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.

Communication Failures

One of the persisting things in the Ethiopian psyche is being unable to answer a series of questions (you are likely to only get a half answer to one of them and never try a two parter, nor does it seem to part of the system to give clear and unambiguous information). So it was that my patient appeared in hospital fully dilated having had two previous Caesarean sections, something that I now believe is being encouraged in the ‘VBAC’ world of the west. Nothing ventured, nothing gained so I reached for the least battered looking suction cap but desisted (wisely it turned out as the swelling I thought might be bladder revealed blood on catheterisation) and subsequent laparotomy revealed dehiscence of both the scar and the bladder dome which was very adherent. Miraculously the baby came out crying and both are doing well. The moral of this story is not of course the advice she was given, which was ‘you need to have your baby in hospital’ but ‘you will need to have a Caesarean section’, which it seems would be far too unambiguous. Even better would be and’ you could be sterilised too. When asked why she did not come before the answer was, as it so often is, associated with transport difficulties, something that a ‘waiting house’ which is tax free might solve and an E-ranger (still in customs being wrangled over) might or might not depending where it and she were at the time. Simple solutions for simple problems are also not part of the psyche.

Despite general approbation from the clinicians in Surrey’s world of female genital cancer my request for limited funding to try and see if local clinicians could help local people with an otherwise fatal disease fell on deaf ‘lay ears’ with some surprisingly pejorative not to say ‘old testament’ remarks about the women in Ethiopia who, like their sisters in other parts of the globe have been challenged with oncogenic papilloma viruses but unlike many in more affluent parts have not been screened or offered preventive treatment or now vaccination. Whether by force of circumstance or choice, and it is rarely choice you have developed invasive cancer matters not a jot, the availability of effective treatment does. Here, of course there isn’t any and in Surrey wildly expensive minimal access therapy is, for the few that need it. From my time in the Surrey colposcopy clinics many of these could be termed ‘new Surrey women’ i.e. those from the Baltic states and eastern Europe whose life style and deprivation is probably broadly similar to that of the women I now see, but fill roles in wine bars, hotels and the service industry to provide the monied of Surrey with the services they aspire to. So it should be said are the stunningly attractive, if orthodontically challenged, young women of Ethiopia who regularly queue, for many hours at Immigration in Ethiopia for a passport so that they can head for the middle east and jobs in hotels, coffee shops and I suspect less salubrious employment where they will get exposed to oncogenic viruses and the cycle will continue. For those however, now in their forties and raising their children, death from renal failure, cachexia and chronic infection awaits, a death that might be avoided by a timely and skilled intervention. If anyone would like to help me help them to help themselves (Ethiopian psyche permitting) please let me know. This charitable concern comes with no overheads just the cost of the operation, around 2000 Birr a snip at £80.
For those of you who were distressed at the sight of the baby that tried to emerge into their troubled world face first I am pleased to report (see photo) that swelling has gone, feeding has been established and the traumatic emergence now the past – let us hope that the future is rosy. I am also amused to see that ‘attitude’ is alive and well in Ethiopia if tinged with ‘I must ask my husband’ which some would regard as a laudable trait in that a lady with quite worrying blood pressure is very reluctant to be induced or as they say in these parts ‘have the pregnancy terminated’ but I hasten to say that that expression does not have the western connotations that we would associate with it.

Happily she has now agreed, or more probably husband permitted, so termination is under way.

Yesterday was Ethiopian Christmas, a day that is as bad for cows here as it is for turkeys in Europe and there was much feasting. I do not know if it also bad for goats but there was a lone and vagrant goat eating in the garden and being male only good for eating or reproducing, perhaps it had wisely decided that it was an away day. We did our bit acquiring a slab of cow and with some difficulty as the knives are blunt and we have no sharpener, cutting it up, cooking it in the slow cooker and serving it with spagetti to our ever hungry youngsters and some Ethiopian friends with pancakes and the local equivalent of Nutella to follow (the latter ably produced by Clara). They all settled down to watch ‘Harry potter and the half- blood prince but I am not sure what they got out of it, more Shrek and similar movies probably required for this paediatric entertainment. One of the young men has infected feet which are being treated with antibiotics, like the gardener’s arm and I had that soaking for the afternoon. My only worry is that he has recently been bought some boots that look alittle large and more important military so I hope that I am not just treating trench foot with more infected salt water. Perhaps open toed sandals are what is required or that I am missing filiariasis or something equally exotic.

Baby 3 days after 'face presentation'

ruptured uterus pt day 2

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.

The Dark Side of the Moon

Are the forces of darkness gathering, if you are able to read this we have beaten the system! The problem is that we are having difficulty accessing the blog site. Karen is convinced that the Ethiopian thought police/bureau of state security has read the politically incorrect thoughts of Winston Wright and has thus pulled both blog sites and taken away our voice. If this is the case and we have circumvented it – read on. Ethiopians do not do criticism, which is possibly why they do not respond to any form of training and that sustainability is but a hollow slogan. As the famous philosopher ‘Pangloss’ would say ‘All is for the best in the best of all possible worlds’ and that must be the way of things in this strangely beautiful, over bureaucratised grubby and chaotic country. Karen and I have major discussions about the need never to offend, the politically correct view of never being forthright about what you believe as it will prevent progress as compared to mine which is speak and be damned if that is what you think. As Voltaire famously said (but in French)’ I strongly disagree with what you say but I will defend to the death your right to say it,’ so with two quotes from the same philosopher I have to defend my position to say in this blog, or elsewhere what I think, at the risk of casing offence, or even as has been locally suggested, cause all blogging sites in this country to be unreadable as the thoughts and stories emanating from them cause offence to the censors or leaders of the country. So is it better to tippy-toe around the manifest problems or to face them head on and say what you think. One allows you to co-exist in a cosy if false harmony, the politically correct and I would say soft centred view and the other is robust if sometimes uncomfortable debate – the problem to me is that no one these days really feels able to say what they really think.

The land here is rolling hills of teff the wheat that makes that sour dough the staple of the food, the trees that cover the coffee plants the main source of income (other than NGO and faranji tax) and with the vast population, rusty corrugated iron roofs that somehow blend into the landscape and from which pour forth small and snotty children if you ever stop with the familiar refrain ‘Faranj, you, you, you give me money (I have stopped carrying any and pull my pockets out to show that they are empty) to the amazement of the young. Meanwhile at home, the only place that Masie will now lay eggs is the basket of baby clothes on the floor, happily so far without skid marks. The noise she makes prior to this is enough to allow the practice to continue – anything for a quiet life.

Meanwhile, back at the ranch we are providers of NAN milk for the neonates of West Wollega as they survive the cold and wet. Wet is inevitable as there are no nappies and unless you are fit and well with enough material to dry the odd bottom that is the fate that awaits you. If you are ill by virtue of say being unconscious or confused having arrived fitting and on your own your baby is at the mercy of local forces and dressing is dependent on availability of clothes, now of course with the added advantage of chicken down duvets!

As ever I never have the head camera in the right place as a woman turns up having travelled many kilometres - the locals say about 4 hours, septic, with a ruptured uterus, the result of an undiagnosed brow presentation in a gravida 5 (aged 25 so if she dies that is 4 orphans) and strangely not too much in the way of blood loss. If I had pictures I would have shown you, assuming they would let it on to U tube, but with the current difficulties of getting this stuff on to the blog who knows. The cervix (in 2 pieces) and the lower segment are a soggy smelly friable mess, so as she wants (as they say in these parts) a BTL (sterilisation to you and me) I do a hysterectomy – very carefully with everything double clamped and particular care around the vagina as two ureters would be in the words of Oscar Wilde be careless. She comes from a different tribe up country and is clearly short of money as when I went to see her next day I was confronted with a request for money to pay for Tramadol, which they could not afford, the antibiotics presumably having exhausted their financial reserve. The charity for which we are here have pulled the ‘safe birth fund’ as of the beginning of the year, on the understanding that treatment is free in the government hospital (though it is not clear if this includes drugs) so the future is I fear even more uncertain for those travelling long distances in the hope of staying alive while giving birth. Those of you who know about third world (sorry politically correctly ‘developing world’) care will know about the 3 delay model. Commendably, here the third delay, that of getting treatment on arrival is virtually non- existent here as resuscitation is brisk, crystalloid and antibiotics and anaesthesia swift with no questions asked, no nonsense about CEPOD lines and fighting for space. The tough and antibiotic naïve seem to survive. Have also managed to find a better suction for the ventouse, so hopefully this will help my on-going struggle too.

In the meantime our second radical hysterectomy went home praising the Lord (not I note her surgeons) on day 4 without immediate mishap – I do hope she does well in the future.

Please feel free to comment then I know you have read this.

Hopefully to be continued……

For those of my readers that are interested I have written a begging letter to ‘GRACE’ which is a local (as in Surrey) cervical cancer fund and has helped fund the ‘Robot’ at the Royal Surrey Hospital. As you might imagine these parts are long way from robots but a very short way from a national problem of untreated cervical cancer. Some of this is treatable surgically and could be operated on by local surgeons with appropriate training – hence my cunning plan. If it works, and sustainability is all, they can all go on teaching each other and we have a rolling program of cervical cancer surgery.
However patients have to pay (probably around £80) for their surgery currently, (and this is out of range for the rural and affected population whose average working wage is £10 a week if they are lucky, nurses here who are trained get £40 a month) but if we could show that it works, even in the short term we could try to get the government to fund it in much the same way that they currently allegedly fund maternity care. Basically I am after around £1,000 to fund 10 cases and see how it goes. Have a read and if you know of a charity that would like to help let me know!