Ethiopia update- nearing deparure day

Have pension will travel.  Took the lump sum in June and now doing my locum till end of this month and my successer appointed-good luck looking after the women of Surrey- Shaheen as we hopefully set off for Gimbie on 6. October.  Why hopefully, well although we have got the airline ticket we yet to have a work permit, a combination of bureaucratic obduracy and charity incompetence or probably more charitably ignorance.  Despite having had a number of volunteers it is apparent that they have never had the correct paper work in place.  work permit requests to the Ethiopian Charities agency start with the expression 'We humbly beseach........' do we now (!) and require a fistful of documents-certainly enough to tip you over the starter pack cheap deal in DHL.  Your original degree, not anything useful or relevant like GMC registration needs to be found (trip down memory lane in the attic) and this needs to be notarised, then legalised by the Foreign and Commonwealth Office and finally stamped and signed by the Ethiopian Embassy before being sent to the Agency.  Do you want me to notarise everything else that goes with it, such as supporting certificates health certificates, job offers etc.?  No no not necessary until you send the stuff over, wait interminably for it to be picked up and then turned down as 'job offer not notarised. Snake-start again, so not there yet!  other little money earner is length of work permit-should be s ix months but try and get more than three-so more trips to Addis I suspect-12 hour journey will be nothing as we will be able to buy food and more important wine so perhaps not a bad thing.  Work permit is probably good thing as web site says work without work permit = gaol, not a pleasant prospect anywhere-specifically one suspects Ethiopia.  Now this presents us with another snake-no work permit no permission to take a car into Ethiopia for personal use without paying mega bucks in tax, and car essential for escape from Gimbie and indeed to carry out projects etc.  Alternative is to take it out on a 'Carnet', as a tourist but this has its own problems as entry may be denied as not coming in on a tourist visa-all great fun if you are not the one in the middle.  With obstruction at every turn, I wonder if any 'volunteer' has ever had a work permit-certainly not in the charity we are going with.  The 'truck' itself is another story of potential venality if not incompetence as it required buying a left hand drive land cruiser in Belgium with very little guarantees that it would arrive and delays, evasions and failed phone calls to the level that you seriously wondered if it would...avoid internet dealers offering purchase of left hand drive cars.  When it arrived the tyres were shot the car unloved, suggesting a long time in a dealership and the paper work missing.  one understands that cars from Belgium have to have the Belgian equivalent of an MOT-this one did not. However some conversions later it is probably ready to go though I have not seen it for 6 weeks and when I phone to ask most things are about to be done, so we will see.  with all the extras it is now of course outrageously expensive so tax on admission to Ethiopia would pay for lots of mothers and babies to have care.  this is of course the main reason for going though on the basis of what is happening would seem to be what they are trying to prevent.  maybe, politics being all they are the wrong babies in the wrong place.

While we were out visiting we copied a year of the delivery book and have, with the help of the redoubtable Hazel been analysing this, a snap shot of the world of hospital obstetrics in West Wollega.  there are 1,500 deliveries a year of which 40 odd percent are paid for by the charity and probably represent the tip of the iceberg of the deliveries in the region.  Appropriately the majority are primips as most primips even in the developed world, with their untried pelvis, are probably best delivered in a institution that may but I hope that this is not a reflection on the care they get and their reluctance to return.  The Caesarean section rate is around 22% but mostly for obstruction and with a worrying number of dead babies.  Being a twin is also bad news, it is rare for both babies to make it.  Four mothers, all under 25 died in the year, one of eclampsia and the others of blood loss-preventable and unnecessary.  These statistics though, sadly are some one's child, sister, partner and their loss will be keenly felt.  How much more carnage, the result of a normal process, is going on the community is any ones guess.  We would like to do something sustainable to stop this loss of life, damage to 'parts' and suffering, perhaps a triage system to direct the appropriate people to a safe birth place-even one that is vaguely nice to people as well would be nice- but such triage systems have not been shown to be robust in the developed world, though they might offer some hope in the developing world.  This together with Education is what we will be trying to do-work permits and car permitting of course.

Aftermath

So, back to the UK and to the next stage.  we have sent our rather soft report off to maternity World Wide and look forward to feed back.  In the mean time we have started looking at the next stage which includes the nightmare bureocracy of car importation.  The most helpful has been from an import agency whose basic advice is don't based on the difficulties of it sitting in some dock side in Djibouti collecting storage charges.  carnets count for nought and the British Embassy have not rushed back with advice yet-but we will get there.  there are also issues about bringing in useful bits and pieces for the hospital-lots of gift certificates etc will be required.  How about trying to source a left hand drive land cruiser with English number plates to import..Thought we had found one but it looked v. dodgy with no paper work french number plated and the suggestion that the front and back were not the same.  for those of you wanting Land Cruisers for overland avoid English sounding second hand dealers in West Yorkshire whose sales force answer to Mohammed.  Worryingly the sales site had a pit to take cars off lorries from the continent.  Boring because it is going to take for ever to get the paper work in order but finding the right vehicle is also problematic.  Now coming accross internet sites that specialise in being tantalising but keeping you apart from the vendor.  Now using european contacts (and very grateful) to try a nd source a suitable truck as they are called in the venacular for us.  Three cheers for Greg from Landcruisers overland for all his help.  Will shortly have to write to Gimbie to set out what we require-letters etc and to get some more info for our paper-Hazel is getting hard to work cracking this so may become all very interesting-watch this space..
Jeremy

To Gimbie and back

So, an exciting 9 days with a myriad of sights, sounds and not least smells!  After a flight that makes Ryan Air look like business class we arrived in Addis and were whisked off to a hotel on the out skirts which was suprisingly quiet but backed on to a school full of international football hopefuls, if their break was any thing to go by.  Curiously the inflight information on the screens of the telly are in French and the Ethiopian Airline logos on the side of the aircraft are stuck on which makes me wonder if we are flying in old and possibly borderline airworthy Air France stock.  one worries that it has fallen off the back of some galliclorryAfter a whirlwind trip around Addis including pick up an English Oromo dictioary we had a tolerable meal in the hotel which was Ethiopian in origin and included my first though regrettably probably not last taste of Injura.  It looks like a dirty grey flannel or a soggy flattened crumpet.  It is not as nice as a crumpet and I have never eaten a flannel but I can imagine.  Next day we were picked up distressingly early in a battered and already full ancient land cruiser and having also stuffed in our luggage we had a 13 hour journey to Gimbie West Wollega, far off the tourist track but the route was suprisingly full of people, goats, cows, donkeys and marauding baboons-the only visible wild life.  We stopped briefly for Ethiopian breakfast-broken up beefburger, omlette and injura and lunch looking strangely similar.  Sadly this was the start of a gastric disturbance that stays-what will the microbiology show.  This however is more than you need to know.  Inevitably the landcruiser broke down with a burnt out clutch, so we were towed the last few miles by a truck with a by now also extremely stressed clutch and then carried our luggage to our new accomodation, which we share with a fellow volunteer.  The truck is not seen again but seems to have been involved in a crash in the past and have a lot of problems bar the engine, and it was absurdly expensive.  The accomodation is dire and unloved.  There is strong forensic evidence that the drawers in the strange wardrobe in my small single room have been quartered by a murine visitor who has left its calling card and I do hope that it is n longer in residence!  I understand however that they come in in the rainy season which happily is not now, but this does say something about the thoroughness of the cleaning between residents.  Having heard about bed bugs and having looked at the rather thin grey nature of the sheets provided I have opted to sleep in my sheet liner on top of the bed and spray for mosquitoes instead.  Happily not bitten during stay by either those flying in or those crawling through.  Although I have bought gloves for use on the wards a pair is pressed into service to takle the bathroom, particularly the shower tray.  I did not believe it was really yellow with rust spots when I first saw it and it is now white and yellow with rust spots so I can bring myself to stand in it.  The shower curtain is hanging drunkenly too but that is fixable.  The hinges of the loo seat are another area of concern but have gone unnoticed by tennants past too.  There is however a daily lady what does so perhaps things can be improved.

Next day we set off for our first ward round and what a scene confronts us, with all the sights (and smells) of Africa.  Patients wear their own clothes in bed and have probably been wearing them for sometime and this is obvious.  Our main focus is obstetrics and although there is no such thing as the obsteric inpatient there is a mixture of those who have survived to tell the tale with their baby and sadly those who have survived, just, but without their babies.  Hearbreakingly there are also those who will survive but their babies wont so they just sit their with them till they die. The ward round is a strangely veterinary affair as communication is difficult through interpretors, who interpret longish questions in a few grunts to be returned by half nods and shy smiles.  The normal or near normal deliveries seem fine but those having Caesars fare badly both in terms of infection and poor obstetric out come.  The ward staff do drug rounds, a lttle haphazardly but any caring is done by the family if any who also bring in food etc.

Even communication with the Ethiopian doctor is a little sporadic as he speaks Amharic and all the local patients peak Oromo so all rely on translators.  We will need to speak Oromo....

It is a crowded ward that is difficult to keep clean and one suspects that the cleaning is a little episodic and those episodes are not frequent. As this is a public blog I will spare you the details but if you want more and have the stomack do comment....!

It is however not all bad, mothers and babies are rescued and some who would otherwise die of complications, such as uterine rupture have the opportunity for timely intervention and a reasonable out come, but those who come late do not.  The real national problem though is not those who come but those who do not..what happens to them in their Kebelles or villages we do not know but i suspect that it is not good.

All this should be compulsory viewing for the National Childbirth Trust.  More will follow together with photos and maybe even a you tube video for those with a keen interest. 

New thoughts

As we approach our exploratory mission in a couple of weeks we are looking for wheels as being stuck with a driver in a car to which we have only intermittent access could be worrying.  Happily a contact in Ethiopia has suggested he can arrange car hire and the possible purchase of one when we go over for a year which would make life easier.  Lets hope that he comes up trumps.  The need for transport is not only independence but also an opportunity to visit the local university and get about the locality and visit some of the Kebeles to see for ourselves what is happening rather than having constant minders about.  Hopefully too we will get some nice photos for this and the linked blog.   What is also encouraging is the number of friends who can also contribute something, who say they are interested in visiting-this may mean though that we start having a well warn path to Labela where the rock hewn churches and major tourist spots are.  Hopefully too can visit local medical school and see what is what.  There are clearly tensions between the faith based hospitals and the government and it is difficult to know where the best interventions will be.  Much I think will be revealed in February.

Background

Having spent since October 1971 in the NHS it is time to move on and with the pension due, new pastures, or possibly waste lands beckon.  Having researched quite hard we have decided that Ethiopia sounds very exciting so we are off to explore the possibility of working in a hospital in Gimbie West Wollega Ethiopia for a year, both looking at the delivery of health care and also possibly doing some good.

  Maternity care is limited with a catchment area of 120 square miles and little transport in a country with a limited infrastructure.  So, the first problem is, if you get into trouble having your baby how do you get help, assuming it recognised you are in trouble.  Once you get to help, how long does it take to get it, and probably most important does it help.  This is referred to in the literature as the 3 stage model but it begs a lot of questions.  We are told that the population of Africa is steadily increasing, yet the maternal death rate is very high (extra-ordinarily so compared to the western world), suggesting that there are a lot of orphans about.

 If you want to get into trouble having a baby in the west have 4, your 4th is likely to be associated with some bleeding but in the west we are both quite good at stopping it, and if it does go on a bit giving you some replacement blood-both the skill and means of stopping bleeding are in short supply in the developing world (the politically correct expression). If you do bleed you will have to rely on your hopefully disease free relatives to give you some blood. Hopefully you will not get anything nastier than maleria, which though fatal untreated does have the chance of being cured-which is more than some of the diseases on offer.  A big issue in Africa is Caesarean section (the 25% rate in this country) may be very unhelpful in Africa when an operation for one pregnancy may lead to a disastrous rupture of the uterus in the next because a second operation is not available in your village or kebele.

 The other big problem is your babies head pushing hard on the skin between the bladder and the pubic bone leading to death of the tissue there and breakdown so that you are no longer continent-difficult with minimal sanitation.

 These are just some of the problems and we will explore more as this blog develops.  We will also look at our own trials as the trip develops.  We are very keen to have wheels and a big discussion is whether to drive out (big adventure) involving crossing dodgy regions with kalashnikov carrying locals and strife or whether we should buy some well used wheels there and be left with a lot of birr (local currency) at the end of our trip.  Our other problems we will look at in more detail and will fill you in when we return from a preliminary trip in February, not least what the accomodation is like and what are the problems working in an environment with scarce resourse.  The actual organisation we are travelling with are called Maternity World wide and you can check them out on the Web.  They too seem to be in a state of change.

 One of the things we are keen to do is to look at the effects of interventions and make sure that they are useful to the population. there is bound to be a tension between this and working at the coal face.
Regular updates can be expected, so stay tuned.