Addis, Djibouti and then.....

So we are into our final week and although I remain fairly laid back the ‘so much to do and so little time to do it’ pressures bear down relentlessly.  The car is stalling a lot and intermittently  producing volumes of black smoke adding to the growing hysteria.  The internet sites to are producing dire warnings of the difficulties of obtaining Djibouti visas, which has had the added frisson of requiring a letter of support  from the British Embassy, an organisation that is dedicated to leaving British subjects bereft of any help, if it actually deigns to open or publish its rather elastic opening hours.  There may be a little help on the horizon as a phone call to the Djibouti authorities suggested that all that was required, other than the usual multiple photographs was $140 in cash per person.  African exploitation is alive and well here in the horn of Africa.  Our trip to Addis last week coincided with the exit of the medical director’s wife, who could stand no more and was back to the home state of Malawi.  They required dropping off at some guest house, of which they had only a scanty knowledge of the geography, sticking another 2 hours on the journey, and when they arrived decided that it was unsuitable so travelled on with us.  Sadly Lion’s den, the usual hostelry has been declared unsuitable, uncomfortable beds, crap showers poor breakfasts etc. and we have been moved away from the Greek Club, nice ambiance, splendid salad and wine by the glass.  Instead we were installed into a guest house which was newly opened and a little disorganised but comfortable enough if in the Addis equivalent of Twickenham.  This may have something to do with Camilla joining us as this is clearly where she feels at home.  Addis itself was fairly trying as the African Union was in town so roads were blocked off everywhere and we were not allowed to stop, so much so that I was forced to abandon Karen and it took the best part of an hour to do the back doubles to get her. (You will understand from this that we are now beginning to understand the local cartography a little better.)  Also in need of rescuing was the aforesaid Camilla who was either abandoned or escaped and found wandering down (or was it up) the Bole road as we were going for supper, before picking up our guests.  Unusually for this part of the world they arrived early (mid meal) so we had to send off a greeting party which was nice as they were able to join us, though Adam has been laid low since.  Buying all that soft paper seems to have been a good thing.  Sadly attempts to buy a picture to take back with us continue to stall, through lack of agreement and the somewhat touristy nature of the ones I like (vague shapes of priests in rock hewn churches).  However as Karen has had enough there may not be the need for many memories but we shall see.

Our long planned trip to Addis coincided with my oppo’s need to register his wife on some course the other side of Ethiopia so with these priorities the population was abandoned for a few days to a visiting obstetrician on call from the hospital down the road.  I arrived back to taking call and sorting out the hypertension of many days. Some poor soul had ruptured her uterus and lost the baby but was a least alive to tell the tale.  Nasty moment when she said she was leaking urine but happily this turned out to be retention issues so will not need the trip to the fistula hospital.  However I continue to be on call and there is as yet little sign of returning Ethiopian obstetricians though I live in hope and look forward to a gin and tonic.  Visiting 16 year old is embryonic doctor, so with only one fainting episode has been joining  the group that moves around with me. Jen, all bouncy enthusiasm, has declared the bus ‘impossible’ and required a lift to Asosa to catch the plane leaving Emily who has taken Adam under her wing and shows promise as an embryonic missionary doctor, she even beats him at table tennis pointing to a past of travel or youth clubs.

So back at the coal face it is business as usual but with some surprising cost savings as the hospital at Nejo (clearly the relevant doctor has gone away) had the wit to put two women with obstructed labour in the same car so they both arrived simultaneously producing the potential of some interesting ethical dilemmas, particularly - labour lasting some time – as both babies were not reaching their happiness potential, but as luck would have it one was deliverable vaginally.

This was duly pulled out with a second or third hand KIWI cup which is not something I will miss as they invariably break suction at the critical moment and spray unmentionable fluids at you which you are ill dressed to cope with.  The baby inevitably needed resuscitation which was managed with much greater competence than hitherto which was pleasing and when not sucking as a little shocked, they spontaneously put down a tube and gave sugar followed by breast milk.  Progress in deed.  Happily the shortly delayed a Caesarean produced a meconium stained (well they all are here) but otherwise very fit baby.

We went off to Aira Hospital to look at the labour ward book and pick up an Ethics letter and it was very muddy, causing me to put the land cruiser in the ditch at a rather perilous angle, there being a very deep hole in the middle of the rather narrow track which I had been trying to avoid.  Lots of sliding cursing a diff lock but with the directions of a helpful minibus driver and Karen we managed to extricate ourselves with nothing other than a few scratches (to the car not us). Predictably none of the documentation we required was readily available and the only way we could get the required letter was to track down the administrator who was doing a conflict management course (I kid you not) in some local but not easy to find school.  Permissions granted though with some suspicion,  we were able to look at the relevant books but were upbraided by a belligerent doctor who thought we were spies.  Bureaucracy delay and paranoia remain part of the Ethiopian culture and will I fear take a long time to change.  As I very gingerly did the return journey later I was given the evil eye by a larger bus  driver who could not understand what the fuss was about.  Next day was not so successful as we failed to get the car up a steep and muddy hill with a precipice off left so after the usual extrication, go back, we had to abandon the trip.  Our last mud extravaganza now is the trip to Addis.

So as we pack up and the stream of Ethiopians to our door for rich leavings grows ever longer, what have we achieved?  Hopefully we have shown that warm fed dry babies survive even when small and certainly they try much harder and this small development may be the best we have achieved.  I have demonstrated that oxytocin in primigravid women can work as well as a caesarean even (horror of horrors) if there is meconium about though at some personal cost as initially I had to sit there for the rest of the delivery.  We have tried to persuade the women with real risk to come to hospital with some result and a few have survived their obstruction, anaemia and even sepsis, for these individuals a result but for sustainability, well that’s another day.  I hope that I have also shown at least two individuals, that targeted radical surgery can certainly bring symptomatic relief at little cost and for probably the majority an improved survival if not cure and that the surgical practice of a different generation is what is right for the facilities available.  We probably have to resist the siren call of the instrument companies who are selling laparoscopic equipment and I equally, though it would be fun, have to resist the temptation to teach laparoscopic surgery to the private practitioners queuing to service the burgeoning middle classes of Addis.   Personally despite the downs the fatigue the squalor and the lack, a great adventure – possibly one that I would repeat, but would I have company?

Pearlygate

Visits of the great and good on ‘fact finding tours’ however brief and the latest such visit was brief achieve little but do destabilise.  So it was that a senior Adventist doctor arrived for 3 days achieved nothing but subsequently uncovered further debt in this debt ridden establishment where any accounting practice let alone good accounting practice seems to be non- existent.  Much money has been given for building projects, the result of which is decaying lumps of concrete but little in the way of concrete building, the rubric being that the money was diverted to running the hospital paying such essentials as salary.  Now it appears that in addition to essentials, holidays of American staff, car costs for travel, per deums (see blogs passim) and general living of ex pat Adventists have left holes in the accounts of several thousand dollars.  So it is good to know where all this charity money goes.  Certainly there are no published accounts.  However, has the arrival of ‘fact finders’ now two groups of them achieved anything?  Answers on a postage stamp – of course not.  Grandiose plans to build new buildings for the theatre, when the autoclave only works courtesy of a rock to appease a yet to be appointed surgeon who wants to do orthopaedics, when most of the staff remain largely demoralised, demotivated, and underpaid with little incentive in a failing institution whose management is divided between two fighting institutions.  The major players in these institutions, the church in Addis and the Adventist docs in ‘Lo Melinda’ southern California seem to be at loggerheads and refusing to meet each other so probably little will happen but as it has been here for some years now the hospital itself will go on lurching from crisis to crisis mis-spending  what little resource it has while remaining in the hands of Adventist children planning their next away day on what funds are available.  As they are all on tourist visas  and have no qualifications the schools and hospitals depend on the registered qualifications of such Ethiopians that are around for their registration, if of course they bother to get it and use of these qualifications do not come cheap – back handers all round chaps.  Meanwhile I shall pay my bill for the rebuilding of the mortuary like a good boy, the penalty for allowing homicidal orphans into my car, the ultimate irony of charitable giving I suppose.  Meanwhile the new medical director’s wife has had enough, and bought a one way ticket to Malawi and a free ride with us to Addis, and he moves into our lovely home when we depart but is unlikely to take on either the chickens or my ‘care in the community’ gardener, thus the sustainability of  my market garden is now in jeopardy.  I say market garden but my ‘greens’ are given away to vitamin deficient faranjis not sold.

Venal misuse of charity funds is not of course confined to religious organisations and, although on a smaller scale is rampant locally too.  The departing ‘program manager’ has set off on a family visit, prior to his departure to a BBC money laundering  operation, taking with him the charity car and forcing the hire of alternative transport adding to the costs of both the charity and the project fund.  Cycling money really well spent and no one about strong enough to say no.  The as yet to be appointed successor will be looking for his own fiddles soon enough. The dear departed is already fixing for a mate to step into his shoes and doubtless travelling Danish charity execs will see it his way. Working for ex-pat NGO’s is clearly the way forward as it seems to allow you both decent housing in Addis and access to furniture at a cost that would make you wince in the Harrod’s sale.  Sadly the charity for which we give our services spend more time with infighting than delivering help (sorry training to potential helpers, who are as demotivated as the hospital staff).  Meanwhile, the now voucher free (and therefor have to pay) wretched rural population will continue to struggle in with their obstructed labours  where at least this faranji will go on trying to rescue them and pass on a modicum of common sense to the sudden explosion of ex pat medical students that infest the place, the local midwifery students having declared some sort of holiday, it being the rainy season.  This particular wretched girl had been in labour at least 24 hours with a head firmly wedged and despite a fetal heart , a baby with fixed dilated pupils that did not get off the cushion that passes as a resuscitaire hereabouts.  A tutorial for the locals on obstructed labour this afternoon I plan.  I now understand the pointlessness  of partograms in these parts as no one labours anywhere near one, they arrive fully dilated and clapped awaiting miracle cure.  However access to miracle cure is only available to those with vouchers, Ethiopian post code lotteries again.

For those who have been following the cancer story I am pleased to report that the ureter has stayed in, and the woman gone home, if not cured at least symptom free, so hopefully some good done and all the money spent on her not free loading.

Meanwhile the delinquent puppy is now due to move on to a third  or is it a fourth home as it it’s propensity to eat small children and everything else is becoming a problem, has a future as a guard dog me thinks.  Message for faranjis – no dumb chums.  Far from dumb chums two chickens also be rehoming and the new tenant of this house is not showing much keenness and they are now absurdly tame, even preferring their tomatoes cooked.

So, forget the big picture, forget the petty and not so petty manoeuvrings of the organisations, just concentrate on the person in front of you and do your best for them – individual sustainability.

Miracle Worker ?

Currently there are 3 very junior and very advenist medical students in town.  They are all from the deep south and all very out of their depth.  The urban myth purveyed by the visiting U.K. near graduate is that they are so frightened of ‘germs’ that they have stuck paper from an exercise book over the place that they keep the loo paper so it will not get germs on it.  As the hospital cess pit is very close to them and overflowing, this being the rainy season, germs I suspect abound.  This is by way of introduction as I have probably unwittingly now increased their faith evermore.  As first year medical students, their exposure to the thud and blunder world of obstetrics had yet to occur until their arrival and their first visit to the OB room (labour ward to you and me but best described as a ‘birthing shed’) coincided with some previously undiagnosed twins in the late second stage.  The first delivered easily but then our problems started with a high but undefined presenting part, lots of limby type things to be felt through the membranes and a fair amount of blood as the first placenta was trying to come away.  The portable scanner was unequal to the task and the fetal heart difficult to detect, in fact not detected.  After a lot of thought and not wanting to rupture a uterus or possibly maim or kill a baby, together with a request to permanently put a stop to any more babies (if this one survived it would be 7 all told) I opted  for the abdominal route.  I explained to the young visitors that this baby may well be born dead so they immediately asked permission to pray (something that one could hardly refuse particularly in this environment) and they asked for divine intervention in this case when the heart could not be heard.  Yes you have got it, the baby came out asleep with a lot of ketamine on board but has survived to tell the tale and to confirm the hand of the Lord, Sister Susie, the nun from Ecuador happened bye with some visitors from California, thus confirming the ecumenical nature of this miracle.  The Lord works in mysterious ways……., but for some with faith I am sure it is strengthened.

I am hoping that divine intervention will help in another direction as in an attempt to introduce some sustainability into the cancer project I set the two Ethiopian’s up to do the next case, so they could carry on the good work, one helping the other, etc. etc.  Disaster as in macho efforts the uterine and ureter got confused and cut, not good in this cancerous field and with the cervix beginning to disrupt.  So trying not to be too snarly I made them finish and finding, surprisingly that there was enough give, have stuck the ureter into the top of the bladder.  So far, no leak, no loin pain and no temperature, so far so good.  However I am concerned that the sustainability of this project is uncertain.  Given that we are completely dependent on a small funding stream sustainability is dependent on funds, who knows what will happen.  However as proof of concept we are to a degree winning and it is something that I would like to continue doing. 

This may prove a little difficult as job opportunities are in smooth private hospitals that want laparoscopic surgery and the primitive rural life, and local scandals are taking their toll on those around me, who are now looking forward to a return to the land of Waitrose and kettle chips.

The tediousness of petty pilfering is also taking its toll as once again the light bulbs that light my path and shine on any waiting Hyenas, as I trail up to the hospital in the shades of the night have once again been purloined to light up others rooms, particularly irritating as the supply of AAA batteries is beginning to dry up too and the uneven steps have the added hazard of being muddy and slippery. These are however minor irritations as is the inability to keep a biro for more than a day.  We came out with hundreds but are left with but a handful, the others like most of our possessions being sold on in Gimbie town.

Meanwhile the usual politics have been accentuated by the decision to put all the guards into quasi military uniforms (olive green) and restrict visitors so the wards are half empty and disgruntled visitors are now another loose fingered rabble through which one has to pass as one enters or leaves the hospital.  The ‘big cheese’ from the Adventists has also flown in on a damage control mission and the staff have already been writing him anonymous letter saying how awful it all is, as they are undervalued, underpaid and under resourced, two of which are almost certainly true and he too is in for an interesting time as ‘e-relations seem to have broken down between him and the current medical director, whose sojourn here is now going to be short lived and his wife escapes next week leaving him to bachelordom and hopefully when he moves into smaller quarters (ours) the company of two chickens providing they survive the ovicidal attentions of Camilla’s puppy who spent the day either chasing them or nibbling me, the latter requiring corporal punishment, which seems to have done the trick.  Camilla, now the new temporary acting project leader, Mosisa being off to pastures new, though at what personal cost I know not,  was persuaded to take on an anarchic puppy which was spending a lot of time here, biting me and chasing chickens.  However with a week in the U.K. and a disastrous attempt at rehoming with the Ethio-American couple (sh*t all over the house) has now gone to the recipient of all that is in need of succour, Mackebie, so we will be inspecting Jabba for bites on his Saturday visit as well as for signs of his continuing Tinea Corporis (ring worm).

Sustainability, a failing dysfunctional hospital, a factional and riven NGO, venal idle and incompetent health centres and surgeons who cannot be let loose on their own, divine intervention required here too I think.