coughs and skyrocketing weights. You might imagine, then, the great disgust that accompanies my increasingly frequent need to tell patients that the multimillion dollar supply chain has not provided sufficient medication to treat them for another month.

            In Ethiopia, anti-TB medications are provided for free to the Ministry of Health from the Global Fund to Stop TB, distributed by the central government to regional pharmaceutical supply centers, then from the regional centers to the zones and from the zones to the woredas (woredas are similar to greater metropolitan areas).  For reasons that appall and confound me, our clinic has faced a severe shortage of these essential medications for the past two months.  We keep meticulous records and duly file the required reports with the government.  We have a file for each patient and a government provided TB Register.  My predecessor as Medical Director even designed a robust, yet elegant Excel file to track our TB patients - from the day a patient starts taking anti-TB medications, we can tell you how many pills they will need for the entire eight months and the exact dates on which they will come to the clinic to collect these pills. Despite the precision and ease with which this information is available, the medications arrive haphazardly, if at all.  Just last week we started rationing - providing only one week of medications instead of a month to each patient, hoping to spread our limited supply until a new shipment arrives. 

            USAID and the Ethiopian Federal Ministry of Health collectively spend tens of millions of U.S. dollars a year to control TB in Ethiopia. In fact, last week USAID’s Supply Chain Management System donated another 1.7 million USD worth of trucks, motorcycles and other equipment to Ethiopia’s Pharmaceutical Fund and Supply Agency.  So the race to the clinic is on - modern trucks in a broken supply chain versus rural patients with an age-old disease.  I’m betting on the barefoot Ethiopians. Just like in the Olympics. But when they cross the finish line here they don’t get a Gold Medal, just a little bit closer to a Multi-Drug Resistant TB epidemic.

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^[1] Gill GV and Beeching NJ, Lecture Notes: Tropical Medicine, 6th edition. 2009; 85-100.

A Salute to Fathers Everywhere

With Father’s Day here I thought I would highlight one of the amazing fathers we have been lucky to meet during our time here.  I have continually been awed by what fathers and husbands have done for their family members while they are at the clinic and wanted to pass on one of their stories.  (Obviously I see mothers do wonderful, kind and generous things as well…but I was struck by one particular parent and so came the idea for this blog post).

Chiri Health Center is little more than three cinder block buildings, painted a dull grey and wouldn’t pass the mustard for even the lowest level of care center in the US.  There is no tv, wifi, cafeteria, gift shop or even a magazine to look through to try and pass the time.  Family members wait on wooden benches for hours on end while their loved ones are being seen by the nurse and days at a time if they are admitted to our inpatient unit.   They are generally responsible for giving medications and providing food to their loved ones, washing their clothes, giving baths and even helping them to the latrine if they so need.  With transportation often being little more than horses or mules (for the better off), just getting to and from Chiri with a patient is often no small feat.  Once a patient is put in the inpatient room, family members often stay here in Chiri for the continuation of treatment.  Maybe one will walk back to their village to get supplies, food and clothes, but this is also quite an ordeal as some live hours and hours walk away.  To put it simply, it is no picnic in the park to be the family member to a patient.

We recently had a patient, Fanaye , who was in her mid-twenties and had the unfortunate luck of having both HIV and TB.  She could barely move by the time she came to Chiri Health Center and ended up staying for over a month in the isolation room.  Her father, Haile, brought Fanaye here and literally sat guard outside the door every day for over a month while she was here.  No books or newspapers to help the time pass.  No walks to the cafeteria for an afternoon snack or checking email to keep your mind preoccupied; it was just him and Fanaye.  He slept in an empty bed next to hers with little more than a heavy scarf to keep him warm at night.  Every day, rain or shine, he waited patiently in line with the other patients for his daughter’s TB meds and brought them back to her.  He would help her walk when she needed to use the bathroom and when she was stronger he would sit with her outside so she could have a little fresh air and sunlight.  Sometimes I would go to say hi to Fanaye and would see her father on her bedside pleading with her to take her medications or try to eat a little.  At some point she wasn’t gaining any weight and so was put on the nutritional formula we give to malnutrition patients.  As he had with the other tasks we charge patient’s families to do, he very patiently held each cup to her lips, helping her drink.  Fanaye eventually was discharged because she wasn’t improving and there wasn’t anything more we could do for her.

Daniel and I were recently out for a run and saw Fanaye’s father walking home from market (they live in the next town over).  We exchanged hellos and asked how she was doing.  Using our very broken Amharic and Kafanono we pieced together that she was okay.  We thought she had maybe passed away as it had been a while since she had been back for TB meds and were glad to hear the positive news. The next day Fanaye and her father returned to the clinic.  As they had been here for quite some time all the staff were happy to see her and say hello.  Her father explained that she wasn’t able to take her medications and was hoping there was something here that we could do for her.  We all tried different ways to coax her into taking it—crushing the pill and making a liquid so she could drink it, adding sugar to take away the taste and Daniel’s best idea, putting the pill in a piece of chocolate.  She was not having any of it and eventually I began to think that maybe she was just done with it all.  Maybe she was ready to no longer be sick and weak, and maybe she was refusing to take her medications not because of the bad taste but to end things for once and for all.  We all sat there watching her father plead with Fanaye to take the medicine just as he had done before time and again.  You could see it in his eyes that he had not yet given up on his little girl.  He sat outside her door for days on end and clearly he was not yet going to let her slip away just yet.

Once it was clear to us that she wasn’t going to change her mind people began to disperse.  It had been raining off and on all day and at that point you could tell the rains were about to return with vengeance. I watched as Haile helped his daughter walk to the gate where their horse was waiting for them. It began to rain and so they sat in a wooden shack built as a waiting area for overflow patients.  I would guess they sat there for at least an hour before they could make the trek back home.  We have yet to see Faneye or her father since then and I can’t help but wonder how they are all doing.  You could tell from looking at Haile’s eyes that if he could, he would do anything to make his daughter well again.  Unfortunately in a place like this there is a lot lacking when it comes to health care, but at least for Faneye and the many like her, when it comes to a father’s love and devotion she has received all you could need and more.

***Sadly this morning I learned that Faneye passed away just a few days ago. I am sure she will be missed by all of her friends and family.  I hope to always remember Faneye and the immense struggle she had fighting two diseases that are both very much preventable and treatable…yet for many reasons are not and therefore still killing millions like Faneye.

Full Circle

Although meetings here can often be a frustrating and tedious experience, I had two today that not only made me smile like a little girl in a candy store but also reminded me why we chose to come to Ethiopia this year.  


Two of my biggest responsibilities has been to create a safe water program in the four villages we work with and to grow their newly formed women’s groups.  Like all things in public health they have both been a slow and arduous process that often made me question if either would prove effective.  One of my last tasks before leaving is to start drama groups in the villages that will focus on health issues as a tool for increasing education.  Today we met with two of the villages, Ogeya and Gessa, to discuss this new project and at each meeting a great surprise awaited me.  Well, it must have been my lucky day as I showed up for these meetings and saw firsthand just how well everything is taking shape.  If this was back home I would assume both things had been planned in advance, but knowing the way things work here I can safely say it was just dumb luck.

At the first meeting the village chairman asked us about buying more WaterGuard. WaterGuard is an amazing product that if used properly can cut water borne illness in half—which is pretty remarkable seeing as one of the leading causes of deaths in Ethiopia is from water borne diseases.   He said that he would like ten more and immediately people started to pull money from their pockets asking to buy one.  Then my co-worker explained to me that they wanted 10 cases, not 10 bottles….making that 150 bottles. We began this not knowing if anyone
would be willing to spend the money on water treatment, but clearly we were wrong.  So yes, it seems as though this intervention is indeed working, check!

We said our goodbyes and after a nice hike to the road we drove to Ogeya.  As we pulled up I noticed a few of our volunteers were surrounded by a group of women.  I walked up and saw what was going on—the gardens we built is growing extremely well and the women were all there to split up and take home tomato plants.  Not that long ago we had the initial meetings with women about creating these gardens and now they were already seeing the literal fruits of their labor.  I was able to take a quick tour of the rest of the garden and again found myself smiling from ear to ear at what a success this program has been.

Things For Our Things

We came to Ethiopia with two bags each; admittedly mine were pushing the 50 lb. limit, with all that we would need for our time here.  Clothes for the rainy season, games to keep us occupied on weekends, books, DVDs, a crazy creek for each of us and even some of our favorite food all made the cut.  Lalmba’s Director forewarned us during our orientation that while we would be worried we wouldn’t have enough stuff; in all likelihood we wouldn't even unpack half of what we brought.  While I thought she was nuts at the time I must admit that I have an entire bag of things stored under our bed unused and not missed. Obviously being here puts you into a different mind frame. Whereas at home it wouldn't be appropriate to wear the same outfit for three days in a row, here no one gives it a second look.  I used to wear a simple twenty-five dollar stone necklace I bought at the Washington DC flea market, but noticed it attracted too much attention and so have foregone it. People here simply don’t have much and being excessive, ie-- changing clothes every day and having a gold necklace, draws attention. It’s funny how something in one situation can be looked upon so differently in another. The clothes that have holes and stains, which my sisters and friends love to tease me about at home, are considered high fashion and top quality here.  If I used all the clothes I brought, changed them everyday and had them washed each time they were worn I would feel like a complete snob.   

As I have described in other posts, some of my hikes to get to the communities we serve are quite difficult.  A few are two hours plus each way, up and down mountainsides and not very forgiving. Needless to say I bring plenty of water and an energy bar or two.  A few months back I was hiking along and began to think about the Camelback bag I had with me.  The other Ethiopian staff members either didn't have water at all or maybe had an old plastic disposable water bottle that was a cast off from one of our trips to Addis or Jimma.  Not only did I have a special water bottle, but also I had a special bag to hold my special water bottle. Then I noticed my shoes.  Not only did I have shoes, but I had special waterproof hiking shoes--different from my special (trail) running shoes-- and special insoles, not to mention special pants and shirt that wick away sweat.... heaven forbid I wear I cotton shirt. 

Daniel and I talked about this and then came up with all the many “things for our things” that we have back home.  Just yesterday I saw in a magazine a contraption to cut your banana into perfect slices, as if using a knife is just too difficult or archaic.  A towel heater to ensure its warm after you get out of a hot shower, paper towels so that you don’t have to be troubled washing a dishrag, pre-made peanut butter and jelly sandwiches, a phone that can use the internet so that I don’t have to bring a recipe to the grocery store or write down directions before I leave the house... the list is endless.  

Here we see kids making toys from anything they find; scraps of wire can become a wheel, plastic bags can be made into a soccer ball and patients use our old cans for cups.  I think it will be interesting to see what its like when we go home.  Being here you see very clearly just how little you need to survive and be perfectly happy.  I would like to think I’ll be able to resist the urge to buy unnecessary things just because they are there and able to make life a little easier, but I have my doubts.  I have a feeling I will be making an b-line to the first Starbucks I see at the airport, eager to go to Ikea to furnish our new house in Ann Arbor and ready to have my smart phone back.  I know there are things to do to curb this ever-present temptation to buy and consume yet it’s still a challenge. Now that we are six weeks away from returning home Daniel and I have begun talking about what it will be like to be back.  I hope this is one of the things I can take with me and try to integrate into our lives back home-- that you don’t “need” so much.  Obviously we work so that we can make our lives comfortable and nice, but to what extreme does it take us? How much time do we spend at work so that we can buy a nicer car, stay at a fancier hotel on vacation, have the newest flat screen tv?  These things are all so out of place here, it almost seems crazy after being in a society where most people work to survive and nothing more.   People here barely have things, let alone things for their things....  

  

Mistaken Identity-- Ethiopian Style

A few weeks ago Daniel called me into his office to see a patient who had come to the clinic complaining of shortness of breath.  Sitting on the bench was a middle-aged woman with a huge tumor growing out of her neck.  It was pressing on her throat, thus making it almost impossible to breathe.  While there are many people who come to our health center with enormous goitres from lacking iodine this one was different.  Daniel drained it and was fairly confident that it was cancer and if not removed soon, probably going to kill her.
    When patients need care that is beyond what we can provide they either go to Bonga, about 45 minutes away, or the larger city, Jimma, four hours away.  Daniel knew she would need more serious help and therefore brought her to see the health center director who would help her figure out the next steps to get her to the hospital in Jimma.   We advised her to return to her town and request a “free letter” (when people are very poor the village chairman can write them a “free letter” which attests to their need to have treatment given at no cost), gather some money for her journey and to come with us to Jimma the following week. We weren’t exactly sure what date the car would be leaving so we collected her contact information and said we would be in touch once we knew for certain.
    A few days later I was in her village on outreach and sent her a note letting her know that a car from Lalmba would be going to Jimma in four days.  (Keep in mind that I am using my very limited Kafanono and hand gestures to explain who I was looking for). As I have written about in other posts, proper communication here is painfully lacking....with no home phones, cell phones, mail, home addresses or internet we often have to rely on letters passed on from one person to the next in order to communicate. As I have seen in other situations and again here-- it doesn’t always work so well.  
    Three days later a woman did in fact arrive in Chiri with a large neck tumor and eager to see what the doctors in Jimma could do for her.  Unfortunately, she was not the same woman!  Our note must have been given to the wrong person....  The lady did have a huge goitre for over 15 years and while we don’t typically take goitre patients to Jimma (its not life threatening) it seemed like it was the right thing to do considering the circumstances. Ironically, she didn’t have a free letter and so would have to return home and come back with one for our next Jimma run. So thus, we went to Jimma without any woman or any neck tumors. 
    Luckily, the real patient returned a week later, still breathing and ready to go to Jimma.  Free letter: check. Family member to escort her: check.  Correct tumor: check.
Ahhh, the pleasure of working in the developing world.    

It's got to be tough

As I have written about in the past, there are 13 children living at Lalmba.  Some are true orphans while others have a parent but for whatever reason they are not able to care for them.  I think it is safe to say that they may be 13 of the most talented, smart, beautiful and all-around amazing children in the world.  They are always eager to help (literally running up to the car every time we return from the market or with a new visitor), they love learning new things, they seldom complain and they are always happy to dance, draw, braid your hair, play a game, cook...and just about anything. 

I have found that the kids can put a smile on my face no matter how rough my day has been, and that overall they are a huge reason why our stay in Ethiopia has been so great.  All I need to do is walk down the hill to the children’s home and seeing them run up to me with with their arms flailing automatically puts a smile on my face.  I have been struck several times at how mature and good natured they are, whether it’s helping translate for me or their excited willingness to work on a new project (such as the mountain bike trail they recently built with Daniel).  Every week or so I try to bring them up to our house to bake something yummy. I wish you could see how patient they are, all 13 of them mind you, while they each get a turn to pick out and mix one ingredient.  They don’t complain, grab, yell or fight over who gets to crack the egg or add the chocolate chips...they all leave smiling and happy to take part in what I think most American kids would think was slow, boring and dull. 

Lalmba’s goal with the kids is not to have them adopted into American or Ethiopian homes as a few people have asked me.  Rather, Lalmba sees them as the future of Ethiopia and aims to give them the resources (mostly by way of a stable home, basic life skills and extra tutoring) needed to make sure they succeed in life.  They are all exceptionally bright and I have no doubt that they will pass the exams needed to get into university here. 

Overall, they are happy and healthy children who laugh and smile often, get good grades and basically are no different than any other Ethiopian kids in the village.  I can’t help but think that even with the benefits they get from living here, it’s got to be tough.  What I can’t seem to get out of my mind is that they are, for all practical purposes, orphans-- they don’t get to run into their moms’ arms when they come home from school, they will never know what it’s like to crawl in bed with their parents or be able to see their parents’ smiling faces when they graduate from high school or college. 

Just today one of the youngest girls, Italey (it-ah-lay), had something wrong with her eye.  I brought her to see Daniel and after some poking around her eye ultimately he had to irrigate it.  During all this she was crying and was obviously in a lot of pain.  I went to check on her just now and she was still not feeling up to speed.  Her eye was still hurting her and you could just tell she felt like crap.  It’s moments like these that I realize how unfair it all is.   While I was able to hold her hand during the procedure and give her a hug just now when I checked on here it’s still not the same as what a mom or dad can do for a sick kid just by being there.  I offered her water and other than that knew I had to just let her be....no silly game or piece of candy could make her feel better.  I’m sure soon enough she will be her usual perky fun self, but in the mean time I’d say that it’s got to be tough.

What's The Right Thing To Do?

On Wednesdays and Fridays, with three other Chiri Health Center staff members, I visit one of the ten villages to which we provide immunizations.  It’s a real perk for me as the drive and hikes are all amazingly beautiful and it allows me to spend time in the local communities. Vaccinations have been a large part of our public health program since Lalmba began working in Chiri twelve years ago.  A few years ago the Ethiopian government started a community health worker program that assigns one or two health workers (called Health Extension Workers, or HEWs for short) to every village.  They are trained to give vaccines, assist in deliveries, provide family planning, and other general health promotion activities.  Community health worker programs are not uncommon and have worked really well in some countries, improving maternal and infant mortality and sanitation-sensitive illnesses.   

Unfortunately we have found the HEW program in our area to be less than ideal.  The workers are often young, placed in very rural communities far from family and friends, and are seemingly somewhat unmotivated to do their assigned tasks.  It seems that in many cases the HEWs spend a substantial amount of time in Chiri (a relatively large village) rather than in their assigned, more remote villages.  Frequently, when we show up to outreach to do vaccinations they are no where to be found and had not told people  in the community that we would be coming. 

I held a big meeting with all the HEWs who serve in our target areas and the village chairpersons to talk about the vaccination program.  I made it clear that from now on the HEWs had to be there when we were scheduled to be in their village, both to help give the vaccines but more importantly to keep track of the records (if both the HEWs and Lalmba are giving vaccines without coordinating, there is a good chance we are over vaccinating people, which is not good). It was a very productive meeting where both their concerns and ours came out and solutions were found.  I made it clear that if we showed up and the HEW was absent we would turn around and go home, no vaccines would be given.  Unfortunately, the very next day and again last week we showed up to outreach and no one was there.  

So here is where the predicament comes up, do we continue to provide vaccines in these areas where the government has its own program to be doing it?  Are we enabling these workers to not do their job by our continued presence?  While it would be easy to understand why we would drop the program altogether (even though the HEWs are adamant that they want us to come) there is a good chance that the people who would be most affected are the community members who would no longer get vaccinated.  It seems like this is the big dilemma for all types of development/nonprofit work- even though the work may positively affect people, in the long run is what we are doing causing more harm than good? 

Friends were recently here visiting and this question came up.  Is it ever okay for outsiders (i.e., white, American, educated folks like us) to work in a country like Ethiopia?    Is our presence here imperialistic?  To me it is a very grey area, with no obvious right or wrong answer.  There are days when I really question our presence here.  Yet on others where I feel very confident that our being here is beneficial.  After-all, by being here, we’re able to bring some of the training and skills that we’ve been fortunate enough to receive and that are not yet available to the local community. I think the vaccine situation is a good example of this dilemma. On the one hand, we are able to vaccinate thousands of people each year against diseases that might otherwise kill them.  On the other hand, we are doing a job that someone else, i.e., the government, should be doing (which is the case with many other issues that NGOs work on all over the globe -- building schools, hospitals, orphanages, doing advocacy work, etc). Is there ever a situation for which it is permissible for outsiders to work?  What about university professors who teach abroad?  Engineers or doctors who come to the US to work? Is there a difference when it is people from one developed country going to another developed country versus developed to underdeveloped?

I am curious to know what your thoughts are on this...where do you weigh in on this complicated issue? Any comments are greatly appreciated!