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.

---

^[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!

The Little I've learned So Far

As I have written in other posts, I am continually amazed at how strong and supportive communities appear to be here.  Just last night Daniel told me about a young child that was brought in after being bitten by a baboon. I haven’t seen any baboons around our area so I asked where they came from.  Turns out they were from Angola, nothing less then a twelve hour walk.  So what means is that about twenty or so friends and family members made a stretcher and took turns carrying this kid up and down windey roads, barefoot, without water, Powerbars, Gatoraid, or really anything that you or I would bring on even a leisurely hike.  Just to give you a sense of how difficult this must have been, when we went to this area for outreach there were points where I wasn’t sure our “super-duper can get over anything tank” Landcruiser would make it. 

So why I am telling you all this? 
Unfortunately I found out recently that someone in my family was diagnosed with a pretty rare tumor.  At first they thought it was in the lung which would require opening up the chest to remove it but after a second opinoin it was actually found to be on the pericardium. A tumor on the pericardium is extremely rare, so much so that they have no idea what the chances are of it being benign or malignant. On the flip side, it means that the surgery no longer involves opening the chest (which is pretty invasive and difficult) but can be done thropscopically, which allows for a much easier recovery.  

Obviously being a zillion miles, time zones and without good cell or internet connection makes this a pretty difficult situation. I can’t be at the doctor’s appointments or able to give good moral support.  At the most recent appointment with a highly respected surgen he said that because the surgery no longer requires opening the chest it wasn’t necessary for family to come in from overseas.  No, this would be routine, in and out in a day or two with a recovery time of up to two weeks. And as it goes in the US, If she needs some help afterwards making food, getting to a follow-up appointment, filling a prescription.....well, hiring someone is always a possibility. 

Perhaps being here for four months has had a stronger impact on me then I first thought because his response seems just absurd to me.  At our clinic when we transport patients to bigger hospital we have to fight with families because they all want to come with.  I’ve seen patient’s families wait patiently for days and weeks by their loved one’s bed with little more to do then stare at the walls (no wifi, tvs or magazines in these parts).  When a patient needs to go to a bigger hospital we make sure they have enough money to pay the hospital fee and get transportation home, which can be no less then a year’s income.  I’ve seen people tell us there is no way they can come up with that amount of money, and somehow their community is able to come together to sell a cow or collect from one another the necessary amount.  

Everyone said that coming here would be a great learning experience and I can’t help but feel like I am being given the ultimate test right now.  Yes, I can listen to this doctor and tell myself that its not worth coming home.  The money, the time, the inconvenience--- all add up to being there not worth it I suppose for him.  If I go home, it will mostly likely mean we can’t go on the trip to Tanzania we were hoping to, my work plan will have to be adjusted and people at the clinic will all have to pitch in to fill in for my absence.  Are these the types of things the doctor was thinking about when we said returning was not necessary? Maybe its more that he only thinks of the physical surgery and nothing else.... not the emotional side that comes with being sick.  I feel confident that the surgery will be fine, but what about everything else?  Don’t people need their family to help them through the scared feelings, the worry, the anxiety?

I can’t help but think about the different things here that might seem so absurd to people back home; from having chickens living in your house to the necessity of collecting firewood in order to cook dinner. And yet I think what this doctor is suggesting would be equally shocking to my friends and colleagues here.  Not being with your loved one in a time of need like this and paying someone else to help them....I just don’t think people would even be able to fathum this as being a possibility.   When someone is sick, everyone pitches in. 

While being here had taught me a lot about public health, malnutrition, driving a stick shift, etc. I think the biggest lesson I have learned is that you should do anything and everything for your family and friends...that you should treat people the way you want to be treated.  If it was me I would  want everyone to drop what they were doing, put off vacations, reschedule meetings and be by my side. So contrary to what this doc said, I will be coming home to be with my mom while she watches tv and runs errands(anything really to keep her mind off of this) leading up to the big day, be waiting in the hospital while the surgery is taking place, have her favorite meal ready for her when she wakes up and make sure she has all she needs when she goes home.  It’s funny that we often think as the developing world as being “behind” and yet in a situation like this they seem to make us look like we have it all backwards.   

Africa Is Not A Country

When I first thought about coming to Ethiopia I expected a dry, brown, sad place where life was difficult and hard and anything but enjoyable.  I would venture to guess that when most people think about Africa there is little positive that comes to mind.  From movies, magazines, newspaper articles and books, I have found there is little positive said about this large and diverse continent (which is often lumped into one place, “Africa”, and rarely its individual countries).  Daniel is in the middle of one of these books, where the only things discussed are how terrible everything is here-- the corruption, the poverty, how NGO’s have destroyed people’s work ethic, the spread of HIV, etc. 

I can’t help but think back to an assignment I was given in graduate school to do a community needs assessment of the Delray neighborhood in Detroit.  My professor wisely told us that we were to look at the area’s strengths--not to focus only on the problems.  As those of you who are familiar with Detroit know, it would have been very easy--and most likely what we would have done. Only focus on the bad....the run down houses, the boarded up buildings, the liquor stores and miss what positive things were very much there but easily overlooked when going in with a negative mindset, the houses with beautiful gardens, the churches, an active community center, etc.  

While I am sure that all the bad things people write about and highlight in movies about Africa are true for some people, it is for sure not the case for everyone.  Where we are in Chiri, I am often times jealous of the life that people have here.  Children grow up in green, lush mountains able to run around and play without worries, families are unbelievably close, people will go to great lengths to help others (even if it means carrying a neighbor who is in labor on a stretcher up mountain roads for up to eight hours in order to get to a doctor), because no one has a car people walk everywhere giving them ample opportunity to spend time with friends and family, there isn’t the constant advertising of products and things that can make you feel like you never have enough...the list could go on but I think you get my point.  Of course there are a lot of hardships that come with living in a developing country like Ethiopia-- the chances of dying from a treatable illness is huge, people don’t have a ton of opportunities for a meaningful career, most people can’t turn on the tap to get water or have a stove to cook.

While I realize no situation is black and white and that neither place is better then the other, I can say without a doubt in my mind that Ethiopia is an engaging country with beautiful, happy and generous people which turns any assumptions about what “Africa” is on it’s head.  I just wish there were more journalists and filmmakers that saw the other side that exists here.  I wish there were articles about the families who sit by their loved ones beds and bring them food for days on end while at the clinic, or the parents who carry their children for hours, and even days in some cases, when they are malnourished.  I wish there were movies about the many families who are surviving just fine working their fields and don’t rely on food aid.  I wish there were NY Times articles about people who work hard, go to college and work in places like our clinic helping their community.  I wish there were films that conveyed how green and mountainous and lush this country is.  I wish the news told the story of the men and women who are entrepreneurs who are growing towns like Chiri.  

What I really wish is that you could see all this for yourself....I don't think that this blog can give justice to all that I have seen and felt in just the short time I have been here.  I do wonder though why this is the case....is there something we get out of labeling places like Ethiopia as poor and in need of saving?  Why don't we hear more about all that is positive here? 

(If you are wondering where the title to this blog comes from, a classmate in social work school wore a button with “AFRICA IS NOT A COUNTRY” which really amused me)

What Makes a Day Great?

Today was a typical day for me here at Lalmba.  I set out early to go on outreach to the village of Angela, a newer site for us, which was a two hour drive from Chiri.  Turnout was good and we gave over 200 hundred vaccines.  We were there most of the day and returned to the health center around 3pm.  I was sitting in my office when Faith told me that one of my favorite malnutrition patients, a little girl named Mizrat, had returned with her father for her follow-up appointment.  As I have mentioned in other posts, I spend a lot of time in the malnutrition room playing with the kids and interacting with the parents.  They are here from one to two weeks, depending on how bad their case is, so it gives me a god opportunity to get to know them.  There was something really special about Mizrat and instantly I just adored her.  When she first came to Lalmba she could barely walk, I should mention she is two and a half, and was in such bad shape that she basically couldn’t do anything but sit in her bed all day. Slowly but surely her health improved was and she became more active, walking all around the clinic with me (my version of physical therapy I guess) and began to actually interact with the world around her.  When her time here ended I sadly said goodbye to her father and her, hoping they would return for follow-up so that I could see them again.  Patients can live very far away, theirs is a six-hour walk, so it’s not a sure thing that they return. 

I was glad to hear that they came back for their appointment but was a bit said to have missed them.  Faith said they waited a bit but must have left.  Bummer…..I was wondering how she was doing and if she would remember me, but I would have to be satisfied with just reading her follow-up paper work. 

As I was imputing data from today’s outreach one of the clinic guards came into my office to say that my friend was here.  I looked and up and wouldn’t you know—it was Mizrat!!  Her father said that he really wanted to see me so they spent the afternoon in town (not sure what they could have done since there isn’t much to do here).  Literally in a matter in seconds my day went from fine, to amazing.  I really can’t tell you how happy it made me to see them and to be able to give her a hug and see them for a bit. I must have had the biggest smile on my face and I think I yelped with delight when I saw it was them.   There happened to be another patient and her father here for malnutrition follow-up, so the four of us chatted for a bit. Something new I am starting here is to give patients who return for follow-up seeds to plant vegetables in their gardens.  People here mainly grow and eat cocho and teff, plants that don’t provide enough protein or calories which causes malnutrition.  While patients are here we counsel them on different foods, show them our demonstration garden and have them attend a cooking class all in hopes of teaching them about the different foods that can be grown here--carrots, beets, spinach, etc. (Unlike in the US where people often know how to prevent diseases, here surprisingly people have no idea that their diet can cause malnutrition.) I gave the fathers some seeds and tried to pick their brains on how to make the program better.  While they didn’t have any criticisms of the program Mizrat’s father did have a lot to say about why it was good.

            

             Before coming people in his town said he was crazy to bring Mizrat to Chiri as it was obvious she was going to die.  No one thought she would make it and the journey would be for nothing.  He came anyway and sure enough she was not only alive but doing better.  When he returned home everyone was so happy and excited to see that she was in fact alive and well.  He went on to describe how he learned here how to change their eating to make sure this doesn’t happen again and about other health issues that can cause illnesses such as poor sanitation, cleanliness, etc. Clearly, the health center had done a lot for Mizrat and he was tremendously grateful as he came with only 35 birr (about $3) and Lalmba paid for all of her treatment and his food while they were here. He thanked us and promised to be back for his last check-up in a few weeks.

             There are moments when I wonder if the work I am doing here really matters.  I can’t help but question if the communities I go to on outreach would be any different if I (or any other ex-pat) wasn’t here….and if there is any real change from the work we are doing.  But then there are times like this afternoon when the sight of Mizrat and her father just made my day.  Knowing that they stayed to see me makes me think that the little itty bity part I play here might just matter after all. 

             

Being Poor Sucks

As the day was ending at the clinic I noticed Daniel and Richard, the other ex-pat doctor, walking into an office with their last patient.  Seeing as I had just finished up with my work I thought I would sit in.  The young man looked pretty healthy but as it turns out he had TB.  This is a pretty common illness here, one which is treated with two months of daily medications given at the clinic followed by six months of medication taken at home.  The key to treating TB effectively is that the patient cannot miss a dose of their medication and if he or she does the infection can become drug resistant which is really bad-- therefore we initially require patients to stay in town and come to the clinic each morning to take their meds.  If you have read Tracy Kidder’s book about Paul Farmer, Mountains Beyond Mountains (which I highly recommend) this probably rings a bell. 

Anyway, the patient was about 17 years old and from a village very far away.  When it was explained to him that he had TB and what the treatment protocol involved, he got a very sad look on his face.  While you might guess this was due to the new information about having TB, the truth was that he was more stressed about how much it would cost for him to be able to stay in town to be treated.  He explained to us that last year his family and he had been moved from another area of the country and resettled to our zone because of the limited amount of  land where he is from.  We sat there listening to him as he told the story of his family’s finances, they used to have more money but now are quite poor, and how he now only has 50 birr to his name (about $4).  He quickly calculated how much it would cost him to rent a room for the two months and to buy food, less then $15 a month, and immediately his head sunk.  This was too large an amount, impossible for him to come up with.  Could he go home and borrow money from family and friends we asked?  He did not seem too optimistic about this.  Could he start treatment today he wondered?     He clearly understood the danger of TB and wanted to start medication as soon as possible. 

Normally we require a 75 birr deposit, but all he had was 30 birr.  Lalmba does have a special fund for people who truly cannot afford their treatment, but I had a feeling he might not qualify.  This may sound crazy but since he had shoes and new(ish) pants and a shirt I had a feeling the committee that decides these cases wouldn’t believe him.  Now whether he can come up with the money or if the committee will find him needy enough to pay for both his treatment and living costs, I don’t know.  I don’t think Lalmba would ever let a person go without being treated, especially for something as serious as TB, but the situation still pains me just to think about it.  If that were me or probably any one of you reading this blog this would never be our reality.  TB is almost nonexistent in the US in the general public largely due to our higher standards of living and better health care, when we need to get from point A to point B it usually doesn’t involve walking for hours or days, most teenagers wouldn’t have to travel and be on their own when seeking health care in a different city, and most obvious--- if we were facing a potentially deadly illness that would cost less than $50 to treat, it would not cause us an unbelievable amount of stress. 

Daniel and the other doc, Richard, sent him home to collect his stuff and bring back as much money as he can come up with.  TIme will tell what the outcome will be for him as he said he could be back by Thursday (it’s about a day’s walk from Chiri to his town).   

Everyday we see patients like this and the same thoughts run through my head.  Whether it’s a child who is so severely malnourished they look as if they just left a concentration camp, or a woman who was burned after having an epileptic seizure and fell into the fire they use for cooking, it all just seems so unfair.  So much of the illness and injury we see is completely avoidable it really makes you wonder if life is playing a mean joke on so many billions of people whose reality is like this patient.

Man's Search for Meaning

I am not sure if this post will make any sense, but I have a few different thoughts running through my head that I wanted to try and share with you....so bare with me on this one.

Last year one of my favorite graduate school professors (Sallie Foley for all of my U of M people out there) recommended to our Grief and Mourning class that we read Viktor Frankl's book, Man's Search for Meaning.  Frankl was both a Holocaust survivor and a well respected psychiatrist. In his book he argues that "life is potentially meaningful under any conditions, even those that are most miserable" and that "people have enough to live by but nothing to live for; they have the means but no meaning." Frankl credits his surviving the Holocaust to the fact that he was in the middle of writing a book when placed in a concentration camp. His strong desire to survive in order to finish and publish it kept him going in even when he was the sickest.  Even in the bleakest of human situations, he was able to find meaning and it was this meaning that made life bearable. 

While I am in no way comparing my life here to living through the Holocaust, it's quite the opposite really-- our life here is pretty amazing....this morning I ate breakfast with Daniel while watching the monkeys play, I spent the day training community leaders from four villages in public health programing, and I sit here on my porch drinking a beer, listening to the birds and looking at  beautiful sunset over the mountains.  Yet, I feel like I am beginning to understand what Frankl writes about in his book.  Yesterday I drove to a meeting in and on the way saw a patient who was beginning his journey home, nothing less then a four hour walk mind you, even though he is missing a foot and on crutches.  He happened to be going to the same village I was and so I was able to give him a lift.  It actually made my day to be able to give him a ride as I knew the walk would have been long, hot and brutal. 

In the end, the meeting I was going to didn't happen as not enough people showed up. Even though I had spent all morning getting there and hiked half an hour in and out of to the meeting place, I still felt the day was a success because of giving the man a ride.  That made me think about Frankl's book and his argument about our ability to be happy in life, no matter what our circumstances.  It really is all in the way you look at things.  One might think that there is no way a CTA bus driver could be happy with his job or find meaning in driving in traffic all day, stopping every block to let passengers on and off, having to give directions to tourists all day long on how to get to Michigan Ave. or the zoo, but now I see how it is all in their point of view.  Without the driver people wouldn't be able to get to work,  to a necessary doctor's appointment, to see the friend they are visiting in town... yup, his job can in fact provide endless amounts of meaning.  And when we see the meaning in life, this makes us content.  It doesn't matter what kind of car we might drive or the vacations we can afford to go on, its these little things. 

Everyday here I am given these opportunities and I feel so blessed that this is the case.  Whether it's playing with a patient in the malnutrition room and getting them to smile or holding someone's hand while Daniel stitches up their arm, these moments provide me with what Frankl describes in his book as opportunities to find meaning in life.  Something I struggle with in my own life is being appreciate of what I have and living in the moment.  I hope that throughout this year I am able to curb my negativity and find the meaning in each day, to which Frankl suggests allows us to be happy and fulfilled.   Hmmm......here's to trying.

Generosity

When I go on outreach to the different villages we work in I am reminded of how rough the toughrain is  here.  I am just blown away when I think about people  the fact that often times patients are carried here on handmade stretchers by anywhere from 40-75 community members.  I think I have mentioned this before, but when someone is really sick and can't walk, they are carried here overland-- in many cases taking up to several hours to a day-- by friends and family as there are no cars or busses and ambulances are unheard of.  Yesterday on the way to the village of Goize we came to walk with a women and her son.  We all began chatting and it turned out she was also going to Goize to visit with her mother.  I asked how far it was from her own village to Goize and she replied three hours. Yup, this woman and her ten year old son were walking six hours in one day just to see her mom for the afternoon.  Can you imagine?  If we had to walk hours up and down mountain sides, would families still exist in America?  Our family times holiday meals around when parking on Lake Shore Drive opens up...walking three hours each way--- I have a feeling there would be a few empty chairs at Thanksgiving if this was the case back home.  Obviously, its a different world here and people's lives don't operate in the same way but it stops to make me think about how much more I can do to be a better sister, daughter, wife and friend. 

On the way we got to a super muddy area and as usual I lost my balance on a rock and my leg sunk deep into the mud.  There was a little stream up ahead where my co-worker Alias convinced me to take off my shoe and wash off my foot.  The woman were were walking with immediately jumped into the creek and began scrubbing my foot and cleaning my pants, shoe and sock.  Even her son helped out.  Now really, can you picture this happening back home?  People don't even stop to help when they see someone fumbling with a map, can you imagine cleaning a stranger's feet?  Also worth mentioning is that her son offered to carry my bag and when I said no he took the backpack filled with a cooler and immunizations from another staff member and carried it for at least two hours. 

Fast forward a few hours....we are in Goize and in the middle of doing vaccines when I notice a woman whose child looks really small.  Since I am not trained to give vaccines I use the time on outreach to check children for malnutrition.  This woman had three kids with her, ten months, two and six years-old and after looking a little closer it was apparent that both younger ones were severely malnourished.  The women herself wasn't in great shape either, she had one of the biggest tumors I've seen so far growing off her neck (possibly a goiter).  We convinced her to come back with us to the health center where we have a malnutrition program and could treat her kids.  While I won't go into it now, hers were just two of the MANY children I saw with severe malnutrition in Goize, something pretty alarming to me.  Honestly, we could have brought back eight more families if we had the room in the car. (You might be asking yourself how I can tell if someone has malnutrition since I am not a doctor or nurse....luckily there is a very easy to use measurement strip for upper arm circumference that I have begun taking to all outreach sites.)

As we began the trek back to the car a random woman invited us all into her home for some coffee, which again made me stop and think.  Have I ever invited a complete stranger into my home?  Sure I am always happy to have friends and family over for shabbat dinner or to hang out, but a complete stranger off the street?....can't say I have.  As we continued  back people stopped to ask the mother why she was with us.  After she explained they were all tremendously concerned and threw their arms in the air to show their sympathy and giving words of encouragement.  At one point it began to rain and we ducked into a hut that is used for selling tela (a fomented barley drink).  Again, the women asked what was going on and immediately hugged the woman, grabbed their chest and poured her a big drink.  In a place where people have so little, giving things away for free can't be easy. You could just tell that these women so cared and felt for the mother, even though I don't know that they had ever met before.  As a co-worker explained to me a while back, people here really feel for one another......this was more then evident on this hot, rainy afternoon. 

As we continued with the walk the woman began to struggle with her two kids, one tied to her front and the other to her back.  My co-worker Sebsibe took matters into his own hands and carried the baby back himself.  Just to set the stage for you, this was no simple walk in the woods.   We were walking basically straight up and down a mountain in the middle of a hot and humid day after going all day without anything to eat and little to drink (the Ethiopians aren't big on drinking water unless it's with a meal).  We made it to the car and eventually back to Lalmba.  As I pulled up I mentioned to the guard that we had a patient in the back of the truck.  He followed me in and halped carry one of the kids to the clinic. 

I am not sure if these stories will do justice for what I experienced today or be able to convey how telling each instance was to me.  I feel like I have so much to learn from the people I meet here.  I hope that one day I can do for others what I have seen others do so selflessly.  I hope that I can feel for others the way people here do.  After thinking about this I realize just how much I have a lot to learn about life and generosity....and luckily for me I have a seemingly endless supply of teachers all around

PS- for those of you who are follow the weekly Torah portion you will share in my amazement at the similarities with my experiences on Friday and what you read this Shabbat about Avraham's generosity towards strangers......beshert, coincidence.....???

Over the past 24 hour I have experienced several moments of immense generosity, directed both at myself and to complete strangers.  In a place where people have so little I am always amazed at the things people do for each other. 

.

Some of My Favorite Photos...So Far