Care in the Community

Care in the community knows no bounds as Karen (though not for a while, see later) trails off to far flung Kebelles, health posts and the like with her scanner personalised risk assessments.  She occasionally takes me too, but I have to confess to feeling rather spare as there is a queue of the pregnant who have walked miles to see her and a scan and few who would give me the time of day.  Their stories are appalling with a litany of stillbirths and near death experiences the details of which alter by the moment making it difficult to give any advice other than come to hospital and we will see what we can do.  Best avoided though are domicillaries, as organised or rather black mailed into.  Take the lady with twins of blogs passim whose husband spends his time taking up valuable clinic time telling of bleeding pain etc. post caesarean of now some weeks if not months ago and his wife’s inability to travel.  Granted she lives in a windowless hut some way up a hill and at our inaugural visit darkness and lack of facility did rather make assessment of any problem difficult but anyway there did not seem to be much of a problem however another visit was demanded and acquiesced to…..

So after an interminable clinic, a lunch of shiro and dhabo (Karen currently has shiro poisoning) we set off for a home visit, to collect the patient, take her to a health post which may or may not be open (it wasn’t) where there may or may not be an examination couch (reputably there was) putting the land cruiser (Hercule or Tintin it is after all Belgian) through all its paces we arrive, wait for her to make it down the hill with assorted relatives (making it down the hill and presumably again upwards answered the question about her general health) but then loading her, twins remarkably still alive and husband together with 2 nurses into the car we set off to the local village and a private health facility which allows us access to the examination couch.  Not much can happen at the village as we are soon surrounded by many hangers on who do not do the usual stand and stare but struggle to get a view through the window requiring much shouts of ‘Demi =go away’ to get some space.  Needless to say scar ok uterus involuted and just general fatigue so purchase some iron and diclofenic for her and wearisome journey back after some hours of wasted effort.  On the way back we acquire another passenger who having heard of the service walks to find us and get a lift back to the health centre and yes another scan.  Advice, as yet not taken was to come to hospital as she had yet to have a live baby, two previous still births one in a ‘private facility’ and one I think on the road!

Another lady then appears in an Isuzu truck, allegedly bleeding and requiring attention despite my rising irritation and desire to get home so I was I fear rather short and hurried and perhaps did not explain my vaginal examination as fully as I might, causing some familial complaint about my bedside manner, which along with my reserve of human kindness had long since gone.  The only thing I could find wrong was some haematuria and my prescription for ampicillin was rebuffed by the local pharmacist as contra indicated in pregnancy when amoxyl was not (why???) anyway by that time I was beyond caring.  Another pregnant lady, also turned up with scaly lesions all over her probably psoriasis but I tried to do some skin scapings to look for fungi but the microscope reqired sunlight and sadly (and unusually) the sun was in so all I did was draw blood and receive another dent in my reputation as the caring doctor.  I did not add that our various passengers were all vomiting copiously by now.  Finally off home with a lady leaking liquor over the seat from her fetal abnormality, firmly clutching an airline sick bag we had nicked on our travels but happily not needed and equally unhappily not returned so down to just a few bags now.  So with my fund of human kindness now at an all time low we return late to various orphan boys awaiting pizza supper and film for which we are late.  But missionary zeal being all we do our bit and give them much of the limited supply of cheese.  They then get the lion king and popcorn with American sugary butter before being escorted off the premises, leaving a sugary muddy foot imprint extravaganza behind them. I wonder if the ancient cave paintings were actually children’s parties especially when I see a perfect foot imprint on the floor.  I arrange for them to help me wash the car next day….read on and begin to think that my life as a medical missionary might be limited.  Next day I wonder if my life might be limited.

Mechanical Trials

As readers of more politically correct blogs will know already, our carefully prepared landcruiser suffered total brake failure despite apparently having the brakes checked both in the UK and Kenya, causing Karen to accelerate down hill backwards at a rather alarming rate and then drive back for 2 hours plus on the hand brake.  It would appear that one of the back pads was so worn it disintegrated and caused the calliper piston to come right out with total loss of brake fluid.  We replaced these, not an easy task but it was apparent that the disc was also very worn (thanks again preparers) so a trip to Addis was in order. A new disc and a service later (during which our Oromo dictionary and a set o I POD ear phones took a hike – thieving bastards) and a few nice meals, we set out again for home for that is what Gimbie has become noticing that car starting was becoming a little sluggish.  Various warning lights, mostly to do with brakes started to come on, which we were told was to do with computers needing resetting etc.  We were told all was well bar some bearings (good service chaps) and continued on our way when even more lights came on so stopped to investigate.  Not a good idea as it was apparent that there was total electrical failure.  Happily we have an auxiliary battery (a better, and in Greg terms) only good development so christened the jump leads and setoff back to Addis, hairy as one by one more systems failed ending up with complete failure on the Bole Road diversion, which is a bit like Hyde park Corner at 5 pm.  So with cars shooting by I wired the 3^rd battery to the main battery with the jump leads, taping them with duct tape to the side of the car in the hope (springs eternal and this time successfully) that they would not fall into the fan system, but meaning I could not close the bonnet or hood to my American readers, so a fairly difficult last few kilometres back to the garage, where it became apparent that during the service they had disconnected but apparently not re connected the alternator or more probably just knocked  the wire off but even standing on a wheel, we had to do a lot of repairs and changing as there were nails in them, it was not the easiest thing to get at – but have power again now.  But what I do not understand is that with most cars, when the battery is not charging there is a large red light, not apparently though with this.  So now apparently we have repaired tyres, blown up to the right pressure, working brakes, tracked wheels, fresh service and all well.  Sadly not so as on the next trip back ‘home’ on the final stretch, braking round corners on the tarmac causes the ABS to come on rather dramatically bring the car to a vibrating and rather alarming halt, making me think that one of the brake sensors may be buggered.  When I have worked out what the button saying RSCA off does, I might try that. In the meantime the tyres may be a little hyper-inflated as they seem a little slidey on the rocks that pass for a road hereabouts but we shall see.  At least we are all in one piece and so are the wheels. I we go on doing this perhaps mechanical night school is called for.

However the trip to Addis included a visit to a (by Ethiopian standards) swanky private hospital by me, as they want to start laparoscopy  and endless trips to government offices by Karen in her quest for ethical approval.  Karen definitely wants her ethical approval but I am less sure about my desire to teach Ethiopians who have yet to pass the diagnostic laparoscopy hurdle how to improve their private practice by doing laparoscopic hysterectomy, but it may prove an interesting way to pass a few months.  Life in Gimbie although it takes up a lot of time is now at a slow pace as the vouchers dry up and one treats the worried well and with less of the high drama stuff than hither too.  I hope that those who are not coming are making it to other places but I know not. MWW however plough their furrow and who knows where that will lead.  Instant and equally instantly forgotten education I suspect, and with the rather dodgy supply of newly qualified and outstandingly incompetent midwives one can only guess and tremble. Care in the Adventist hospital has its limitations but by and large it is safe.  There has been a faranji invasion with a clutch of medical students on their elective visiting so much of my time is teaching them, which is interesting but not what I am here for.  If I can get them to think a little though perhaps I will have achieved something.  They are quite fun to have around.  Maternity worldwide personel are however a little isolationist and being predominantly a hospital worker I see little of them but given the rather back bighting politics that may not be a bad thing.  Equally I am pleased to report that the cancer project is going well and may actually make a difference.  So three months to go and Adventists in trouble with inadequate funding, MWW up their own fundament and general lost despair.  Adventists are praying for you I think!

Educational travels

The current and well established political maxim the world over is that the key to success is education so with the recent visitation of a keen primary school teacher and teaching opportunities I looked forward to hearing how education for the emerging middle classes of this land was faring. You will not be surprised to hear from the reports I received that all is not well. Much of the classes seem to be spent with the pupils in the room undertaking or not various set activities, but apparently without much in the way of resources, while the teachers sit in rows outside the class room chatting before presumably moving on to their second job. There is a (locked) resource room which contains books and other useful educational material which is apparently used but the dust on the books raises suspicion that this may not be the case. Lessons by our visitor seem well received after initial embarrassment but the only interaction between the regular teachers and the pupils was calling out answers to times tables questions. Overall, and I was not there to witness this, there is perhaps an insight into why the Ethiopian psyche is as it is and the ability to synthesise information or even to use it usefully rather than just partially absorb is as it is. Melanie Phillips (Guardian Journalist, sorry about that) once wrote a polemic entitled ‘All must have prizes’ decrying the state of British education and here in the horn of Africa the combination of patchy dumbed down education (morning or afternoons, you take your choice and not at all when required to pick coffee) together with great difficulty in failing anything goes a long way to explaining the poor level of understanding that exists. If however you have found a Faranji to support you failing becomes very important as you can go on repeating years for some comfortably financially remunerative time until someone finally pulls the plug on you. Thus is the state of the unemployed poorly educated of Ethiopia. Many of these sadly hang around the gates by the car, shout abuse, demand money with menaces and even lob the odd rock. Welcome faranjis all! Travel, it is said, broadens the mind (and here possibly the waist too) and thus we set out to be tourists last week and slipped comfortably into that bubble taking a bemused local Ethiopian with us so that she could see her country and have her first ever aeroplane flight. After the usual terrible drive we got to Addis and having cracked Addis by car found wonderful restaurants and met up with friends. My trip to Immigration, usually fraught with banana skins was mercifully easy and having completed endless forms and brought all sorts of photocopies, I am now resident and legal again! Nearly fell at the last post though as I did not have enough Birr, as Karen thinks I am too demented to handle money so she had to hand me more through the bars (high security) for my replacement green card though the other snake was a Kenyan not an Ethiopian police report and a wrong form filled out. Any visitors, you just wait! So off we flew to Gondor (castles and Simien mountains) and Lalibela, rock hewn churches and angina inducing mountain walks to monasteries, all this going on in the fasting week leading up to Ethiopian Easter. Thus the churches were full of Ethiopians chanting Ge’ez , the fore-runner to Amharic but oblivious to our visits but handy to have a guide and they really are quite dramatic. If by the way you are having problems conceiving your troubles can be sorted by dunking in a rather septic looking pool (see photo, the reeds are not usually there, something to do with palm Sunday I believe. What our stunningly attractive but largely silent Ethiopian guest made of it I do not know but I am embarrassed to think that we probably spent more money in a week than she earns in a year but I hope she enjoyed the experience. Although deeply supressed I think she may be capable of deductive thought as I was left to entertain her while an overlong pedicure was taking place and I espied a Sudoku in a magazine and taught her how to do it – suddenly she was thinking, something I had not seen before. Perhaps mind expansion for Ethiopians is through puzzles, but what is apparent is that it is not through their education. Our current administrative mine field is the Ethiopian national Ethics committee, regulations down loaded from an English Ethics committee site and an Ethics committee manager out of the helpful English, make sure this stumbles mode. Ethiopian Ethics required because U.K. Ethics say this is necessary but U.K. ethics probably not necessary but number required if wish to publish so here goes. Having given in papers, complete with Afan Oromo consent translation, though most probably cannot read it and letter from local NGO organiser saying O.K.we now need letter from local health office saying they happy too. Not of course told about this before and also if goes in post never seen again. So more trailing around offices, I am beginning to understand why they all have sofas. But may be we will have to deliver it ourselves. Trip to the bright lights of Addis to deliver said letter perhaps! My Afan Oromo lessons have taught me that Addis Ababa means new flower. Meanwhile back in Gimbie, there is no internet (so when this goes up is any one’s guess) and my Ethiopian oppo is delighted to have someone else to do the nights with him. I think local obstetricians must be away as there seems to be an upturn in obstructed labour, heavy bleeding (Hb 2.8) and mal-presentation. Some of the local health centres have clearly decided that episiotomy is in, though they seem to be cut on the latera lwall and into the ischeo-rectal fossa producing some interesting haematomas and reconstructive surgery, carried out with the helpof a head light and the left overs from a recent influx of prolapse tourists most of whom I managed to escape by visiting churches. Happily so far I am not left with a lot of pelvic cellulitis but early days. Out patients, (there was a failure of pre planning) is now full of the hopeful but droopy and they will either have to wait till the next trip in November or pay up. Equally the new regimen means that women with previous caesarean sections, and small of stature are being turned away and scandalously a lady with a ruptured uterus and little circulating volume, until she could come up with the reddies. For a predominantly socialist country a little socialised medicine would be a good thing. Those of you in the U.K. system will know that it is ‘elective season’ and the place is crawling with faranji students so I am teaching them more than anyone else and little other than enthusiasm changes, otherwise they would not be here, however like medical students (though all girls) the world over they have discovered the ‘Green Bar’, however sadly and our medical politicians have a lot to answer for, their education to date is –perhaps- a little Ethiopian. They are perhaps having their minds broadened here! The pool is a fertility pool, dunk your self in and there you go.

Angles saxons and history

Those of my readers (if there are any now that I am effectively censored) who remember any of the history they were taught at school particularly early history will know that if you want to understand the present you have to study the past. The teaching of history however is now so impoverished that all anyone knows anything about is the origins of the Second World War, and Tudors and Stewarts. However, if you go back further you may recall how the Vikings fought with the Angles and Saxons and discovered that it was less costly in lives and more profitable to extract money with promises of safety from further attacks (menace money in modern parlance), the so called Danegeld (nothing to do with Germany). So after various incursions on this foreign soil by both Angles and Vikings an uneasy truce now exists though inevitably the locals are bloodied and having to rebuild their lives now it seems as educationalists rather than the bringers of relief, but both I am sure are important. It is however currently 30 luv to the educationalists (that is quite enough mixed metaphors). I am however saddened, being used to a system where care is free at the point of delivery to see people turned away if they have no money and to watch, as I am at the moment, a young woman die of heart failure as her family are either unable (possibly the case) or unwilling (probably the case) to donate any blood. I will do my best to keep her alive but am concerned.
We have more faranji visitors now in the shape of midwifery students from Edinburgh, who are innocents personified at the moment but will I hope develop as a result of their experience and might perhaps decide that a career, particularly an early career in the developing world may greatly add to their ability to cope in the developed world and perhaps see some of the flaws in the system from whence they came. You can keep people alive and safe even with minimal resources and perhaps that may be enough, certainly rescuing people from their obstructed labour when you can will keep them alive, and perhaps some education may stop them getting into that situation again, but in this country the education has to be directed at the husband and keeper of the geld as it seems wives are expendable, and not worth either transport costs or a temporary 2 Grm drop in haemoglobin. I have suggested to our Faranji visitors that they try to look at the history of those who turn up with obstructed labour (sadly fewer as no danegeld to pay) and see where the delays occurred. I am told we have some medical students coming too so maybe I can get a research team together – we shall see. The private sector which if nothing else bought me alimony and children’s education was fine when there was an alternative but is uncomfortable when real need remains unmet, but then I am sure that sustainability and education will stop all this!
Meanwhile my other nearly exsanguinated patient (bad tear, normal delivery, yes it happens here too), is well and going home as her brothers rallied to the cause and she is pink and well and now home. I am off on a week’s holiday soon to visit Lalebela and rock hewn churches etc. happily over the time that the prolapse tourists arrive so I will not have to vent my spleen on them though I have hopefully arranged for the mesh erosion ladies to return for their remedial surgery over this time, I wonder if they get a second dress? Our own complication is a wound infection following removal of rotting cervical tumour but it is granulating well, though her husband is pursuing me with unstamped receipts and tales of starvation. She comes a distance so I hope we can get her home soon. Histology reports are beginning to trickle in but contain no useful information like resection margins but tell us like many histology reports, what you already know – er got cancer. Ultimately they will either survive or not, but as Thomas Stone remarked (yes I have read the novel, novel reading is unusual for me) you do not want to operate on a patient on the day of their death and I have yet to do that on one of the cancer patients though one of the young septic obstructed labour patients sadly succumbed from her complications shortly after her twins. All avoidable of course if intervention had been timely, perhaps education would have helped.
If it were not for the importance of Karen’s research which also suffers from obstruction but of another sort, I would leave the Angles, Saxons and Vikings to fight it out with their local lascars and go south to where an unwell single handed obstetrician would welcome a hand and a new medical school would welcome some teaching input, but no I will remained a censored voyeur and continue to report in more guarded terms to my remaining readership, in academically correct and measured words (get real that is quite enough cant).

Just when you thought it was safe to get back into the water

So just when you thought it was safe to get back in the water (fade up scary music and read on).One of the abiding rural myths in these parts, and indeed Africa is that humans get attacked by crocodiles, particularly if they go down to the same place more than twice. This is I have to tell you actually no myth as walking through the operating theatre I spied a young man awaiting secondary suture with these injuries. It would appear that he was bathing with his mates, somewhere near the source of the Blue Nile, which is reasonably close when set upon by a hungry reptile and only survived because it was beaten off by his friends – a lucky escape but he will bear the scars.
Meanwhile having thought that the financial changes and withdrawal of funding would mean undisturbed nights of sleep I was rudely shocked by a night of registrar activity which included sedating a young lady who subsequently died as a combination of stroking out with her eclampsia (probably but being at home not really clear) and her sepsis, a sad and squalid end in the open ward, the other patients weeping quietly. Other activities included a breech delivery on a pre-eclamptic lady who laboured quietly in the ward, two retained placentae, an emergency section for a breech that looks strangely Down’s syndrome like and to round the night off a shoulder and cord presentation at full dilatation! I remain unclear as to where they all came from, whether they were paying for themselves or did they come bearing vouchers which will soon be rejected. Although wearying for the aging obstetrician manqué it does restore my faith, albeit temporarily, that I am possibly doing something useful. One of the worrying features however is that people come either when it is too late, preterm delivery at home and brisk bleeding having had two previous caesarean sections, and another fully dilated with a very low fetal heart rate. The latter is doing O.K. but the former baby does not look that great. I suspect they hang on in the hope that they can save the money and this may reflect the lack of a voucher, but I do hope not. The new MWW rubric is educashun and as part of this there are chats to women’s groups and worrying stories that either suggest education failure or male dominance of a degree that even disturbs this bastion of male domination. Women ruptures her uterus at home and kills baby, uterus sutured, has next baby at home, surprisingly ruptures uterus again, kills baby has hysterectomy and now ‘quote’ @must bear this burden. Failure of education, understanding or permission of husband? Who knows but goes some way to explain the Ethiopian condition. Not so though the trip to Gueliso I was conned into taking together with the ‘Adventist team, which was recruited patients for free prolapse operations, yes time to herald the return of the prolapse tourists, this time a slightly different team but still due to arrive any day, so some punters might get an operation and they can sort out the mesh erosion that popped up last week. Happiliy I will be away for a good portion of their time here so will not get too irritated I hope. One of the reasons, falsely it turned out, for going was to see if there were any cancers about but none came forward. Histology so far has shown resection margins clear but out into the parametrium so hopefully a slightly longer life. We await more punters but I suspect that the other hospitals, though not offering surgery are jealous of their trade.
So as we move into the final third of our trip here (3 X 4 = 12) but actually slightly over half as we are doing 10 months it is an interesting time to take stock. I have I think been a little over harsh on the Ethiopians, not because of what they do but why. There is no government net so they rely on local support and a sort of Marxism rules in that if you have and they have not you are expected to share, the more you have the more you share (and thus presumably you have less) but faranjis always have more so start there.
Do they care, they certainly stand and stare and invade your space, there is relatively little in their lives so anything is a free show and they are clearly trained to remain expressionless until there are episodes of collective joy (singing at marriages etc.) or collective grief (ululating at funerals) but they do turn up in their multitudes when there is illness but whether to help or watch I do not know. The occasional happy smile is a sign that they do have feelings and when you do get to know them you will get some idea of these. Though if you do piss them off this may well last for ever. If you live small parochial lives (and mostly they do) you get small parochial views and it only those with satellite TV that are ever likely to move away from this.
Will they steal anything from anybody even their friends, if you are the street kids yes, the top to my memory stick has been nicked from the table outside where it was left for 10 minutes during a recent visit – irritating as useless to them and quite important to me. This adds to the list of trivial nicking, which includes for the second time one of the outside bulbs, doubly irritating as it lights my path when summoned to the ward in the wee small hours. The kids sadly, and this goes for the vast majority, are bored feckless destructive, begging bastards, whether it writing on the car with stones, shouting obscene requests for money while being vaguely threatening (Teenagers) or if ‘orphans’ taking faranj hospitality and gifts while outrageously upping the ante, more expensive food and drink when being entertained, and lording it about in football kit that they only just manage to keep clean, though to be fair when given a tub of water they did wash their clothes followed by each other. I suspect that their life consists of intermittent neglect and then the showering of treats when what they really require is tough love and life lessons.

Life here is hard and in the main brutish, with low living standards, little in the way of facilities and a government service which is more in what they say they do rather than what actually happens. There is a lack of care and in a strange parallel with our own health service it is more about measurement than delivery, and that which is delivered ain’t that great. Despite this they are survivors, but with only a little help, and a little real thought rather than the parroting of what they have been told, they could make great strides, but that would require initiative and sadly, in the last analysis that is what is missing

longer boats

And so the long boats left, this time with a new helmsman as the usual and trusty driver, Kume has had enough of the dusty Addis road and has turned his hand to house building for a few weeks, and the representatives of MWW.DK return to inhabit the land of Hans Christian Anderson.
There is, if my readings of their deliberations are correct, now a completely new approach to the provision of financial support for those needing help with paying for intra-partum care (delivery). Previously (see blogs passim) vouchers paid for intra-partum care for those in need and this had been rapidly accelerated to those who asked and care was delivered in a mission hospital at a cost. Now the maternity worldwide voucher now pays for medication, if required in a government hospital for those in a rural community, provided they are seen to be in need by a committee of their peers. Means testing comes to West Wollega. Medicines here are remarkably cheap by western standards, some chloramphenicol eye drops and paracetamol syrup cost me 16 birr yesterday. Private travel is however not and some poor wretch with a ruptured uterus was required to pay 2000 birr (£80) for a lift on a lorry surrounded by eucalyptus logs for emergency surgery that was to cost her 1600 birr (£60) at this now private facility, having initially, despite being moribund been turned away either as a result of poor assessment or having no money as it had been spent on transport. The former being less morally reprehensible. For someone who has been brought up in what the Americans would describe as ‘socialised medicine’ it is a rude shock to realise that I am to spend my last few months here working in the American commercial sector. The parallels sadly run deeper as the Adventist Hospital boasts two obstetricians, by local standards adequate resources, much provided by western benefactors not least our own supplies and access to emergency surgery more quickly than is available in many U.K. hospitals (no nonsense about CEPOD lists in this neck of the woods). The government hospital meanwhile is under bedded and under resourced but with a keen and competent obstetrician who has trained one of his general doctors to do the caesarean sections when he is not around, though with the more complex surgery who knows, though it might explain 2 ruptured uteri in one day here. There is however only one operating theatre and if in use by others, tough. Another NHS parallel here as there is usually only one emergency theatre and surgeons wrangle over access to it. Transport as ever remains an issue and there has been much discussion over the deployment of e ranger motorcycles currently children’s play things with ever flattening batteries (they have discovered that it is fun to turn the lights on and off) ensconced in the hospital foyer but soon to be deployed in two rural areas and will with shoulders of strong villagers, a single health centre car and local buses become the transport at either cost or means tested subsidy for those on their way to the government facility whether or not they bear vouchers offering them free antibiotics to help offset the incipient sepsis from their obstructed labours as they await skilled help and access to an operating theatre - we live in interesting times.
The new watch words are of course sustainability and training and much training is to be offered to those in health centres, though little is delivered on site as trainees like to gather in centres to be instructed as this carries transport and the ever important per deum. (these are a day rate for attending courses and are an important income stream for health officials and explains why they are regularly at these courses at every possible opportunity). Hopefully they will learn useful skills like recognising when labour has become obstructed (it has been going on for more than 12 hours and no end is in sight) and make provision for transfer to somewhere that can do something about it before it is too late. Sadly restrictions on what is permissible in health centres, basically an outpatients with a labour ward, means that oxytocin, a uterine muscle stimulant, is available for third stage problems but not intra-partum, so the prima-gravid with uterine inertia are condemned to a long ride to hospital and a caesarean section to protect their multi-gravid fellows from possible overstimulation and uterine rupture. Storing up trouble for the future me thinks and the training will never be subtle enough to make this distinction.
Although the management of first stage uterine inertia may require more skill and judgement than is available in health centres the management of eclampsia does not and is much needed given that the maternal death and other acutely nearly dead people I have seen could have been rescued by earlier and very straightforward intervention and with this in mind I have on my trips to various health centre offered some in situ but per deum less scenario training around patient stabilisation prior to transfer. Treatment is by magnesium sulphate, cheap but actually apparently available free and safe, effective and easy to administer (painful injection in the bum) and probably does not matter if you have the diagnosis wrong (cerebral malaria is about in these parts) and might actually save a few lives. Problem – well yes, though apparently free not yet available in health centre or indeed a couple of local hospitals which may go some way to explaining why some women have come a long way, apparently passing various treatment centres to be here. A strange and topsy turvey world we live in. What is on offer, curiously is large amounts of free methyl dopa, useful if carefully judged in the chronic situation, but requiring frequent monitoring, which is non existent and to be given in appropriate doses, which by enlarge it is not, effective emergency treatment is just locked away. Sustainability is about training and retraining to understand and react to the problems we encounter in an appropriate and in this case diagnostic or therapeutic way, but in order to do this one requires the tools. The training is shaky but the tools which that training should equip you to use are yet to be put in place.

Those of you who are reading this will realise that you are now on a restricted reading list as the forces of, well I am not sure what, are so upset that what I have said, which has actually gone, and now probably more important what I might say that I am strictured only to allow it to the select few. I am told that I need to reflect on what I say as it is deeply hurtful, which indeed it may be. The hurt equally should probably reflect on why they are hurt as however distorted there is always a grain of truth, but if I have been too negative and hurtful I am of course sorry, but those to whom it has happened will probably no longer get to read this. I am too incompetent to get a link but listen to the words of longer boats cat stephens on you tube!

Corinthian letters

‘And if thou hast not love, thou hast not anything, you are but a sounding brass or tinkling bell’, which is how I think that letter to the Corinthians runs, and is perhaps the epitaph of the departing hospital administrator. Though it could of course equally apply to your correspondent but he at least recognises himself as a ‘sounding off brass’ if nothing else.
So we have the changing of the guard. St Paul after a lengthy if muted send off (we buggered off to Green bar B at 18.30 but it went on to 20.30 with speeches and Ethiopian delicacies) is off back to the good old US of A via Norway and is to be replaced by Austin (of statement beard fame). Austin is now moving into the CEO house next door and will hopefully be adopting the orphan deer. He is now in a partnership with Becky (are you keeping up) the Adventist with strong views on alcohol so we may see some more puritanical changes in these parts. However responsibility has seen the statement beard being replaced by designer stubble and a more normal hair style and my reading of the community is that they look forward to the change. So what will Paul’s epitaph be, given that he was thrown into the lion’s den at a time of crisis and with little experience to deal with it. He has given the hospital a reasonably secure electricity supply which for night time operations is a bonus and he has (for which he is not popular) made big staff changes. Is the hospital a better place for his tenure, on balance yes, it was I believe in dire straits before he arrived. But the delivery of much medical care remains in the hands of the very poorly trained on the dubious grounds that some medical training is better than none, but not realising the reality that it can actually be more dangerous. Certainly there is the handing out of antibiotics in profusion when you do not know what you are treating. The most common medical diagnosis in these parts is pneumonia, that well known chest condition of the tropics. His relationship with our sponsoring organisation remains unhappy and the loss of maternity funding means that the staff remain uncertain in their jobs. His legacy is thus mixed as indeed is the future of the hospital but I suspect, despite protestations to the contrary, the hospital is a little better than its government competitor down the road. He does however irresistibly remind me of Kaa (thanks Karen L.) and if he has a future in the first world he would make a good CEO of a hospital in the U.K. or USA or even an academic administrator. New arrivals include a Dutch missionary doctor (predictably and no they would not listen or read Karen’s wise words on how to do it) his registration is hopelessly bogged down in the Ethiopian administrative system and his wife a midwife who are now housed in the surgeon’s house though eyeing ours. He drank Ethiopian coffee which is a good sign (Adventists do not do coffee I believe) and one hopes that missionary zeal will be tempered with some medical good sense but too early as yet to say. We did not stay long enough at the ‘hail and farewell’ to chat to him and I know not whether we were really missed. Today is an Adventist rest day and yesterday the hymn singing coming from next door was lusty. We were invited to that and temptingly mango ice cream but had to decline as it was unlikely that the invitation included increasingly unwashed orphan boys with remarkably smelly feet whom we were entertaining with spaghetti and spam and tomato source followed by monsters inc. (this was not as much of a hit as Shrek and we only have the trailer to Shrek 2). Even the orphans declined to sit next to Lalisa’s feet and we ended up soaking them in Moulton Brown Shampoo for the whole of the film and the bucket is still pretty nasty and his socks…..information you would rather not know.
Continuing the biblical theme there is a ‘star in the east’ as there is a move to pull out of Gimbie where ‘our work is done’ and head to the pasturalist communities of the east which appear to be poorly provided for despite being a relatively easy commute to Addis so there was a move to follow that star at least by two wise persons if not kings and certainly not the desire of Queens, so off they set on a mission. Star following in the modern parlance is called ‘needs assessment’ and this is what was planned, i.e. a jolly to Awash(beauty spot withnice lodge, waterfalls etc.) and beyond, but was not to be as the appropriate ‘permissions’ had not been obtained, this is after all Ethiopia not Galilee, so the two wise persons are now hold up in Addis, one bored in a grubby hotel and the other on a family visit, their camel master on his per deum in an adventist hostel awaiting the arrival of the angel Gabriel on a flying visit. In terms of nee d there is really no need for an assessment ‘Gold and hold the frankincense and Myrrh’ though the latter two might be useful for the feet round here. In terms of ‘Gold’ well spent a little sad as the trip of star following was ill planned and thus came to naught. Presumably cost of stay in Addis met by charity.
The Angel Gabriel and the bringers of Danegeld in the shape of the Danish team re- arrive next week on a ‘visit’ suspiciously similar to that of the Adventist’ of last week, and were unsurprisingly as communication is not the watch word totally unprepared for the changes. Given that relationships with ‘St Paul’ had reached a record low, that particular meeting was not me thinks on the agenda but now there is a flurry of e mails wanting us to set up getting to know you meetings – Karen as Mary Poppins or the U.N. however the question of course is whether the ‘geld’ will go East or West. We are scheduled in for a meeting on Tuesday evening sans local organiser – paranoid times. Given that most of these meetings revolve around communication (or lack of it) there is little shuttling due.
Gee I am glad we have our car despite the costs and the grief as communication about travel and places in cars etc. reaches all times complexity and yes some have to take the bus and sit in really bad bench seats – all jealousy and bad feeling, and sadly probably unnecessary, yes communication again!
Despite protestations to the contrary there is no doubt to me that the poor and needy of Gimbie and Environs are not being catered for here unless moribund or with 1000 odd birr to spend (and some do, the coffee is picked) as unlike the first few months there is often little activity apart from the multiparous middle classes dropping their sprogs and then sitting around for a couple of days in their private sheets or the occasional nearly dead arriving with some ancient birth fund voucher which seems to get them a nearly free Caesarean section.
For those of you who are following the cancer of the cervix project the word is out and patients are beginning to come in, despite the best efforts of the lower echelons of the hospital to charge them, and despite my writing over the admission slip that the project pays. Equally distressing, the communication gap is such that operable cases with medical problems in which we start treatment (blood pressure tablets) disappear and do not reappear but will probably do so when they are beyond help – with limited funding I am loathe to admit them to the ward for a week. Soon off on a mass screening project so we will see. A difficulty unforeseen is the clinical diagnosis of cancer which I thought would be relatively straight forward but is complicated by such issues as previously undefined and undefinable vaginal surgery and my Ethiopian colleagues desire to operate on every fibroid that comes through the door ,by calling them cancer – sorry but we have limited funds.
So, we live in uncertain times and the forces of political correctness bear as ever down, trying to ensure, that the unpalatable vision of truth is wrapped in soft soap and that no one is ever upset by the vision of the world as maybe it really is.
Here endeth the lesson, but is it teaching or learning?