Medical Mission in Ethiopia: Week 10

January 25, 2015 Kristen A. Austin

January 25, 2015

I am a bit behind in my blog.  Life has all of a sudden become rather busy.  In the span of a couple weeks we experienced Ethiopian Christmas, a funeral for a beloved surgery professor and the three day festival of Timkat or Epiphany.  This alone would have kept us busy, but the hospital has had a flurry of events as well.  The fourth year medical students have started their clinical rotations in obstetrics/gynecology, the chief of the department took a one month personal leave, the most senior obstetrician started his six month sabbatical (they are given six month sabbaticals every 7 years), and the third attending went to Kenya for a week-long colposcopy course. That would have left me as the only attending obstetrician gynecologist physician in the hospital.  Fortunately, a new attending started this week.  This tidbit of information was shared with me the day before he started. This new Dr Yeshiwas is a very kind person.  He is one year out of residency in Addis Ababa, and spent his first year of practice trying to make a little money by working in a rural hospital as the first and only obstetrician at that hospital.  He is originally from Gondar, his family is here, he completed all of his undergraduate training here, and he wanted to come back.  So Yeshiwas and I were in charge of the OB/GYN department for a week.  It honestly felt quite nice.  Amusingly, I had to sign a few documents written in Amharic, which were then ceremoniously stamped three times before being submitted.  I have no idea what I was signing, and there were pangs of guilt that ran through me as I vividly remembered my dad drilling into me that I should never sign anything that I had not read.  But I can’t read Amharic with all of its funny symbols, and I trusted the chief resident, Chernet.  He told me I was signing the cover letter for the residents’ monthly salary records.  I had to sign some other documents that listed all of the residents’ names, so at least it seemed to make logical sense.

Over the past couple of months I seem to have acquired some projects that are starting to take hold.  One is the cervical cancer screening program at the hospital.  The other is the evaluation of referral practices between local health centers and the hospital.  I have tried to combine these projects for several reasons, the primary one being that I only have one of me, so combining projects seems easier than splitting me.  After the last month of planning, the two chief residents, Drs. Chernet and Tadesse, the Gyn GP, Dr. Semenawit, and I set out to visit some clinics.   The trips have been some of the happiest moments of my time at Gondar Hospital.  These three resident doctors are truly special people.  We have shared many a laugh, many a frustrated expletive, personal jibing, some of our hopes and angsts.

These visits offered the awesome experience of watching the student become the professor.   Dr. Semenawit taught cervical cancer screening to the health care providers from these health centers.   We are in a low tech world in these clinics, so our teaching materials consist of a permanent marker and large flip charts.  Most of the residents have very nice Samsung smart phones with good photo optics.  Dr. Semenawit is no exception.  She has been taking photos of her VIA cases (with no names or patient identifiers) on her phone, and now has a set of visual aides to assist during her presentations.  It has been amazingly satisfying to see her do so well, to command the attention of these health care workers, some more than twice her age.

After Dr. Semenawit finished her presentation and question/answer session, the four of us started interviewing the health care providers about the referral process.  While creating this questionnaire I tried to remember the organization development models Mark and I were taught during our College for Congregational Development courses.  I think I remembered some things, because the responses have been interesting, and not what I expected.  There is one section titled, “Trust.”  The first four questions require scaled responses, 1 through 6.  The last question is open ended, “What could the hospital do to improve trust?”  These responses have been the most interesting to me, because the answers have nothing to do with improving technology, fixing the equipment, adding more subspecialties or teaching the physicians more advanced skills.  Developing world or developed world, my hunch is that the answer to this question may be the same, be kind.

We started by going to two local clinics in the town of Gondar and to two rural clinics, each about an hour drive from Gondar.  Ato Mubratu, the hospital administrator, supported our project and helped us by facilitating the acquisition of a formal letter of introduction (complete with its three official stamps) and transportation for the rural clinics.  Neither letter nor transportation were easy acquisitions.  It seems that these three official stamps always need to come from three different people in different parts of the campus, if not town.  I would be lying if I said there were not a fair amount of frustration during this process.  Yes, I was frustrated, but honestly, I think the Habesha (native Ethiopians) were even more frustrated.  I may feel frustrated at times, but I am also continuously fascinated by the process.  There were several times that I felt like the cheerleader, trying to encourage those around me that we can still accomplish something, despite to system.  Fortunately, the visits have been satisfying for all four of us.  The health care workers at the clinics have been extremely receptive and engaged.  And so the visits themselves have become therapeutic for the visitors.

My idea was to visit four or five clinics, teach VIA and interview the care workers about the referral process.  I then planned to arrange all of the data we collected and present it to the department.  I would like the department to do the evaluation part and decide what type of intervention we could do to improve this system.  The “data arranging” seems to be the current step.  Somehow, interviewing and collecting the information seems much more interesting than arranging data.  My Excel skills are not nearly as refined as Swedish OB/GYN clinic administrator, Joni Farris.   Oh, how I wish for a Joni Farris here.  The thought has often occurred to me that Ethiopia should be spending more time training clinic administrators to actually improve the health care system here.  Training us doctors is all fine and dandy, but we can’t do anything with even remote efficiency without someone organizing our work lives for us.  Alas, there is no Joni Farris, and I will attempt to arrange the data in some semblance of an organized fashion.

This next step is somewhat crucial, as several folks have all of a sudden become very interested in what we are doing.  Last week I met with the CEO to try and arrange one final transportation visit to our fifth clinic.  It turns out he was not aware of this project, and thought he should be aware.  He also had heard the University and Hospital had just received $100,000.00 donation to work on cervical cancer screening which may be able to be used for our project.  Well, this sounded great, only I had not heard of any money destined to support cervical cancer screening.   “Great!” I said, “So where is the money and how do I access it?”  He wasn’t exactly sure, so suggested I speak to the Dean of Medicine.  Now I suddenly had another project…find out the whereabouts of this donation and how to access it.  I started with the Dean of the School of Medicine, who suggested I speak to the Director of Public Health, who promptly scheduled a meeting for me to inform the Director of Outreach about the cervical cancer screening projects at the hospital.  Well, a week later has passed, we have had a couple of meetings and now the Director of Outreach has information for the Poster that the hospital is required to submit at the Ethiopian National conference on Cervical Cancer next month.   The $100,000?  That was for one of the research projects that involves testing a new cervical cancer protein in the form of a Q-tip swab kit.  It has been decided that teaching screening and treatment to residents at the hospital and teaching screening to health care providers in local health centers falls under “clinical care” and not research.  Research money should be kept for research.  However, the director of Public Health likes the idea of expanding preventive medicine and has vowed to help us with transportation.

In the meantime, the fourth year medical students have started their OB/GYN rotation, all 114 of them.  Another 120 have started their pediatric rotations.  Both the OB/GYN and Pediatric students attend lectures together.  I had been assigned a few 2-hour lectures in February and March.  However, as I mentioned earlier, the three other attendings who had been assigned lectures last week were not here.  It was a bit confusing, because one of the three actually made the schedule, and another was physically in Gondar and planning to do lectures while on sabbatical.  It was completely unclear whether or not they planned to complete their assigned lectures.  Several emails and texts questioning the lecture schedule were sent.  I have not given a formal lecture to 234 medical students in a fairly long time, or rather, ever.  As the medical students’ first day approached this ‘ole thing called “anxiety” started to make its’ home in my head.  Crimminy!  The obvious became clearer, I would be giving the first lectures.  I started gathering the basic science material needed to describe “The Normal Menstrual Cycle” and “Menstrual Disorders.”  These were the titles of the lectures I was to give.  No outline, no list of topics to cover within the lectures, just the lecture titles.  Complete freedom, I guess.  A day before the first lecture was scheduled I did receive a message from one of the other attendings suggesting I give the first lecture if I were prepared.
It went better than I expected, although I flew through my 84 slides in about 70 minutes.  For some reason it is difficult to admit that I like standing in front of a couple hundred people and telling them what I know.  There is an inner voice that keeps saying, “You are shy, you should not enjoy speaking in front of people.”  That inner voice is wrong.  Lecturing is performing on stage.  Performing is testing the audience to see if they will react.  Hmmmm.  This sounds a bit like an older sister trialing her little brother.  Perhaps my little brother deserves a delayed “Thank you for the practice.”  When I asked an outgoing medical student for some feedback he said, “Very nice, but a bit short.”  After the 70 minute monologue I needed a glass of water, but I guess the medical students were prepared to listen for a while longer.

During this flurry of activity at work we also experienced the holiday season in Gondar.  This started with a lovely Christmas at Semenawit’s home.  She invited us for Christmas dinner, homemade Tibes and Doro Wat.  Her mother didn’t think Semenawit would be able to prepare dinner all by herself, so mom helped out.  Wow.  Homemade rocks, man.  I took a picture of the Tibes, and that picture keeps showing up on my computer’s rotating picture program.  Every time it does, my mouth starts to water and my tummy starts to rumble.  Yum.  After an amazing dinner complete with popcorn and a coffee ceremony, Mark went back to work and the rest of us headed to the Piazza.  There was an art, food and cultural dance festival at the main square.  Sonja and I admired some traditional dresses, but nothing fit.  People were gathered with their families, buying and bargaining.  Traditional dancers sang and danced on the stage.  Semenawit’s mother had a booth selling the traditional “Tej” or honey wine.  We completed the day by meeting a few other foreigngees we had met the previous week for drinks.

Christmas was very nice in Gondar.  Even so, there was a sense of sobriety that hung on the town.  Word had spread quickly that a beloved surgery professor died on Christmas Eve.  Bernard Andersen died back in the U.S., but had only just left Gondar Hospital four months earlier to be treated for pancreatic cancer.  “He was so kind.”  “He was a wonderful man.”  “He cared.”  “He was kind.” “He would take time with you, no matter who you were.” These are the words that were repeated.  “Dr. Bernard would take out the garbage at the end of a surgery case, can you imagine?”  “Dr. Bernard was one of those people who cared about each individual, if a patient could not pay for his or her surgery, he would pay for it himself.  He didn’t worry about money or himself.  That is such a rare characteristic…most of us are concerned about making money, advancing in our careers, trying to do  better for ourselves,” said the previous CEO, “he was incredible.” One intern told me about the time he met Dr. Bernard.  He was doing bedside rounds with about 20 medical students, and one of the medical students asked “a silly question, I mean a very silly question.  Most seniors would scold the student and tell him he should read more.  But Dr. Bernard did not.  He started with the very basics, he started at the beginning.  And then he explained.  The way he did this was so kind.  It made me excited to learn again.”  There is that word “kind” again.  I heard a few stories about what a fantastic surgeon he was, and that he taught many surgeons to do complicated surgeries, such as the Whipple procedure, the same surgery he eventually had himself.   He is remembered, though, for his kindness.

Dr. Bernard was born in Jamaica and spent most of his life in the U.S.  He was an American.  He spent the last ten years of his life volunteering at Gondar hospital.  Per his request, his body was brought back to Gondar.  It was two days after Christmas.  We had initially planned to do a clinic visit this day, but the residents wanted to be present when Dr. Bernard’s body returned.  They wanted to greet him once more.  Communication does happen here, by word of mouth.  Surgery residents told OB/GYN  residents, who told me that his body was to arrive around 9:00 am.

Around 9:00 people started gathering.  Black strips of fabric appeared and were tied around the left arm of our white lab coats.  Nurses, residents, interns, seniors, medical students, all in their white lab coats and black arm bands.  Slowly these white lab coats with their black arm bands made their way to the main road in front of the hospital.  In about an hour, both sides of the road were lined with white lab coats, solemnly waiting.  Absent was the usual chit-chat that often accompanies waiting crowds.  The silence was serene.  Locals started to gather along the roadside hill, watching, again, mostly silent.  The waiting continued in the intense sun.  I moved to the shade.  And then, a car with its lights on appeared from around the corner.  This car was followed by a few other cars with their lights on.  And then a pickup with four priests standing in the bed, decorated umbrellas over their heads leading a black extended SUV, flowers on the trunk, banner on the side.  This car stopped at the main gates and a woman draped in a black shawl opened the door, slowly stepped onto the pavement, looked around her, and then wailed.
She put her hands into the air then to her face and then back in the air. Deliberately she stepped one foot in front of the other as she faced the crowd and made her way around the black SUV, all the time wailing.  I looked around me.  Tears were streaming down the faces of men and women.  Then my view became blurry, and I tasted a salty trickle that made it to the corner of my mouth.

The car in front of the priests had a loud speaker rigged to the roof.  In Amharic a man started speaking.  He gave a synopsis of Dr. Bernard’s life, much of his career spent at Howard University.  Only ten years of his life were spent at Gondar.  He was not born here.  He didn’t die here.  But this is where he chose to be laid to rest.

The full funeral ceremony took place on Saturday.  We first gathered at an amphitheater close to the hospital.  There was traditional chanting by priests, what appeared to be nuns chanted and danced in a circular pattern.  Rural Habesha assembled with their (empty) rifles and danced.  Interns in their white coats and black arm bands carried palms with banners attached.  There were some decorated horses that also appeared, and were led around the circular pattern I assumed was the stage area.  During this time I watched, and then moved to the shade.  A young man stood next to me in the shaded area and asked if I knew Dr. Bernard.  “No, but I feel as though I want to give my support to those who did.  Did you know him?”  I asked.  He did know him, as an artist.  Dr. Bernard and he would recite poetry together.  He also helped to start an Artists’ Society with Dr. Bernard.  He showed me smart phone photos of some of Dr. Bernard’s paintings and sketches.  The poet practiced law, and wrote poetry for pleasure.  Later he introduced me to another artist, this one a sculptor and painter.  He had created a beautiful tombstone for Dr. Bernard’s standard poodle as well as other beautiful sculptures.

The funeral eventually processed up to a beautiful church on a hillside above the hospital.  The setting was stunning.   Quiet, large trees surrounded this church.  Dr. Bernard’s casket sat in front of the church and the priests started singing and chanting again.  They used their great big drums and jingled their trinity rattles for about 45 minutes.  This was followed by several speeches, and fortunately two poetry recitations.    I say fortunately, because this was all in Amharic.   At least poetry is interesting to listen to even if you don’t understand the meaning of the words.  2 ½ hours later we processed out of the church grounds.

In two short weeks we experienced Christmas, a funeral, and then Timkat.   Timkat is Epiphany.  And for those of you who don’t know, Epiphany is celebrating Jesus Christ’s baptism.  To symbolize this remembrance, all of the churches in Gondar convey their embodiment of the Ark of the Covenant down to Fascilide’s Baths where there is an enormous service, and then they are dipped in the water to relive the baptism.  That is the religious synopsis of Timkat.  In actuality it is a three day party with a little religion sprinkled in for good measure.  I have never been to Carnival, but I imagine it is similar in spirit.   Have I mentioned the exuberance of the African peoples?  They don’t have much in terms of material goods, but man do they know how to express themselves and party.  Gondar has a reputation for being THE place to be on Timkat.  For months and weeks leading up to Timkat we noticed several official buildings receiving new coats of paint.   A roundabout was fixed 2 days before Timkat.  And the police presence increased threefold.  The kids have only had one official day off since school started, that was Christmas day.  They had a four day weekend off for Timkat.

The first day of Timkat involved watching and being a part of the great procession down to Fascilide’s Baths.   We watched church congregations with floats, decorated priests, and singing parishioners jubilantly make their way.  This took hours.  After the main crowd (thousands of people) had passed Josh and I were interviewed by the AP, the Associated Press.  Josh does better without a script.  Maybe they will use him in their video.

Police officers were everywhere, and warned us to keep our backpacks in front of us.  They told us about the pickpockets who were also celebrating with us.  Little Gondar town was not so little for these three days.  Despite their warnings, I managed to lose about 1000 Birr ($50) on the second day of Timkat.  But at least I only lost money.  I heard of many others who lost cell phones, wallets, cameras.  Other than that unfortunate event, the second day of Timkat was quite special.  We arrived at 6am to an already crowded Fascilide’s Baths.  It was dark.  Candles were being sold for 1 Birr each (5 cents) outside the baths, so all you could see were hundreds of people dressed in white and walking with their lit candles.  The priests were singing.  People answered the prayers in unison.  It was stunning.

We stood with the Habesha, the local people, for a few hours.  Mark, Sonja and I did not push our way into the stands with the other foreigners.  This meant that we could not see the ceremony, at all.  I spoke to one local person who said he had come for years, always hoping to see the ceremony.  This falls in line with the Ethiopian sense of hospitality.  We have been to people’s homes and been offered a Coke or Mirinda soda, when that person’s daily income could only afford one Coke per week.  Foreigners, especially white foreigners, were ushered up the crowded eucalyptus scaffolding stands.  Habesha were literally dragged off the stands.  The police used sticks and wooden hooks to keep order.  Sometimes this meant beating down people who were trying to climb over walls and up the underside of the scaffoldings.  Sometimes it meant hooking a person around their neck to pull them back.   Josh wiggled his way forward, and being white, the police allowed him through.  I passed him my camera and he took pictures of that which we could not see.  His pictures showed priests lining the baths jingling their trinity rattles and drummers with their decorated drums.  At some point a flaming stick was thrown into the baths, then people started jumping in.  The foreigners quickly left and made way for the Habesha.  Soon Habesha were pushing their way over and through the entrances to the baths.  Swarms of people just crushed their way into the baths.  We swarmed with them, holding hands, caught a glimpse of the baths, and then made our way out.  We all agreed that we had had enough for our second day of Timkat.  There was more singing and partying, but our family is a bunch of introverts, and we had had enough people stimulation.
On the third day of Timkat I went back to work in the morning and then ventured with Mark and the kids to the main square, the Piazza.   Here we sat atop a stone wall with a calmer crowd and observed the mayhem masses below.  People still dressed in traditional clothes walked about.  Groups of young boys ran around singing and chanting, waving sticks into the air.  Eventually the church floats, processing priests, and singing and dancing congregations made their way back through the square bringing the Arks to their home churches.  After the floats passed, the throngs of people slowly dispersed.  Sonja and I made our way to a pre-determined meeting point.  Mark and Josh had entered the masses a bit earlier.  Ethiotel gave us the friendly message that “the network is busy, please try later” when we attempted our cell phones.  The meeting place was a little caf�.  After a cold soft drink and a piece of cake Sonja and I decided that Mark and Josh had found their own way.  We were lucky to find a bajaj who didn’t overcharge us on this holiday to bring us home.

And thus ended Timkat, the three day party with a little religion sprinkled in for good measure.

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