No light at the end of the tunnel

As keen readers of this blog will know we are privileged to live in the Adventist bit of the compound which, at night is a dimly lit path of some 200 yards to the hospital. From the house for the first hundred yards there are or were a few ‘incandescent’ light bulbs (these are the sort that are regarded as bright and energy inefficient in the U.K and are thus difficult to get, and may well be energy inefficient in Ethiopia but bright – no). Last night, as I walked to the ward I noticed that the last one was not only not working, but gone …. stolen I suppose by a nocturnally challenged Ethiopian and joins if less valuably in commercial terms one of the head torches, the list of that which has been pilfered from trusting open pocketed faranjis. This is tedious as it is actually quite dark and the urban myth around here is that Hyenas prowl at night after various bits of offal that could potentially include me. Certainly there are jungle noises and quite a lot of rustling but I never seen anything other than the odd thin stray dog which we try not to befriend as it is yet another thing that will require, eventually some form of long term support. Allegedly you are supposed to be escorted by guards, who carry bits of pipe or stick but this has never happened, nor come to that have I felt in any danger- but light would be nice especially as the path is often covered in some form of ordure and it would if nothing else be good to avoid this. As I write I have just had to break up a Vervet monkey fight on the veranda and chase a particularly thick (Ethiopian borne) monkey out of the chicken cage. The chickens meanwhile have found a way into the vegetable garden and seem to like coriander so some blocking up will be necessary. They are becoming absurdly tame now and like being hand fed, one even does jumping tricks!

The coffee picking season is on us and as this is the main cash crop, illness real or imagined is banished for the little red bean so all is quite quiet except as I arrived this morning there was both fetal distress and an odd presentation which turned out to be a face, and very puffy to on delivery, but seems to be breathing but may not want to suck for a bit. There also seems to be an outbreak of hypertension which is quite difficult to manage when you have little idea of gestation and as soon as your back is turned there is exhibition of poly-pharmacy and is the headache from hydralazine or the underlying condition? Our last fitting patient has been out of it for a few days and I have had a tube in the baby but fortuitously auto-removal (quite common) has coincided with both a suck reflex and return of a sentient (well in Ethiopian terms) human and I can even discern a cheek bone.

Maternity Worldwide has now theoretically withdraw the ‘safe birth fund’ which was the main provider of cash for the maternity service of the hospital and there seem to be fewer women around and as my Ethiopian colleague has pointed out none of them look as if they can afford any sort of treatment - -perhaps and I hope, the Government hospital is taking up the slack as I would hate to see the pathology that comes through the door suffering at home. However what is sure is that the charity has made and is making no attempt to monitor the effect of its decisions, that would be too thoughtful and also the answer might be very uncomfortable. The main function of Maternity Worldwide is to provide training and they have 3 managerial staff, one of whom is keen to relocate to Addis and a midwife who is going around assessing training needs but not as yet delivering the needed training. The English training team, following a lot of wrangling appeared and being English did Stirling work but only just made it with the various barriers put in their path and the only useful help they got was not from the local management team but the ex-pat midwife who did much organisational work on their behalf (such as buying them food and photo-copying teaching material). It seems to me that there is a lot of ‘need assessment’ little in the way of ‘need delivery’ and crude if any measure of the effectiveness of the training that is delivered. It is all to do with something called EMOC but I am not sure what it stands for. Not so the delivery of useful clinical equipment though, and there has been a lot of counting of various toys, including some rather mouldering looking tents – I am not sure I envy the sleeping quarters of the upcoming cyclists. There is now an inventory but most of the drugs are out of date but I do not suppose that out of date iron is very dangerous, and might be quite useful for the young lady with a haemoglobin of 5 gms. and a 4 hour walk home, she is a bit breathless getting out of bed.

Our non Danish and probably unrepresentative of the English Maternity Worldwide volunteers (this being part of a political battle being played out in the U.K) brought with them useful goodies, such as scrubs for the local surgeon, swabs for surgery and sutures etc. Instead of the scrubs being handed over, the swabs dropped into theatre etc. all was laboriously counted into stores from which it is never likely to emerge, on the spurious grounds that the team will want to know what happened to them…do they care and do they care enough to think that it was worth the best part of a day of the teaching midwifes time? I actually have a personal gripe here as I went along to say hello to the local chap who is very nice, which took all of 30 minutes as he was working (probably looking after those who can no longer afford the Adventist Hospital now there is no ‘Safe Birth Fund’) and I did not want to hold him up. I was then left kicking my heels until I started to walk back when a car appeared as apparently as with a lot of NHS hospitals it is in a rough part of town and I might get robbed!

Meanwhile I am very pleased to say, our radical hysterectomy lady is home and well and hopefully will remain disease free for quite a while and certainly unpleasant, blood stained discharge free for a good length of time. She poor dear had been having symptoms for 5 years and some symptom alert information would have easily allowed her to have earlier treatment and a greater chance of disease free survival. Current efforts are about trying to pick up the disease in the premalignant phase by painting the population’s cervix with vinegar and freezing it with cryotherapy if it looks white. Probably harmless but for those of you who have done the evidence base module of the MSc I dread to think about sensitivity, specificity, and probably numbers needed to treat, but there are not many cryoprobes about and no obvious means of gas transport so the treatment will not be that available. A rechargable battery driven ‘cold coagulator’ which my generation might remember would be a more easily assessable treatment tool, and would have the advantage of self sterilisation. Perhaps a free screening service for those with symptoms and early recourse to surgery might be a better way to spend scarce resource – but then there is not any resource anyway and what is certain is the punter sure don’t have any of her own.

If there is a light at the end of the tunnel it will be the glimmer of a largely unlit and certainly unenlightened on coming Ethiopian train.