And Atlas Shrugged

Sadly, and down purely to my incompetence, fatigue or whatever, my last missive disappeared into the ether never to be read again, which means that much of my transient musings are lost for ever. Given that many of you will regard it as a cynical rant perhaps no big loss. As we contemplate the sad death of a 16 year old from overwhelming sepsis, and another not looking that great on the ward I am reminded of the title, if not the content of a block buster novel of the early 80’s called ‘And Atlas Shrugged’ which concerned the multi-layer goings on in high industry but also sums up the curious chaos that is Ethiopia, a combination of personal tragedies, both high and venal government ideals and underneath the real desire to change as little as possible, keep everything chaotic and in a state of flux and do your best to profit yourself from the chaos around you – so possibly more like big business than you might initially think, particularly one suspects the armament industry. The tale of our maternal death transpires to be even sadder, in a Victorian melodrama way than you would think, unbelievable in a novel. She is the third death in the family, the mother now having no living children and bringing up 2 grandchildren on her own, so it is not surprising that she has rejected the other child who is lying rather wet but well up in the obstetric ward, destined I am afraid for an orphanage, and currently with the expectation that we will provide the NAN, clean clothes etc. in the meantime. What else can one do, but what it is not is sustainable. A high quality infant, young parent very healthy etc. is however destined for institutionalisation for a year or so and then to be sent psychologically under stimulated if not damaged to some home in the western world if luck, pity it cannot go now, but that is part of the system here. Equally, those who are having trouble conceiving, which is some on the staff are not able to grasp the concept of adoption, anther tragedy of the country. I am reminded of Plato’s ‘Myth of the cave’ when he contemplates what view of the world you would have if you were tied down in a cave and spent your life looking at flickering fire light, this is I suspect how Ethiopians view the world, though the influence of T.V. is there. An interesting observation of priorities is the T.V. is the erstwhile carer of young Jabba, who has been resident here for a couple of days having been to the hospital with his chronic cough and put on I.V. penicillin, an odd choice of both route and antibiotic, so not wanting to sit around the ward given here, till I raided pharmacy and found something suitable that was oral, if a little bitter. This meant that we needed some vimto (local Ribena) and required the solution to be kept in the fridge, which our carer of course does not have so stored here. But readers what would you have spent your money on a fridge or satellite T.V – but I suppose the latter, which as in many western homes is on all the time does provide some stimulation, but the antibiotics gently warm. Happily however the cough etc. is abating and I was heartened to see how well he has been accepted into the family which I do hope will continue. So, in this land of strange contrasts will we ever get to a situation where women can find somewhere safe to deliver in a timely fashion, where tissue destruction and devitalisation will not be so great as to let overwhelming infection take over and that housing will at least be reasonable. On a happier note, both Ca. Cx. ladies have done well and one is home. The bill 2400 birr about £100 which is a little over budget but includes histology at 440 birr which we had not budgeted for but in terms of trying to make it all faintly kosher is probably a good thing, but will it help the lady herself – no of course not!
This is a week of visitors, all of whom need entertaining or explanation. A rash of senior Adventists are going round inspecting – with some transient impact I am being given discharge summaries to do. The NHS is creeping in! The management apparachnics hereabouts were very keen that impressions should be good but the local workers, when I was guiding them around were letting rip on lack of resource so we will see. These visits were a funny mixture of long prayers in Oromo, (requiring me to stand and look solemn) and trying to keep a straight face as they uncovered layers of chaos. I was particularly amused to learn that the only autoclave works because they keep a rock on the pressure relief valve to ensure that there is sufficient pressure to kill a few germs, though it may explain why the tape on the instrument wraps never has dark lines on it! These senior Adventists are an odd lot, a paediatrician come obstetrician from Canada by way of Manchester, an Internist from cape Town and a surgeon from Nairobi who was not entirely amused by my story of car jackings. I am not sure if I did not put my foot in it as I said that there were not that many wound infections, touch wood, which suggested a non Adventist spiritual world…..there was a moments uncomfortable silence, but I did gently put across my lack of spiritual commitment. What I wonder, though I doubt if their report will be shared with me, did they make of this place.
The other big invasion of course has been the arrival of 17 odd velocopedists with assorted hangers on whom I have been required to show round talk to and try (and probably failed) to be reasonably politically correct with, though there were some slightly sullen expressions about from the leaders of the pack. I understand that the journey had been a little encounter groupy. However, as we were not serving alcohol on the veranda, Green Bar B being the venue of the reception, we were able to use the paper plates to be a banner of welcome, tastefully decorated by orphan boys and strung across the hospital entrance where we greeted them with powdered orange juice, water melon (very nice) and orange quarters, like break time at school football matches. Unsuprisingly the keen volunteer who climbed the gate to help put up the sign demanded payment which as yet (I no longer carry money) he did not get. We continue to live in a donor culture and I continue to get requests for help with education (self and others) orphans (here and away), building materials ( new and as yet completed houses) and of course teeth falling out (sugar cane and no tooth brushes).
So today has been spent wheeling (sorry!) them about the facility and trying to keep them out of the way of the adventists and allowing them to take photos of smiling people with babies and perhaps putting the not so well in the back of the picture. How much I wonder is adventure (camping amongst the monkeys) but wanting all done for them (not it turns out frightfully self sufficient but I would be a bit tired and whittery if I was cycling too, and how much is collecting for some greater good. Happily my 2nd sick lady is I think turning the corner, no collection and wind! Her pulse rate is settling so hopefully all getting better. The state of Ethiopia- well that might be another story, but then ‘Atlas Shrugged’.
P.S. Big changes around the corner in ‘Adventist times’ see next instalment.

in for the long haul

Before I get going, for the less squeamish of my readers photos of the sort of cervical cancer we deal with. The first picture shows a small atrophic uterus with a very (3.cm+) expanded cervix and the second the tumour.


One would like to think that changes one makes are sustainable but sustainability is going to be hard work. I was struck on the ward round this morning that an 18 year old girl (probably 15 as they all say 18 so the government does not get involved) who had had a caesarean section for obstruction having been transferred after many hours in labour and a bus journey of at least 2 hours was now 2 days later unconscious, Glasgow coma scale responding to painful stimuli only. Catheter had been taken out and not put back in, pyrexia 38 and clearly not well. Not really looked at for 24 hours and closer inspection showed her to be very septic and after the appropriate blood test very neutropenic too. Not surprisingly the baby looked pretty unfed as well. Lots of shrugging and not a lot of action but have started some treatment and fiddled as much as I can with the antibiotics and we can but see, though not looking good. Thought a little prophylaxis for the baby might be no bad thing but unsurprisingly not really thought about. Do not really want eighteen year old kids dying on the patch but if, as usual hey are a. unable to spot if some one is ill, b. unable to do anything urgent about it when they actually realise that they are, life is difficult. I feel a little guilty as I was not on the ward yesterday having gone to a peripheral health centre with Karen but to be honest I can not be there every minute of every day – depressing though. Apart from dreary ante natal clinics, and I have always found ante natal clinics dreary, the day was enlivened by another labouring primip mother in the clinic with uterine inertia. Oxytocin stimulation in these clinics, which have very limited facilities, no running water etc. is not allowed but it seemed to me the better option (think of the 18 year old) than a long trip to the hospital, so I found some oxytocin, dextrose and a canula and set it all up and waited. Was gratified by a spontaneous delivery of a healthy boy an hour later, though the Health Officer could do with some remedial training on his delivery technique. Trying to deliver fetal shoulders in the transverse is doomed! But lets not bitch too much, all is well that ends well.
Our plan to travel back ently and possibly stop for a picnic of Bhuna (Coffee) and cinnamon rolls was stymied by agreeing to give lift to a weepy, in pain but actually normal primiparous woman with a breech and her husband, declining to take the rest of the family and some health extention worker who also wanted a lift and stopped in the village to pick up her daughter, who screamed with fright in the car and vomited copiously over the floor, Karen’s ultra sound wipes coming in useful here and the sucked noisily on an ample boob for the rest of the journey. Thank you (Galatoomi) does appear in our Oromo dictionary but not in common parlance as our various passengers drifted away without saying a word leaving me to wash the vomit stained and rather nausea inducing rubber mats. It is distressing how vomitus is able to find all the crevices in the mat and stay there. Particularly galling was the ability of our psychologically deranged gardener to hide the detachable tap from the outside stand pipe somewhere where I could not find it making mat cleaning even more difficult than it need be. Ethiopia is water metered (drought, famine and other biblical catastrophes being part of the culture, locusts any day now) and detachable taps are a form aqueous theft prevention I suppose, though apparently there is enough water at the moment. The cervical cancer program is gathering a little momentum despite the usual delays, this time adventist induced as they seem unable to get their act together to put a letter, electronically delivered onto the right note paper for circulation but then time in this country probably produces the ‘Ethiopian condition’ and certainly confirms the cynicism of your author. Never the less we managed to remove completely a large tumour and there is another booked but delayed for today. The delay is for an emergency ‘goring’ some chap having run foul of a bulls horn though in these parts not a matador just probably irritating it or being in the way at the time, health and safety is not high on the agenda here.
Perhaps we will get on this afternoon. Operation for Ca Cx went well but have a suspiscion that there was no cancer, though it did feel hard, one of the problems with clinical diagnosis I suspect. Having said that PCT permitting, she would in the U.K. have had a hysterectomy anyway, though perhaps with not the dissection she has had.

Just when I thought it was safe to get back in the water another 15 (18) year old has turned up from some distant health centre with a 2 day labour, obstruction and meconium. Well stuck in and an inverted T to get it out, she also appeared with a voucher though what this means I have no idea……given that they are supposed to have stopped.

Our other kid remains hypoxic, acidotic and thrashing about so I am very gloomy about her prognosis but hereabouts there is not much I can do.

Jabba news is that he is on I.V antibiotics and coughing and is going to spend the night here, Karen says sleep but I do not think that that is on the agenda. Abdi seems to have moved in too with his septic foot now with iodine dressings and my socks, will he be staying too? Sepsis all around me then.

I have been approached to chat to the senior Adventists after supper with boss Adventist here, prayers, water out of jam jars (living like Ethiopians?) and lots of lovely Injera. But moves are afoot with changing staff, an influx of Adventist physicians and surgeons, what is for sure is that the visiting gynaecologist is not an Adventist and there is going to be a change of guard.

There are lots of monkey attacks at the moment and they shut themselves into the chicken’s coop and then panic, so do the chickens who take refuge in our sitting room and cower (but still crap) on our feet.

Ah well, in for the long haul then.

Visiting Times

Despite protestations to the contrary the ward seems very quiet to me and the only thing different is that the clientele are predominantly rich and normal (this of course being a relative term), apart from a run of gross hydramnious and sadly even more gross abnormalities, most of which I suspect would be prevented by a little folate in the flour that makes the ever present injera, as would the goitres by some iodine in the salt. However agencies that are about education and the improvement of peoples lot are about to take a hit as the NGO office has now decreed that charities can only spend 30% of their income on admin. Not a bad thing you might think when you see all the local NGO officers swinging about in their land cruisers with fading U.N. signs on them (not surprisingly the U.N. which is what everyone aspires to work for, lots of dosh, super perks and a diplomatic passport is exempt) most of them achieving little as most of the resources never hit the ground, and a very good model if you are building dams and roads but not good if you are delivering education or medical services. The infrastructure cost also includes transport, so the 30% cost has to include getting educators, doctors or whatever out to the rural areas, ergo it will not happen and our local chap is thinking of investing in bicycles. Talking of bicycles the charity cyclist have now arrived in Addis so assorted lycra clad and sweaty cyclists will be starting their journey through Gimbie and back to Gimbie for their charity run complete with tents cooks support team and crutch rot medicine. The police have told them that they cannot take photos of local housing stock and kids but views are all right so it will be interesting to see what the instamatics produce. There is an assumption that the local organising committee (now us as everyone else is travelling support) will fix a grand welcome, orphans with flags, tee shirts and probably more useful coldish drinks. The fridge still does not work well so cold is not an option. My original plan was to serve Pimms on the veranda but this is in doubt as there is a simultaneous visit by senir Adventists looking for signs of lack of spirituality as mentioned before so plan B is beer and cheeseless pizza in green bar B, but less mess for us to clear up. We also seem to be doing the leader of the gangs laundry for him and for reasons that I have yet to understand I found myself folding someone else’s boxer shorts…….
The week generally has been one of ceaseless politicking with general bitching about cyclists, teaching local midwives to do abortions (I kid you not, it is called Manual vacuum aspiration and it is to allow local midwives, health officers etc. to do evacs but it is but a small step to significant income generation dealing with unwanted pregnancy. Thus twice this week I have found myself teaching a variety of future abortionists to suck green gunge (ripe advocado) out of infant feeding bottles without going through the top of them as a reasonable proxy for a uterus. Such is the life and calling of the do-gooding expat retired obstetrician, what is it you might say all coming too. This yesterday was witnessed by our other visitors, a Christian financial services consultant (yes they get everywhere too) and a Berkshire GP into good works who seem to run some sort of health facility in Uganda and who and with whom the cycling leader is trying to form some sort of partnership. This has meant even more entertaining and worryingly ,if not disastrously the complete quaffing of our remaining supply of Drotsky Hof red wine, even more sadly without my help as with vestigial feelings of responsibility (there being so few deliveries) I was on call and thus on the water. There are vague promises that this will be replaced but then how much can you balance on a bicycle. We have been given (bizarrely) a bottle of Baileys which I hope will keep but we did serve this with pancakes, yes pancake day was recognised, but what to do with the rest? The visitors, who like all business peoples and do gooders seem to regard themselves as good judges of characters (which makes me wonder what they think of me as I probably seem a nice gentle boxer short folding sort of chap superficially, and a cynical bastard if and when they get to read this) did the rounds of local NGO organisers and hospital administrators and spent the next few hours discussing their impressions.
One of the afore mentioned sits with his legs akimbo waving his arms about while being increasingly disingenuous and dissembling madly, the other being more and more cautious, careful and less openas he tries to balance budget constraints and the competing demands of his impossible 30-70 split, the battles of his surrounding faranji and Ethiopian colleagues and ever changing and developing relationships (no I shall say no more). Relief from all this is clearly required as further inroads into the remaining red wine resulted in a middle class Ethiopian all male dancing group with much shoulder waving (this being the difficult to reproduce by nonindigenous local dance style) and by the look of it rather sore heads next day. Ethiopians have no lesser difficulty coping with the results of rough red wine than their faranj counterparts though we were excluded from this group on this occasion and I have had to rely for this on second hand reports. So healthy exercise and deprivation is being replaced by red wine and late night dancing, what would the Adventists say if they knew – let’s hope that this blog is still locally blocked. Quite what our visitors think of all this as they cope with their ill advised restaurant meals, judging by the frequent trips to the facilities and the need to stock up on rolls of soft if grey paper and whether we will be merged into some greater charity, remain to be seen. However the offer of an exploratory trip to Malawi and a further trip to Uganda are there and may prove exciting new adventures if accompanied by politically correct report writing and much less politically correct blogging.
Our other Faranj visitor, a current student from my old alma-mater, but really a bit more ‘Royal free’ seems to have enjoyed her time in the visitors dorm despite being surrounded by evangelical Adventists and being groped by Ethiopian male nurses (who clearly do not have the sexual proclivities of many of their U.K. counterparts) and whose ruse of wearing a wedding ring has not proved useful. She now returns to the north of England, her boyfriend a medic destined for Epidemiology and a desire to make babies from the safe haven of general practice, her taste for developing world medicine now being sated. Perhaps, when the boredom of the worried well, the demands of the western overindulged young and the understanding that she has ability dawns, she will return to something that is actually quite fun. The need to grasp the opportunities that arise from career change, failed relationships and the lack of ties would not be wasted on others too.
Looking back from a career, which consisted of taking clinical risk from safe jobs and bearing the intermittent opprobrium and eventual grudging respect of safety conscious WHO safety list toting colleagues, makes one wonder whether really you could have had more fun, though certainly most of it has been quite amusing. Would I have done it differently, probably not apart from tedious management roles, which have only really produced enemies and being party to change that was not really to the benefit of anyone other than bean counters, certainly not our patients.
Meanwhile back here, management bean counters have stopped the money flow that brought women in need to a place where there was facility and driven them to a place where there is undoubted clinical competence but limited facility, no sheets or anything useful like that and sadly very few beds to put them on, poverty means that needs will need to be assessed, time taken for them to be agreed to be met, and even more time before they are even partially met, so suffering all round. What happens to those who do not make it to any facility, well some doubtless ‘Adventist or other factional’ god only knows.

Monitoring times

And so it came to pass that the time came for our al to short sojorn in the U.K. but first the knotty problem of sorting out resident (and probably in view of blog status, enemy) alien status. You did not expect it to be easy did you and predictably after the usual short and curt conversation and the lifting of $20 I was instructed to return for a 30 day visa, not a problem as we were flying out next day. They did however, despite ignoring it, find my status on their computer. As soon as we returned to the U.K. we were off to the passport office where we were also on the system but even our recent photos were unacceptable (no smiles) so some £s in the machine and a cadaveric photo later we were in the system with new and visa less passports. Karen with resident status was O.K. but I had another trip to the embassy, nearly wasted as I did not have a photocopy but helpfully they did one for me. No chance of 6 months though! So a wonderful week in England, hot showers with plentiful water that does not smell, bacon lamb and even Christmas dinner. Really nice to catch up with friends and the generosity of those who have given things that will help is overwhelming – thank you all. A week in Switzerland with deep snow, seriously expensive eating out and a bad fall (I would like to say it was on the skiing slopes but in reality down the chalet stairs at night) - even more painful but a great change from the reality of every day life down Gimbie way. The change has made it difficult to come back but now we are returned and in for the long haul. In addition to all the medical goodies (read on) I also elected, as they were so keen to bring back my old sonicaid fetal monitor, in an aluminium case. Predictably it got stopped in customs and impounded as the computer was down. When I returned to try and pick it up they were at a loss to know what to do, it is after all some 30 years old. Off to see the man (woman?) from the health office next door but no one there, no one expected and a lot of shrugging in a silent Ethiopian dancing sort of way so there it stays pending confiscation or some reasonable though unlikely compromise, little do they know how many Ethiopian women might be spared a caesarean section, but we can but speculate. The reason for the delays in picking up the monitor was our trip down south to Moyale, the seat of much tribal trouble on the Kenyan side, murder strife, lynching (yes really) and the like and the place of arrival of the newly repaired but despite the enormity of the bill un-cleaned car. It arrived, only partially repaired and very battered, from its trip in a lorry and there had been some desperate attempts to remove a relatively bullet proof and very expensive roof rack which culminated in the breaking of a bracket and the loss of important nuts and bolts requiring a lot of superglue and ingenuity to make it fit for the extensive luggage gifts and things that it would have to take. Dealing with lots of surly Kenyans and not a word of apology from the perpetrators, but really what would you expect. Some readers will recall that I was winging about the air conditioning not working and the reason was that the expensive service by Guildford Toyota did not seem to include re gassing-really helpful that ! However a big result, the result of a marvel in chat up lines from Karen is that we have the car for 6 months, which will see us through to our return so although we have some doubts about its ability to stand the roads-dry season and very dusty we have wheels and Karen can do her work, unhindered by Ethiopian prevarication. That now being done I can get my resident enemy alien status and we should be there. Our trip back included a lovely afternoon in Haile Selassies 1950s hotel on the lake at Hawassa, a great mini break and we can see why he went there for the view. Back to Addis and on to Gimbie offering, without thought of charge lifts to those who wished to charge us per deums petrol and all the other extras – white mugs or what!! On our journey back we met the new surgeon, they now come from the Black Lion Hospital, the big one in Addis for a month at a time and he was appalled by the small size of Gimbie and he remarked that he was glad that there was only 28 days to go-on the same reckoning we have 178 before the car, sorry truck, has to be in Djibouti so that is our time then. Camilla, reborn or rebadged, depending on your perspective, is now an NGO training GP/ex GP public health doctor / do gooding NGO sort of person and will be part of our little disparate and potentially deeply dysfunctional band for the next 6 months too but we will do our best to keep out of the on going and troublesome conflicts. As it is some interesting potential conflicts, or potential for great farce are on the horizon including the simultaneous arrival of cycling people, thirsty from great killometerage and in need of beer and bum rubs and a group of senior ‘adventists’ concerned about the possible lack of spirituality about the place and of course for a general inspection as trouble there has been. It is thus, duty free permitting, that they may stumble upon a form spirituality that they least expect and of which they will undoubtedly disapprove.
Meanwhile back at the ranch the vouchers for the deserving poor have been withdrawn and thus so have the poor who now have to travel through the bad areas (even red light or thieving district) to a woefully inadequately equipped government hospital which will not be equipped until they show need and need is of course shown by damaging or neglecting by lack of resource those who are denied care in an adequate facility by sudden withdrawal of a resource that was there. This is I think what passes as forward planning. I have some equipment that may help and will bring them up but travelling up there may at night be difficult because of the relative roughness and my inability to fit in easily. This has meant that my week end on, my Ethiopian oppo having done the last 4 weeks on his own, was relatively peaceful, the only excitement being the usual suction less Ventouse and a poor newly married young lady whose first night adventure resulted in a significant vulval tear, bleed and surgical repair, to the horror of our visiting elective med student. Her experiences must be interesting a combination of Ethiopian life in the raw and a an American ‘dorm’ full of proselytising Adventists, the wedding ring however is a protecting fake.