Addis Interlude

So after an extremely muddy and slippery ride we find ourselves in Addis, obstensively to celebrate my birthday but more importantly for some relatively gourmet experiences, the power of excessive lentils having finally taken us to make the journey, which is longer than that from London to New York.  Not as gourmet as you might think as we have endured a Chinese meal of such oiliness that my fat free diet of the last few months has now been blown and it was served in a wind tunnel that actually blew the mosquitoes at you.  Karen is also paying the price of some other meal with intestinal hurry which adds another layer of discomfort to her intermittent febrile illness.  Discussions in the car and over coffee reveal that the Gimbie rumour mill has credited us with all sorts of sexual misdemeanours and proclivities that might be rather fun if they were true but are laughable as they are not.  The source of the gossip is the local ‘bad adventist’ drinking club at the ‘Green Bar’ a small all male group but transmitted by farangi gone native with much to be gossiped about.  Our consciences are entirely clear but there is much rustling of bed covers and much else in our little microcosm.  Our charity is melting down with the imminent departure of the project leader to pastures new (a BBC charity probably as loosely organised as this one) a farangi shoe in temporary replacement and a deeply dysfunctional local work force.  The hospital too is in turmoil as bankruptcy threatens, the work force has not had a pay increase and is in mutinous mood and inevititably the patients (such as can afford to come) are even more ignored than before.  The employment situation however is such as there are no other jobs, they have all been there for years and are far too frightened of moving as that would require effort, so they will just go on bitching and pilfering as before.  Even, sadly the new medical director has had enough and will depart in December, though his wife given half a chance would be gone yesterday, and the Adventist hierarchy is in turmoil, such that the church elders want to sack everyone and the seemingly terminally arrogant head of Adventist Health International is due to fly in on the equivalent of a ‘needs assessment’ visit. I say this merely on hearsay but this is on good authority, I have never met him and probably not being of the faith never will.  There is of course lots of needs assessment but little in the way of needs met.  As news of our impending departure filters through so do the visits of vultures to our doors to see what we might leave behind for them and the requests for clothes, sponsorship and money all become more urgent.  I have it mind to say we are going a week later than we really are and then ‘steal softly into the night’.

A visiting and very enthusiastic medical student has joined us, and virtually moved in.  this may be to escape from a bunch of first year, innocent and barely coping Adventist girls from America and we have set her to work trying to find out what happened to various women who have delivered in the health centres.  What is revealing about this is that all though the notes have covers with numbers written on them (seemingly random as men seem to have babies) the papers inside are bare of writing, the only note that I have seen is in my hand!  What is so sad is that the care offered in the health centres is so poor and so rudely and arrogantly delivered that the women vote with their feet.

Faranjis (us) with portable scanners and a smile get 60 odd women coming and we are able to give some sort of advice about where to have babies etc.  As an example of how sad  it can be, I saw some wretch who had attended 4 times, thought she was term and had a 22 week sized dead baby which had clearly been that way for some time and gone undiagnosed, despite gifts of sonicaids and all the rest.

Somebody also turned up with a fistula of about 4 years duration but they at least get free treatment and free transport.  The fistula hospital which I am about to visit is also in turmoil however having also been the subject of something of a putsch, though more of this later.

The two are probably not related but my departure coincides with a flurry of cancer patients and hopefully the skills passed on to the Ethiopians I have been training will bear fruit but I think that they will be scared of doing them without their hands being held.  However both I think will be on the move having learned what they can and also with the prospect of me going do not fancy being on duty one in one.  This may be a good thing though as I am encouraging them to build cancer teams and that might make a difference.  Screening too may in some nascent way become a possibility as someone wants to do pap smears.  So if there are any old Aylesbury spatulas and fixative about do save them.  What of the cancer?  The operations are possible even with big tumours, and can be achieved with relatively little morbidity, mostly wound infections, which I do not entirely understand as the caesars are relatively unscathed and so far reasonable clinical clearance.  I have found it difficult to persuade the pathologist to look at the vaginal edge and I am not sure that the formalin is a s strong as it could be given the slightly putrid smell that accompanied us to Addis with the last four specimens.  This mixed uncomfortably with the smell of vomit which always seems to occur when charity dictates that we fill the car with indigent freeloading Ethiopians piling in the back for travel to Addis or elsewhere.  We have tried to contain this with aircraft sick bags but they will not use them, merely steal them.

On a brighter note, having got the fetal monitor to work after a fashion, there is a lot of noise, I have achieved vaginal deliveries with inert primips pouring meconium, with the judicious use of oxytocin and a lot of patience.  More gloomily however the Adventists are getting more toxic about abortion, despite desperate pregnant unmarried teenagers who may well do themselves damage by going off to the back streets or abandoning their probably hypoxic and brain damaged babies, once they have delivered themselves at home.  Few misoprostol tablets and all would be safe, but then we move in strangely contradictory circles.

Venalmalignancy

For much of the time I have assumed that the Ethiopian condition is brought about by incompetence but I fear that the combination of grasping venality and cynical manipulation suggests that something much more malign is about.  This thought struck me as I saw various off white coats and our new (but shortly to depart as he cannot stand it) medical director down by the incinerator hut burning boxes.  The smell of cardboard mingled unhappily with that of plastic which I was to learn was that of many blister packs of just post- date drugs that would now no longer be able to help the needy.  These drugs it would appear are actually provided free at the point of use by the government but delivered, with the usual mountain of paper work when they are about to expire.  That is to say with only two months to run and as they know when they are about to expire they can come and do random checks, and hey presto the hospital is in trouble and a nice big hefty fine.  Meanwhile, blood transfusion sets (ones with filters) have run out and there was a plan to refuse blood to the seriously anaemic because of this.  I explained that the odd small clot would just block the cannula and not the vein but they were not happy.  Given that the planned recipient was about to die, (or expire as they say in these parts) with a haemoglobin of 2 gms I felt that this was the least of her problems but they were still being difficult about who was going to pay.  Currently too the charity to whom I am increasingly loosely linked is handing out free drugs (bought from the same government warehouse) to the local health centres in an effort to redress the imbalance set upby something called the 30-70 rule.  This seemingly sensible idea is that only 30% of a charities money should be spent on administration the rest given over to good works.  Problem is that ‘training’ is administration and readers of this blog will know that all our particular charity wants to do is train, so in order to redress the balance give a few sell by date drugs but only the sort that have the going cheap stickers that you see in super markets and that allows you more on your 30%, get the picture.  It also turns out to be a nice little earner for the health centre, or at least their employees too as might be expected they are sold on to the punters.  The antibiotics are probably useful but not many actually need the methyl dopa for their blood pressure and without careful monitoring actually probably counter- productive. (Venal and malignant?)  As the effort goes into training so the available funds for care fall away and there are now few health centres that have vouchers which does at least mean that my nights are less disturbed but the Government hospital takes the strain but only limited resource (this remember is going to health centres).  The result of this and probably chronic lack of planning was that there was an urgent call for cord clamps of which the charity store revealed 3, the result of some calamity when there was nothing in the government hospital to tie a new-born cords (not it seem even the apocryphal shoe lace), so a gauze was placed over the cord as the unfortunate bled to death, incompetence of an astounding malignancy in probably a very overcrowded area.  The local obstetrician who is competent and nice is clearly at his wits end and there are plans to expand, but need has to be shown.  How many have you got to allow to die before you show need and how many would receive at least some care if they were given a voucher, but no education is all so an institution with facilities and capacity is starved of funds and will probably close. (To be fair there are a lot of problems as well) while the institution down the road will drown and the punters will feel it more sensible to deliver at home and some will rue the day as they turn up too late (malignant planning, forcing disaster before change or just incompetent planning?)

This particular institution is particularly cash strapped at the moment, made worse by falling maternity income, but the employees who would otherwise vote with their feet work in an area of chronic unemployment so just have to stay, stay demotivated or beg (never borrow) or steal to survive (venal?).  Certainly the begging is increasing and the theft will certainly rise the former certainly and the latter probably as the date of our departure approaches.

Intra partum care now is largely care in the second stage and the combination of hypoxic encephalopathy and meconium aspiration is difficult particularly when useful drugs like phenobarbitone for neonates is not available which makes treatment difficult.  Not insurmountable though as you can take an adult tablet dissolve it in dextrose and pop it down the nasogastric tube.  We are getting a bit of explosive diarrhoea though but at least there is some breast milk.  The meconium aspiration, well we do have a little way to go.  If she had come in earlier and maybe that was cost it would have been a different story. (Malignant choices?)

A safe place of birth for the majority is I fear a distant fantasy.

 We seem to be running short of wine, now that is definitely a malignant change!

Closing debates

One of the things that Ethiopia’s poorly trained rural health service has been foisting on their local populace in an effort to keep the population down and to offer treatment for miscarriage is something called MVA which stands for manual vacuum aspiration and is basically a vacuum curette attached to a 50 ml syringe and I have even been persuaded to teach these locals how to use it using ripe avocados (quite enough of that) though personally I am not sure it has much to offer over some misoprostol under the tongue, but never mind there we are or were when I got the usual summons but this time to a 40 something old who had had this procedure some distance away and was not well, barely conscious in fact and very septic with a reported white cell count of 39,000 (normal range non medics up to 12) and a large abscess in her pelvis. After such resuscitation as is available a trip to theatre where I planned to just drain the abscess until I saw the state of her uterus but this was trick and the combination of blood loss and acute sepsis prompted sadly her demise which sadly is the way with overwhelming sepsis.  Of course she leaves 5 children, some of who were big enough to give her some blood with a little arm twisting but was her grubby initial surgery really necessary and could she not have got access to appropriate treatment before it was too late.  Probably not, this is after all rural Ethiopia and sepsis is the biggest killer but I still wonder if I had just drained the abscess she might still be ill but also still with us. 

I tell you this story as I despair of the health planning.  There are hospital but they are basic and cost but yes we do save lives.  There are health centres, they are very basic and theoretically free, but the staff are poorly motivated badly paid and by and large very poorly trained.  They are there because they have to be there and have no choice.  They are serving time before hopefully getting a desk job cooking the figures for the government and they care little other than to flog the odd free drug to increase their income.  Their rudeness to the patients is staggering and you might think that this is the lot they put up with, but most of the punters vote with their feet which is why there is so little take up of the service.  The pity is of course that if the service was taken up more things might actually get worse not better as the off the wall treatment is often worse than no treatment at all and the two things that might actually save the odd maternal life, misoprostol and magnesium sulphate are not allowed. My only contribution has been to persuade them that 5% Dextrose run fast can produce enough energy to start people contracting again and get the odd vaginal delivery, but things I am sure will soon slide back.  Simple things like welcoming your patients, giving them advice pertinent to them and exploring with them how they will get to hospital in reasonably timely manner if things do not work out well will go a long way to tackling MG5 (maternal health) which is nowhere near there but I am sure that the book cookers will sort that.  Investment into some sort of transport infra-structure would however be the biggest contribution.

Last Monday was a bank holiday here, celebrating the fall of the ‘Dirge’ (the communist lot) but as one Ethiopian wag pointed out (and Ethiopians with an overt sense of humour are rare) what they are actually celebrating is the change from overt to covert communism and you do have to ask what us NGO workers are doing, and more importantly what is our government doing, pouring so much resource into an environment that really just squanders it, but then it is probably more to do with the bigger political picture, it does after all contain the Somalis to the coast where the American Seals can blow them out of the water if they get too close to a ship.  Meanwhile the government here continues to bully, humiliate and despise the NGO workers, what they really want is the money not the people and probably they should get neither, but Chinese and others would come rushing in to fill the gap so we will doubtless just go on giving them the money -   A mad world indeed.

Meanwhile the organisations for which we volunteer seem to be going through one of their periodic convulsions about which I shall have to be careful as a local reader would be mighty cross if I was to tell all, but promise all will be revealed on or about 07 August.  Suffice to say many are looking for new jobs or may even have got them, some relationships are closer than they should be or is healthy and others are very strained indeed. Happily ours is not included but we are dispensing tea and sympathy while blithely pretending all is well.  The Adventist too, have their problems both with paper work and a general desire to maintain the status quo at all times.  I am told that when the work force come for discussions with their faranji counterparts the translating big wig Ethiopians who are all related start by saying that they are going to be told off but it is alright as they will protect them.  The problem however is bigger than this as the hospital is failing and there is a rival (probably equally failing but government supported) up the road and the withdrawal of safe birth fund funding means that a great proportion of the populace remain unsupported and the government hospital has not the resource.  MG 5 is indeed a long way off.

NB For those of you who do not believe in disproprtion see below!