The Quest for Gondar: Days 1 and 2

Yesterday we left Bahir Dar on a relatively short 170 km drive to Gondar, which is where we’re scheduled to visit Gondar University Hospital. Before leaving Bahir Dar, we drove up to a hill overlooking the entire city, along with the Nile River. It really was a spectacular view. We got some great pictures, and were even able to see some hippos from afar. We were a little disappointed because we couldn’t get close enough to get good pictures. Gondar is a nice little city built into the hills of northern Ethiopia, relatively close to Lake Tana. Apparently Ethiopians have nicknamed it the 51^st state because a lot of people left here for the US in the 1990s. Many of them are coming back here now and building large houses, which we drove by on our way into town. We had a relatively relaxing afternoon and evening, enjoying some food at a local hotel before turning in for the night. Many of the food dishes here have slices of jalapeno in them. I had picked most of them out of my lunch today and had them lying on my plate. Creighton reached over with a toothpick and ate the largest slice, with the most number of seeds, like he was the champion of peppers. He looked fine as he chewed the pepper and swallowed it. However, within seconds his eyes started to water as he realized he’d never faced off with a jalapeno of this magnitude. Unfortunately he’d just finished off his water and had to run to the bathroom with teary eyes to blow his nose. It took him a decent amount of time to recover, but he eventually did. Ethiopian Peppers: 1, Creighton Petty: 0.

Today we visited Gondar University Hospital, which was the nicest hospital we’ve been to so far. It’s also a teaching hospital, so there were many medical, nursing, and midwifery students around. We began the morning by briefly meeting with the Vice Dean of the School of Medicine, before being assigned a guide to take us around to the different units of the hospital. First, we met with staff in the ART Lab. The power was out around the city for most of the morning, which was a substantial problem at the hospital. The workers in the lab were unable to perform any tests without power, and feared blood samples and reagents being stored in the refrigerator may go bad. Apparently power outages at the hospital are near daily occurrences for varying amounts of time. This is definitely a major design constraint for whatever project we choose to pursue. After the lab we spent the rest of the morning in the surgical unit. One of the surgery residents gave us a tour of the facility and answered our many questions. We were then able to view the beginning of a cholecystectomy. The organization and flow within the Operating Room is actually pretty similar to the way things are done at Hopkins. We left mid-surgery to head over to the delivery unit where we were just in time to witness a birth. The delivery went very smoothly as a healthy baby was delivered. The mother was fine as well and we were a little surprised at her nonchalance during labor. She was extremely calm during and after the birth. We didn’t identify many needs, but I’m sure we will during our meeting with the OB/GYN department tomorrow.

After a quick break for lunch we had a meeting with the pediatrics department to kick-off the afternoon. There were many more kids here than at the hospital in Bahir Dar. They were able to point out many needs for us, including shortages of supplies and lack of equipment, specifically oxygen generators. We viewed the neonatal unit as well and were able to present the staff with NeoNatalie, which they were very grateful for.

Our last meeting of the day was in the main testing lab, where we spent almost 2 hours! The lab staff was extremely excited to share all the gaps they’re aware of from their 8 different laboratories. We were able to have some good conversations with them about point-of-care tests that would be extremely beneficial, as well as rapid testing that is not currently available within the laboratories. I think we’ve gathered several very good needs from the time we’ve spent in laboratories in the hospitals we’ve visited. Before we left, the staff had a very interesting question for us. They asked how we could guarantee that any technology we provide to them to solve a problem would not be a short term solution. They were concerned that we will provide them with a technology, and once they change their standard of care and procedures to implement use of this technology, it would somehow not be available to them anymore. We assured them that we are not looking for short term solutions. We are looking for low cost, easy to use, permanent solutions. It is not our intent to implement technology for a short amount of time, and then take it away. We explained to them how our partnerships with Jhpiego and Laerdal provide avenues for manufacturing and distribution of potential solutions to ensure implementation is permanent. It’s actually quite sad to see the hesitation to adapt an improved standard of care for fear that resources may not be available in the very near future.

Overall, it was a great first day of learning and interacting at Gondar University Hospital. We’ll be back there tomorrow morning to meet with the departments we didn’t visit today. In the afternoon we’re hoping to visit a health post, which is the lowest level healthcare facility within Ethiopia’s system. We should be able to define some very good design constraints here.

Ethiopia North: Rest day

Today was a bit of a break for us to go out and experience more of the country. We went on a boat to Lake Tana which is the largest lake in the country. We traveled to two “islands” (one of them was really a peninsula) and we got to walk around and explore a bit. There were some beautiful plants and birds that made it really interesting. On one of the islands, we went to a monestary that they say was built near the beginning of the 14^th century. It had some really interesting paintings and carvings around the outside (we weren’t allowed to go in) and a museum with many old artifacts. It was really interesting. We didn’t see any hippos like we thought we would, but the scenery was great. I still can’t get over how green this country is!

At lunch, I tried something called shiro. They give you a very large piece of ingera and then dump an orange mashed-bean like substance on it and you eat it (like most Ethiopian food) with your fingers by tearing off bits of ingera at a time, and scooping up shiro with it. I enjoyed the flavor, but it started to be a little much after I’d eaten most of it and my stomache acted like it didn’t know what to do with it. It felt a little weird for a bit, but nothing bad.

Then tonight, we decided to go see some African dancing. So we went to a place we were told was good. It was like small bar with chairs and benches lining the outside of the room so the middle was open for people to dance. They was a drum player pumping an African beat as another man played his single stringed violin-like instrument with a horsehair bow and his fingers. Periodically, one of the dancers would blow a horn in beat that produced two pitches, seemingly one from breathing inward and the other from blowing out. I had no idea people could move and shake the way these dancers did! Their shoulders and head could shake and move like they were completely unhinged! Their body would smoothly move with the beat, but their shoulders and head could vibrate and jump all over the place. Or they would jerk themselves around while standing or kneeling on the floor. Within a couple minutes of entering, the violin-like player spoke to us directly and (we found when it was translated to us) said something like “Hello and welcome. We hope you enjoy being here tonight. We will not forget you”, and then continued to play. Soon after, a dancer came up to me and pulled me onto the dance floor. Now I can hardly even dance in the United States much less in an African style! Think of the Tin Woodman from the Wizard of Oz, and you’ll get the idea. But I gave it my best shot. Before long, they pulled Nate on the dance floor too and I’m pretty sure everyone there was watching us. We imitated what we saw them doing (somewhat) and everyone had a lot of fun with it. We had a few people come up to us and show us how to shake our shoulders and dance like they do. After a couple songs we sat down and observed the others. A woman dancer came up to us and starting singing at us, but we had no idea what she was saying. Our friend from Jhpiego, Sarewet, was laughing. “She says ‘I am dancing for you and you don’t do anything. She wants you to give her money on her forehead’.” By the time we figured it out, she’d moved on. I’d seen a couple other people do it, so I pulled out 10 birr and gave it to her next time she came by. We stayed a bit longer and had a great time.

Tomorrow we will be traveling further north to Gondar to visit a university hospital and a health post on Monday and Tuesday.

Team Ethiopia North: Hospital Days 1 and 2

Yesterday and today we got our first taste of life in the hospitals here in Ethiopia. It’s definitely a lot different than what we experienced during the summer at Hopkins, but it was extremely enjoyable and we learned a lot. All of the people are very nice and welcoming. We began by visiting Felege Hiwot Regional Hospital. The structure of hospitals in Ethiopia is as follows:

1)      Specialized Hospitals, of which Black Lion is the only one in the country

2)      Regional Hospitals

3)      District Hospitals

4)      Health Centers, which provide care for patients as well as support 5 health posts within the area

5)      Health Posts, which are run by 2 health extension workers who are responsible for providing basic care to 1000 total families

Within this structure, each level will refer patients up the chain if they aren’t able to provide adequate care or treatment. Upon arrival at Felege Hiwot we met with the CEO of the hospital to explain who we were and what we were doing at his hospital. He was very welcoming and said he expects big things from us in helping them fill some of their gaps. He assigned Sister Yeserash, one of the head nurses, to guide us around the hospital during the day. She proceeded to take us around to all of the units in the hospital to meet the staff and ask questions. The units included antenatal care, vaccination/family planning, pediatrics, neonatal care, general medical care, surgery, and maternal care. Personnel within each unit graciously took time out of their day to allow us to interview them in an effort to identify existing problems, as well as discuss some of the problems we are already aware of. The feedback we received was extremely valuable and everyone seemed to be excited that we were there. It was a joy to see how much the healthcare workers genuinely care for their patients and are actively seeking ways to improve the care they’re able to provide. They really do make the most out of the limited resources they have.

We also had the privilege of visiting the test lab and the pharmacy. The test lab had some relatively modern equipment that allowed for blood chemistry testing as well as hemodynamics. However, there are still many limitations and gaps the staff identified for us. Within the pharmacy the most significant problem seemed to be the expiration of drugs. It was unfortunate to hear that a lot of the drugs that are donated to the hospital are near their expiration date at the time of donation and expire before they ever reach the hospital. There is commonly a shortage of potent antibiotics and even things that seem simple in the US, such as saline, are in great demand here. The day was definitely an eye-opening experience. After hours of interviews (our translator, Sarowit, must have been exhausted from talking so much) we headed back to the hotel for some food and much needed rest.

During our second day at Felege Hiwot we were hoping to view some surgeries and deliveries since we had spent all of the previous day speaking with the hospital staff. Unfortunately, the hospital preferred that we did not observe these things. We were a little disappointed, but found other ways to stay busy. We hiked back behind the hospital and viewed the incinerator and the way medical waste is currently segregated and disposed of. The hospital is currently in the process of building a new incinerator, which is nearing completion. We also had the opportunity to observe a BEmONC (Basic Emergency Obstetric and Neonatal Care) training course being funded by Jhpiego at the hospital. The course is taken by nurses and midwives from health facilities throughout the region. The training consists of 3 weeks of classroom learning and simulated labor situations. We were able to meet with the trainers, who provided us with some additional needs specific to the training as well as general care. A picture of the training is posted below.

Before leaving we went back to pediatric unit and handed out some toys that we had brought from home. This was definitely the best part of the day. At first the children were a little shy and unsure of why the Ferench (what they call white people) were there. However, they quickly warmed up to us as we started handing out mirrors, squishy balls, frogs and coloring books. The kids and their families were anxious to pose with us and their new toys for pictures. 

They love to look at the pictures on the camera because they think they’re on tv. We said our goodbyes and thanked everyone who’d helped us at the hospital before heading out.

In the afternoon we went to the Merawi Health Center, which is about 30 minutes outside of Bahir Dar. This is two levels down from Felege Hiwot within the Ethiopian health system. We showed up unannounced, hoping we would be allowed to observe some things, and we were welcomed with open arms. The doctors and nurses at the center spent a couple of hours guiding us to various units of the center as we peppered them with questions (Sarowit continues to be our hero as a translator) and took pictures. It was interesting to compare the center with a regional hospital because the capabilities and resources are even more limited. Some of our needs are beginning to come into clear view across all levels of the health system here. At the end of our time at Merawi we presented the staff with a couple of the penguins and they were very excited and thankful.

We’re continuing to learn new things as well as gain a depth of understanding of some of the problems we have already identified. This is such an incredible experience! I apologize for the semi-long blog entry, but a lot has happened over the last 2 days. We have tomorrow off and hope to do some sightseeing on Lake Tana. Hopefully we’ll have some good pictures to post. Stay tuned!

Team Ethiopia South: Yirgalem Hospital (Thurs and Fri)

On Thursday, we headed further south to Yirgalem hospital and again saw a lot of rural scenery on our way. We arrived at the hospital and it was of course different than what we’re used to—lots of open-air passageways linking several buildings, with people crowded around outside the buildings waiting. Some people were lying on stretchers made of canvas tied over the top of a recycled metal frame. We started out sitting down with the hospital manager, a doctor, an environmental engineer and a couple of biomedical technicians to explain our mission. After we showed them the examples of projects last year and explained our goals, they had a whole list of issues to tell us about. A lot of the issues center on existing donated equipment that isn’t working and they don’t have the parts or service support to repair it. Yodit did a great job of helping to explain that we were there to look for ideas for new medical inventions and I know we will help a lot of developing hospitals in the long-run, but I still couldn’t help wishing I were also a device technician who could go around and fix at least some of the literally dozens of malfunctioning equipments they have. After that extremely useful overview meeting, we visited the eye clinic and talked with them about the exams, glaucoma surgeries, and cataract surgeries they perform. We learned all the eyeglasses frames and lenses are donated from an organization in Germany, and the Yirgalem clinic re-shapes the closest available combo of lenses to fit into a frame. Interestingly, the eye surgery team also travels out to health centers 10 days out of every month to perform cataract surgeries on more rural patients. They have to pack up a bunch of equipment that’s not really designed to be mobile and take it with them… Their microscope for doing the surgeries has a malfunctioning light, so they have to use an external light source to illuminate the eye from the side, which I think would make the surgery a lot more difficult. The clinicians were extremely knowledgeable and I really admire the level of skill they must have to be able to do procedures with far less than optimal equipment and conditions.

We also visited the waste disposal area to see the incinerator and waste pit. We got to talk with the laboratory about lots of different tests that they do, and had a really long visit in the labor and delivery ward, although there were not any active labors going on. Finally, we visited the ACT center for managing HIV patients before calling it a day.

It was a bit overwhelming not only to see the contrast in the facilities compared to what we’re accustomed to, but also to hear so many issues from the clinicians about their equipment and other resources. There are so many things that need to be tackled… And I wish there were a way to give them a more immediate improvement to their everyday work. It’s going to be a challenge choosing the biggest problems… It’s only been my first day of actually being in a hospital and already I wish we were choosing more than 4 projects for the developing world.

Today (Friday) we were back at the hospital to visit more areas. We talked with people and observed in the ER, x-ray room, maintenance/repair room, laundry room, children’s ward, delivery recovery room, and the operating room. We watched a hysterectomy being performed and got to talk to the surgeon afterwards. He made a very good point about them not needing the “best” or “latest” equipment, but just needing simple stuff that doesn’t break! The biggest issue that seems to be facing the hospital is equipment that breaks down and doesn’t have parts/support for repair. In the maintenance area, we also learned that the only available defibrillator was not working. The ER was also interesting: We learned they have one ambulance to bring people from as far as about an hour away, and the ER staff deals with whatever emergency comes in the door, but the only equipment they had were a BP machine, stethoscope, meds and suturing supplies.

Team Ethiopia South: Travel to Awasa (Wed.)

On Wednesday Luccie and I traveled south from Addis down to the city of Awasa. The drive took several hours and we really enjoyed the scenery on the trip… Around the Addis area, there were a lot of seemingly abandoned construction projects going on with rickety-looking scaffolding built from raw tree branches. There were tin houses and shops alternating with frequent decorative orthodox Christian churches and Muslim mosques. As the city slipped away, grassy meadows with dramatic hills in the background appeared. There were more and more donkey-drawn carts on the road, and the clusters of tin houses became fewer and farther between. I dozed off briefly a couple of hours into the drive, and when I awoke, my first thought was whoa, I’m in the African Savannah! The gray morning had transformed into a sunny day; there were patches of dirt fields surrounded by grassy plains as far as I could see, and huge trees that spread into flat far-reaching branches dotted the landscape. Occasionally someone would be walking along the street with a few cattle or there would be people laboring over hay or other crops planted alongside the road in the good old fashioned way. I think mostly because it was so flat and the views so far-reaching, it really seemed like we were in the middle of nowhere. There were traditional huts with mud walls and straw-thatched roofs. Some people had painted random murals on the outside of the muddy walls that look pretty cool and most certainly African! As we got closer to Awasa, the drier dirt transitioned to a greener landscape full of more large-leaved palm-type trees and other more lush vegetation. Jagged hills once again appeared on the horizon. We had our first wildlife sighting of HORNBILLS, and when we stopped to get photos of the birds, we also drew some attention from cute curious kids!

We arrived in Awasa and found it to be a cleaner and either newer or more up-kept city compared to Addis. We settled into our hotel before our Jhpiego leader Yodit met up with us. Yodit might be the coolest person ever—She is really easy to talk to and extremely knowledgeable and also fun! She showed us around the area a bit, including Awasa lake, where we may have accidentally found ourselves on a boat ride and may have spotted hippopotamuses… There were also a couple different kinds of monkeys and some huge ugly birds around the lake. Yodit took us to a traditional Ethiopian coffee ceremony as well and told us lots of interesting facts about the country before leaving us to rest up for our first big hospital day.

Team Ethiopia North Drive to Bahir Dar

This morning at about 6:00 am, our friend Sarewit from Jhpeigo picked up Nate and I (Creighton) from our hotel and started our 650 km drive north to Bahir Dar. Luccie and Lauren went south to Hawassa. I thought I would sleep during most of the drive, but I hardly slept at all. It was fascinating! The country side is very different from the city. About 84% of the 82 million people in Ethiopia live outside urban areas. Just over 4 million live in Addis Ababa, and only 260,000 in the next largest city Mek'ele. So it’s clear the great majority of people live in rural areas. And that's what we saw today; a bit of that rural life. Ethiopia is a very beautiful country. It is very green and there are endless fields of crops and tilled dirt. In many ways, it was like stepping back in time and watching people farm in the 1800s. Their plows were pulled by donkeys and composed of tree branches that were tied or nailed together in such a way that a branch dug down into the dirt as the donkey walked. And there were a lot of farmers working in those fields! We also saw all kinds of natural formations, plant life, and animal life including amazing views from cliff sides, red rock cliffs, Acacia trees, tons of various livestock, children with whips, and other towns on the way. But there were definitely two highlights: 1) TONS of Baboons hanging out in the middle of the road that wouldn't move until we were practically running them over and 2) the longest river in the world: the Nile river. It was amazing! But equally interesting was the conversation we had with Sarewit and Berhanu. We've had an excellent overview of the health care system by Jhpiego over the last couple days, and today we had a firsthand description of the country's history, current status, customs, language, pop culture, and interesting facts. A few highlights were:

-The detailed lesson of the language's alphabet and grammar structure. By the end I could partially sound/spell out Amheric words

-A description of the civil war struggle to overthrow the previous socialist government from a man who experienced it all

-Information about their 13 month calendar which is currently set on the year 2003

-And information about Lucy (the 3.2 million year old pre-human fossil) and old churches constructed from a single stones

Now that we’ve had a good overview of the health, history, and culture of the people here, we’re even more excited to visit the health posts and health centers that provide basic care to the people in rural areas. These facilities reach out to the greatest number of people and could be an excellent source for innovative ideas to help the most people possible. We’ll keep you posted on our experiences…

Day 2 at Jhpiego, Plus a Shopping Experience!

Today was our second day at Jhpiego's office, and it was just as informative as day 1. We started the day off by discussing the Standards Based Management program Jhpiego has implemented in many hospitals around the country. The program works by training healthcare providers on various quality standards, including Prevention of Maternal to Child Transmission (PMTCT) of HIV and maternal and child healthcare. The hospitals are then responsible for becoming compliant with the quality standards that have been implemented. Some of the more difficult quality standards for hospitals to comply with were presented to us, which should give us some more areas to focus on when we're out in the field. Following this meeting we met with the maternal and child healthcare team, who we had MANY questions for. We were able to have a very detailed discussion around some of the pre-defined needs we have, as well as some of the new needs we've already identified from our discussions with Jhpiego's staff. I think all of our meetings have really prepared us for what we're going to see over the next several weeks.

We had the afternoon free, so we had the pleasure of going to Marcado, which is the largest market in Africa. I have no idea what the actual size is, but it was enormous. Taktek, our guide from Jhpiego, was great at showing us around the market and making sure we were safe and well informed about the extensive cultural aspects of Marcado. We were able to see a tent where Jhpiego offers free HIV testing for people as they shop, which we thought was a great idea. The atmosphere itself was madness, which I think is the best way to put it. There were goats running around the streets, donkeys carrying supplies, people selling everything imaginable, and cars nearly running over pedestrians around every corner. It was quite entertaining for all of us. We captured some of the images from our experience.

We also got the opportunity to haggle for some souvenirs, which is always an interesting experience. After Marcado we ate a quick dinner and turned in for the night. Creighton and I have a nice little 9 hour drive north to Bahir Dar tomorrow, and Luccie and Lauren are driving south to Hawassa. We're not sure how the internet situation will be in those locations, but we'll attempt to keep our blog updated.