This dirt yard is actually the waiting room - for both family and patients alike - for the outpatient clinic (which is that building on the left). There were, depending on the time of day, up to ten times as many people as seen in this picture. Of course, I didn’t really want to appear like the ferengi who was taking pictures of those who are less fortunate, so most of my pictures are a large under representation of the amount of people the hospital usually sees.
Hello again. After a relentless bout of jetlag and truly the most culture shock I’ve ever had (coming BACK to the USA from Ethiopia), I’m ready to finish out the summaries of my trip. We pick up at the HIV clinic…
A week after arriving in Gondar (and 2 weeks after arriving in Ethiopia), Dr. Bien – one of the heads of the Scholarship Pathways program – received a long-awaited email from PEPFAR. As I’ve stated earlier, the President’s Emergency Plan for AIDS Relief is a major contributor of outside funds for AIDS research around the world. This email resulted in me getting introduced to the main infectious disease doctor at Gondar University, Dr. Desalew. I’m not sure if it’s because I was coming at the request of such a large organization or if it’s just in his nature, but he greeted me with open arms. He showed me anything and everything dealing with the HIV clinic, and he introduced me to a lot of interns and doctors who all seemed to be equally willing to help me get some experience. It was truly a relief.
Most of my days in the HIV clinic found me in the interview room specifically for patients with opportunistic infections. Though the cases were varied, there was an overwhelming number of patients with tuberculosis, and it was easy to see why. Tuberculosis is spread through the air by coughing, sneezing, etc., and with the lack of patients covering their mouths, I was surprised the entire country wasn’t infected. The interview room was smaller than any doctor’s office I’ve been in, and they were interviewing two patients at a time. 2 doctors, 2 desks, 1 bed, a host of bacteria and viruses flying through the air, and one bottle of purple rubbing alcohol for the hospital staff. It certainly wasn’t pleasant, but it WAS eye opening and incredibly educational.
During our downtime (given it wasn’t during the daily two hour lunch breaks…seriously), both Drs. Selam and Binyam were very interested to learn about the American medical system, so we exchanged our experiences. These conversations were probably the best of my time at the hospital because these docs weren’t afraid to tell me the truth about the Ethiopian health care system. Most other doctors I met were only minimally in tune to what I was doing there, so they showed me the good parts and that was that.
Though most of my time was spent in the aforementioned interview room, my time in the wards and patient education rooms were also quite enjoyable. Truly, there is too much information from my time in the HIV clinic to write here, but trust me when I say that I have an arsenal of information for my project. Can’t wait to share it!
After 5 days of cancelled flights, volcano Nabro calmed down long enough for me to get to Addis. It’s still bubbling, but I don’t expect it to cause any problems for me on the way home. In other news, I’m a lot more relaxed here in Addis. There’s much more to do, and the people are less amazed by foreigners. Vegetarian food is also all over…a plus. I’ll probably not update the blog until I get home…so I’ll see you in 3 days!
As the ferengi party was winding down, I met two UK doctors who were here to teach anesthesia students about what the Western world might call “common practice”. They expressed concern about the number of students they had to teach between the two of them. With my less than ideal introduction to Gondar University, I jumped at the opportunity. “I’d love to do help!”
So there I was. Finally, after months of trying to find something health-oriented to do in Ethiopia, I had an itinerary. What a relief. The rest of the weekend went by quickly, as it usually does when you’re exploring a new environment. More staring, more “ferengi!”, more delicious food…then it was Monday.
I arrived at Gondar University Hospital at 8am to do surgical rounds in the ICU. After the brief introduction to the incredible amount of trauma cases they have in Gondar, and after another early-morning scavenger hunt, I tracked down the room where the teaching was scheduled to happen. It was empty. While I searched for the new classroom, I began to realize that my initial experience at the hospital wasn’t an anomaly. This blatant disorganization would be echoed throughout my experience here. I’ve since gained an appreciation for Ethiopia’s ability to adapt, however, for if an American hospital were presented with this type of disorganization, I can almost guarantee that nothing would ever get done.
When it finally started, the teaching was wonderful. I helped out when I could, but more importantly I was learning. I was learning about medical education in Ethiopia – their resources, techniques, commitment to the profession…everything. I even got trained in CPR for the twentieth time (seriously, if you ever go into cardiac arrest around me, fear not).
Overall the entire teaching experience was great, though there was one issue that disturbed me. Medical jobs are so unwanted here (due to low pay, hazardous conditions, etc.) that these students were actually PAID foreign aid money to attend the classes. “What a deal!” I thought. Sadly, this set up a perfect opportunity for exploitation. The UK doctors and I learned later that the students had signed the log sheet for 5 days, when in fact there were only 4 days of actual teaching. Even while the class was happening, it was apparent that some of the students were only there for the money, but I never thought something like this could happen.
It really made me question the entire system of foreign aid. When we start having to reform the way charitable organizations have to operate in order to be effective, at what point do we say “enough is enough”? Obviously, not everyone is out for a free ride, and those people need help. But how do we accomplish that without people taking advantage of the generosity? The experience added yet another layer to the already complex issue of global health, and honestly, trying to focus my thoughts on these problems is making my head hurt, so I’m going to stop here.
Coming up, Dave heads to the HIV clinic. Stay tuned!
This is incredibly interesting (the title of this post is a link). I’ve come to a lot of these conclusions myself after being here for only a month. It’s reassuring to hear it come from a native Ethiopian. Like the millions who have witnessed this problem in the past, however, she too doesn’t have all the answers. The topic now should be: how do we solve it? Logically, it needs to be a global effort, but how does that get started?
Arriving in Gondar on a Thursday evening, I would only get one day at the hospital before the weekend when, just as in the US, the hospital effectively shuts down with the exception of emergent cases. As I previously blogged about, my first day left a lot to be desired. I was abandoned by my “host” minutes after setting foot on campus, and I spent the rest of the day getting clearance that I didn’t need. This lack of security is a change from what I’m used to in the US (magnetic key cards, visitor logs, etc.), but it allowed me to experience much more during my visit than I would have if I’d been limited to the surgery department alone. Being tired from the bus ride, frustrated from my first day, and not knowing what my future held, I welcomed the weekend with open (yet hesitant and very tense) arms.
Enter my posts about being a ferengi.
From my research on other blogs, I’m not the only white person who has had a difficult time in Gondar. The town appears to be incredibly good at making you aware you’re foreign. Leaving tomorrow, I’m still not entirely used to it, and I’m not entirely certain there isn’t a small amount of hatred in some of the stares, but who knows. That’s for another discussion on another blog, and I don’t think I’m in a position to analyze it anyway. I agree: I do look weird, I do take pictures of people with a camera that costs more than their yearly salary, and I do tend to ignore the constant “hello, mister”. I might have a little hatred for me too, if the tables were turned.
Anyway, I think I’ve explained that issue well enough in previous posts. Back to why I’m actually here.
The segregation worked in my favor that first weekend. I was invited, through the German medical student doing an elective here, to a ferengi party of sorts. A doctor from Kansas City who had been here for 10 months was leaving, and people were saying goodbye by having a BBQ for her. While people gorged on sheep’s meat (slaughtered feet from where it was eaten), I was introduced to the world of Ethiopian health care through the eyes of doctors from the Western world. “Education! Sanitation! Low incomes!” These problems would soon be apparent to me as well, though the reasons for their profound existence still remain a mystery…
Well today is my last day in Gondar. A week in Addis, 2 hours in Khartoum, 7 hours in Amsterdam, 2 hours in Minneapolis, 18 hours on a plane, and I’ll only be an hour’s drive from home!
While I plan to continue updating this blog, it will obviously not be as frequent as it has been over the past month. Before I leave I want to summarize my thoughts about my time here. I feel as though my frustrations, most of which were strictly culture-based, may have obscured one’s perception my actual educational experience (when taken in text form). I want to assure everyone that I’ve really enjoyed my experience overall. It’s a lot easier to complain about something than to do any critical thinking about how to help an entire country’s healthcare problems, especially with a very limited knowledge of both the political and medical systems. Just thought I’d clear that up. Here we go…
Upon arrival in Ethiopia, I had a culture shock-free orientation to the country thanks to Chaltu’s family friends. This acclimated me to an Ethiopia that, in my opinion, is only a possibility for a small amount of the country’s inhabitants. I kept being asked “So is this how you pictured Ethiopia?” with the implication that my vision of Ethiopia was thousands of starving children covered with flies. This was never my perception of Ethiopia, but as I felt like a representative for the entire Western world every time I was probed like this, I would answer, “It’s very nice” and smile. In hindsight my response should have been: “You’re obviously educated enough to know English, and you’re wearing a tie, so I probably shouldn’t make any opinions based on the time I spend with you. I’ll tell you in a month.”
Please don’t misunderstand. I’m very grateful for the treatment I received during my first few days here, but the person who was showing me around worked for the government (a government that is not necessarily a crowd favorite, mind you), and he was obviously better off than most. I was chauffeured around in his car the whole time, going from one sanctuary of Addis Ababa to the next all while turning a blind eye to the miles of aluminum shacks and beggars in between. I don’t feel like I really experienced Addis.
In an effort to see the country rather than fly over it, I opted to take the bus from Addis to Gondar. The trip was definitely worth it – literally – it was only about $15. It’s only a little over 400 kilometers as the crow flies, but with a 2 hour stop due to the alternator breaking, it took over 13 hours. This was no fault of the driver, however, as I feared for all pedestrians when we entered a small town. He slowed for no one. The insane kilometer:hour ratio was actually a byproduct of Ethiopia’s hilly terrain. Just take a look at the topography!
The bus ride revealed a scene that was much more reminiscent to “starving children covered with flies” than what I had experienced in Addis Ababa: women who travel for 30 miles to gather pounds of timber and kindling only to turn around and carry it home on their backs; 5 year old children leading their family’s donkeys, the unsung heroes of Ethiopian agriculture, back to the farm; men dragging a single hoe behind two very unhealthy-looking cows, cultivating one acre of land in the amount of time John Deere could cultivate one hundred. The disparities between the upper and lower class - an imbalance that I believe makes up a major piece of the country’s health problems (yes, I’m still talking about Ethiopia)- were starting to show. Still, I was shielded from this reality by a bus window. It felt more like I was in a museum than a foreign country. Then I got to Gondar, and the hospital…
Part 2 to come.
After I graduated college, I took two years off to work in a hospital. I wanted to make sure I wanted to be a physician (something I was always strangely too certain of), and truthfully I just wanted a break from school before I was essentially tied to it forever. During my two years at St. Joseph’s Hospital in St. Paul, I primarily worked in the ORs, and I learned a lot. Not only did I learn a lot from the world of academia, but I learned about the “social” aspects of working in an operating room – things that, until coming to Gondar, I hadn’t realized were almost globally standard operating procedures.
Considering yesterday was probably my last day with the surgical team, I figured I’d summarize the similarities and differences I’ve noticed between my two experiences. Keep in mind these are ONLY the differences between the ORs at St. Joe’s and those at Gondar University Hospital. I don’t want to make any glaring generalizations because I’m sure there are differences everywhere.
To be honest, the similarities are almost comical. There were FAR more similarities than differences – something I definitely did not expect.
- there are the same few key players in each OR : a surgeon, an anesthesiologist, an anesthetist, and a nurse
- each person plays the same role
- the sterile procedures are the same, and the sterile packs (containing gowns, towels, instruments, etc.) look identical
- the charts that document the vital signs are nearly-identical
- the best view of the surgery from an outside perspective is right at the head of the bed, over the sterile drape separating the anesthesia team from the surgical team
- when a blood clot causes the suction to be clogged, it’s somehow still “not the surgeon’s fault” for the suction not working (this one almost made me laugh out loud yesterday)
- the patients WALK THEMSELVES into the OR here. Imagine seeing that in the United States.
- they don’t do the “Pause for the Cause” in Gondar – a ritual of sorts at the beginning of the surgery to make sure the proper procedure will be performed
- they don’t have an automatic ventilator here. The anesthetist was squeezing the bag inflating the lungs for the whole surgery
- they use halothane for anesthetic here. This hasn’t been used in the US for years due to side effects, but it’s cheap.
- they don’t have automatic pumps for IV drips here, but they also have a lot fewer drugs that need to be closely monitored.
- they don’t have EKGs here! I know they do in Addis, but this one surprised me, as it was SO commonplace in St. Paul.
- there were FAR more people watching each surgery in Gondar than in St. Paul, on average (though this probably has a lot to do with the fact that the hospital in Gondar is associated with a university).
As anyone can see, there is a general theme being formed here. It’s one that should be obvious, but having seen it first hand, I can be confident that it’s true. Health care in Ethiopia is struggling not because they are incapable; it’s struggling because they are denied the means to give great care to their patients. It really is a money issue, when one digs far enough.
I’m not claiming to have the answers to solve this problem, but I think as a society we can come up with something, right? Why haven’t we done it?
Anyway, today is Saturday, which means there’s a crazy market on the outskirts of town. If you come up with a solution, you can find me there.
Piles of salt from the market in Lalibela. Sadly, this salt is the indirect culprit for most of the goiters and thyroidectomies (one of which I saw this morning) in this country. Most salt one finds in the United States is iodized, meaning it is fortified with iodine. This iodine is an important substrate for thyroid hormones. When the thyroid gland is starved of iodine, however, it enlarges to try to produce the maximum amount of hormone it can. This is called a “goiter”.
The salt pictured here is directly from a salt mine, so it’s not iodized. Although iodized salt IS available here (and more can easily be imported from the middle east), the lack of education results in a plethora of goiters. This is just another example of a very solvable problem that has been overlooked for far too long. Education is important!