- Never again would doctors be involved in carrying water to the hospital or in arranging for it to be carried as this was a government responsibility.
- No auto transfusion would be used unless a modern cell saver were used (of course there were none in Ethiopia!) as the country was not a ‘banana republic’.
Standards of nursing care, vary from place to place. I have sympathy for people in developing countries. Trained personnel are few; wages are low; materials are in short supply; sometimes patients personal habits are fairly low by the standards of those who have everything at their fingertips. Looking up Mr Google, the poverty line in Australia is said to be just under AUD67,000 annually. The wage of a newly graduated surgeon in Ethiopia is about AUD 500 per month. A house worker gets about AUD 50 per month.
I remember several events very clearly from my first few months in Ethiopia. I wanted to look down a patient’s throat, so I put my hand under his chin to lift it for me to inspect the inside of his mouth. He spat a glob of juicy purulent spit into my hand. Rather shocked I went out and washed my hand before coming back and trying again with the same result. It was the custom with no handkerchiefs, if you were sick a relative or friend took your sputum and wiped it somewhere, often on the wall. No wonder our walls looked like they did. But I learnt a cultural and very practical lesson.
When a second doctor joined me we made a combined effort to get the floors cleaned up. There was a layer, several, maybe five, mms thick of hard dirt ground into the floor. We got no response, until one day, walking through the ward, I accidentally put my foot in a ‘paw-paw’, their name for a bedpan. You will understand why now I never eat the fruit ‘pawpaw’. I enjoy Papaya, however.
But it made me mad. So I got the other doctor onside and, down on our knees with scrubbing brushes, we dealt with the floors of our 35 bed general hospital. I think it embarrassed the other staff as it was much cleaner after that. They talk about leading by example!
I remember a day when a new young worker was in the ward while I was doing my morning round. I was told that he had been employed as an assistant to the nurse. He seemed an affable chap. The next day he wasn’t there so I asked what had happened. There had been a patient with an IV Drip running and a tube into his stomach draining the contents as his intestines weren’t working. Without the drain he had kept vomiting. The new guy had been told that he was just to watch and learn for the first week or so. The nurse went for lunch and, on returning, was told that this patient had died. Apparently during the morning the new worker had seen someone put up another bag of IV fluid. Not content to wait , when this patient’s IV ran out, he took the gastric drainage bag and ran it into his IV line – with fatal results. What a tragedy.
I had two experiences at another hospital, which made me realise that I came from a different world. The first was when we had a Hong Kong anaesthetist for 2 weeks with me. We had got to know each other working in Australia and he came during his holidays to help me. He was an excellent anaesthesiologist. A man came in having been beaten and speared after committing a heinous act. We operated and I felt that we had everything under control, in fact, I expected a quick, complete recovery. Late in the evening I had a visit from my friend saying that he had just been to see the chap and everything was stable. The next morning he was dead. We couldn’t think of any reason why until I heard a worker say that he didn’t deserve to live, and I remembered hearing staff murmuring when he was admitted that he wasn’t worth the effort of operating on him. Judge nurse, I think had the final say.
Later I had a lady who with an obstructed labour had lost the baby, her uterus, her bladder, and needed a colostomy for bowel control. She survived after I did a colostomy and a very simple thing to drain her urine. When it appeared as if she would recover I created a new bladder out of intestine. On about the tenth day postoperative everything was going well and I took a two day trip to Addis. When I came back I went to see her and she wasn’t in the ward. They were honest enough to say that they thought that no woman in Ethiopia should live with that set up like that. So they had taken the opportunity of my absence to take everything out and send her home to die. Maybe they knew better than me, but it was hard to take.
We had many more good, rather than bad, results!
I have a friend, an African friend, who did his medical training in Russia. I don’t think that he is a liar. He told me that when he was there, not infrequently, as he walked on the streets, he would feel people checking his lower back to see if he had a vestigial monkey tail. I have not checked for myself, but I know that he has an excellent brain! You probably think that in the twenty first century this behaviour is unbelievable. And yet almost all educators of today are teaching that we have come from monkeys. So why not test the theory?
You probably know the story of the little girl who asked her mother where humans came from and got the ‘God story’. She later asked her father the same question and was given the ‘monkey story’. At the evening meal she accused someone of lying to her. Her mother replied that she had given her the story of her, the mother’s, own family, and that the father had given the story of his family. He was dumbfounded! The child seemed satisfied.
This coronavirus affair has I’m sure made us all question the way it has been handled. That is not to say that we’re complaining at what has been organised, but we would be dumb domesticated animals if it didn’t make us think, and ask questions like..
- How many have died of other viral illnesses, during the same period? And maybe, how many have died unnecessarily of other non-treated diseases?
- Why can you have an abortion but not meet your ageing parent in a home?
- Why are the suicide, domestic violence rates, and incidence of mental illness climbing?
- Are we living in a runaway world?
- What will happen to my family if I die?
- What’ll happen to me if I die?
The list could go on for a lot longer and maybe your questions differ from mine.
When I was a Surgical Registrar in the 1960s I saw the film ‘Lord of the flies’. It was not based on a true story, but graphically pictured how a group of higher class youngsters from England gravitated into selfishness, murder and cannibalism when marooned, for roughly a year, on a deserted island. Just recently I have read an apparently true report of six Tongan boys who to escape the rigours of a strict school, stole a boat and paddled towards New Zealand. They coped by cooperating. They were marooned for more than a year on a deserted island, until they were found by a fisherman. This without doubt is at its root a true story. The recent report about this event leads the author to suggest that whereas the theory of the imaged book highlights the weakness of human character, the truth of the true story is that people are really basically good. And our basic goodness should be highlighted.
Compare how Australians pull together during bushfires versus why do Australians light bushfires and steal from what is left? How do we balance the generosity of the government when they want cooperation, with their usual treatment of some segments of needy society? Why do some blossom in community service at times like we are going through, and others crash into terrible attitudes and situations as mentioned above? Is there truly good and evil in the world? Should our goals be self-centered, financial, comfort seeking or maybe “goodness and truth”? The eternal question – why am I here?
The SAD One
When I returned to Ethiopia in the 90’s I had the ‘run-around’! I went with all the paperwork settled by both ends to become Associate Professor at the Black Lion (the large University) Hospital. The paperwork was not enough for a newly inducted set of hierarchy. So I was allocated as ‘Head of the Department’ at the soon to be opened Kidus Paulos Hospital (St Paul’s). Before it opened I was twice demoted to become another surgeon on the second surgical department in that hospital. In addition I was employed by the University on a contract – to be paid a salary, which was not exorbitant but livable. The contract was made in Ethiopian birr when the US dollar bought 2 Ethiopian birr. Within weeks without warning US$1 equalled 6 birr. At the moment it is nearly US$=30 birr. So my wage was effectively reduced by two thirds. I was still paid at the two birr level! Then the Kidus Paulos was slow in opening.
After pleading negotiations I was permitted to work at the Menelik II Hospital until Kidus Paulos opened. But I was paid from the Yekatit Asara Hulet hospital. Which brings us to “The Sad Memory” mentioned above.
Yekatit is a month of the Ethiopian Calendar. Asara hulet is the number twelve. (February 19th in our calendar – our calendars don’t match.) So why is that a sad memory? It is quite a story….
During their occupancy of Ethiopia 1936-41, the Italians had apparently built a huge poison chemical factory near Mogadishu in Italian Somalia. They had 37,000 gas masks kept for their own use. The fear, from an Ethiopian point of view, was that they themselves were a major target for attack by chemical warfare. In a failed attempt to assassinate the Italian Viceroy of East Africa, Marshal Rodolfo Graziani; he was injured but several Italians were killed. The Italian response was over the next 3 days to slaughter over 30,000 Ethiopians, including about 20,000 in Addis Ababa (at that time 20% of the population of Addis!) Talking to local people they say that, as part of this slaughter, 1,000 people were lined up near the Sidist Kilo corner in Addis and the Italians shot every tenth one. The Yekatit Hospital is built at Sidist Kilo and there is a monument there until this day. Italians still walk and work in Ethiopia. The Emperor, on his return from exile in Britain after the Italians were driven out, said that they should be forgiven. Not many Italians, however, are seen out and about on February the 19th!
The GLAD One
If you look in your computer to see if an African Nation has ever conquered an invading European force unaided you are given “The Battle of Adwa”. I can find no other. The Italian invasion discussed above was the second of their major attempts to conquer Ethiopia. In 1896 the Italians planned to enlarge their empire in Africa. They already had Eritrea as a base. In the end after much fighting the countries faced each other at Adawa. Without trying to go into great detail the following facts seem to be basically true.
- The Ethiopians had a much larger force being on home soil. Roughly 80,000 to 20,000
- The Italians had much the better war machinery.
- There was previously after some squirmishes an agreement between Ethiopia and Italy with different wording in the Italian and Ethiopian copies. Menelik II acted on his copy which meant having discussions with Europe without going through Italian sources. Italy by their copy of the agreement obviously saw Ethiopia as a subject nation and invaded.
- On March 1st 1896 the Italians were routed. The story is complex but the victory complete and is celebrated with vigour every year.
Amharic is the language of the Amharas, one of the major tribes of Ethiopia. Emperor Haile Selassie (The power of the Trinity) was an Amhara and sought to make it and English the main languages of Ethiopia. French was, for a while, a popular alternative and a number of words in modern Amharic also come from the Italian invasion. There are apparently 83 languages in Ethiopia giving rise to about 200 dialects. Ge’ez is the old language of the Orthodox Church and introduces the ‘ in the middle of a word to indicate a glottal stop.
To show how different these tribal languages are I will give four greetings with a rough English translation. I will use our script to give an idea of how they sound
- Amharic greeting is classically Tenastilygn – a shortened form of the sentence Igzeehabeeyer Tena Yisterlygn – May God give you health for me.
- In Oromifa – Neggaa, Fiya, Errga – Hello, how are you, it’s nice to smell you. In this situation I think the ‘smell’ is conceptually ‘to have your presence with us’.
- In Wolaitata – Sero Lo’oo Lo’oo Fiedaitey – Hello, How are you., nice to see you.
- In Hadeyan – Tuuma, Tuuma. Hello, hello!
Haile Selassie attempted to make Amharic the common Ethiopian language and it was taught in primary and secondary school with English being added later in primary school. English was the official language of tertiary education. After Haile Selassie was murdered the era of Mengistu HaileMariam (The kingdom of the power of Mary) sought to elevate other tribal languages with English as the second language, leaving Amharic for the Amhara tribe. It is thought by many that, whereas Haile Selassie was seeking to unite the country, Mengistu was seeking to divide the tribes to make the country easier to rule.
Certainly when I went back after the overthrow of Mengistu I experienced some trouble from this. I was living in the Wolaita area and patients coming from the Hadeyan area only 40 km down the road could frequently not be understood by the staff. The present government seems to now have a three language policy.
In Amharic there are two ‘t’s – both normal for them but with very different meanings. Also with ‘k’s and ‘ch’s differences which we describe as soft or explosive. You can get into real trouble. I was in the bank with a couple of friends and our business was drawn out. I said to my friends ‘Chiger alle?’ thinking I was saying ‘is there a problem?’ but actually saying ‘do you have pubic hair?’ Embarrassing for them and for me, when it was explained. But their letters are written differently and so easily read but not easily heard by us, who think anything like a ‘t’ sound is in fact a ‘t’. In Amharic ‘sebake’ and ‘sebake’, depending on how you sound the ‘k’ means a ‘preacher’ or ‘a bearer of false tales’.
In English we have many letters and letter groups with same or different meaning. We spell Monday with an ‘o’ and say it with a ‘u’. We have the ‘ou’ and say it differently in the following – cough, mouse, tough, through – and pronounce it differently in each word. We have the one letter eg ‘t’ and pronounce it differently in different words. The ‘t’ in tough and the ‘t’ in take are made with the tongue in very different places. Or more significantly the ‘c’ in cat and centipede. Say them and see how your tongue is in a different position for each. We have f’s and ph’s which sound the same. In some of the languages you don’t differentiate p’s and f’s, so people, when they speak in English go to fray or pray at church; they wear certain clothes either because it is the new fashion or new pashion, without recognising the difference. In Amharic if you know the syllabet you can read it with the correct sound even if you maybe cannot understand it!
I once told a patient that, as I had spent hours fixing the problems which his venereal disease had caused, ‘that if you have sex with anyone apart from my wife after this, I will kill you!’ I used the sound for my instead of the one for your. Fortunately he spoke in Oromifa and after my Amharic speaking fellow workers got up from the floor, having ceased rolling around in laughter, they translated what I had meant to say!
Learning another language is always a challenge and we all make mistakes!
I cannot boast of being a good photographer. Here are a few photos from the past with a bit of explanation. The first photo was taken through an airplane window. The smokiness is real in that without electricity every home has an open fire, and picture was taken early in the morning.
During our last term in Ethiopia we only had our youngest adopted son living with us. But that meant we had a house full of boys. Three ate with us three or four times a week and there were others from time to time. The memories of those three are precious to us and I might get to write about the other two sometime. I’ll call this one Habtamu, a name which means ‘the rich one’, although he was and is truly poor. As time passed we got to know the history of all of them.
Habtamu was scholastically the brightest of them all. In grade 8 where the pass mark was 37% in the government exam he got 80 something. He was the only one of the three who had a vision of a tertiary education. He was orphaned at age 5. His parents had bought a place in Arba Mintch, and having sold their village place were killed on the way to their new home in a bus crash. Their three children survived. The home which they had bought had 3 rooms. Their eldest child was a girl who was given the responsibility of bringing up her two younger brothers – Habtamu being the youngest. The sister is now married and has a child. Habtamu lives in a little room on the side of the house. He often asked our son to help him in the evenings or weekends when they, like the Israelites in Egypt years before, trod mud and grass together to patch the walls. We paid for all four boys to go to a private school (a cheap one – but they got a full days teaching, whereas in the public schools you only got half day teaching). When we left our son came back to Australia with us. Two of the boys started work but Habtamu wanted to continue his education. Without being lavish we have continued to support him, with the help of a couple of generous people.
He still lives in that same small room on the side of his married sister’s home. But he may well be seen as richer than most because we have bought him a computer and a few other things. Have these things been a blessing? It needs a yes-no answer.
Yes, it has allowed him to continue with his now tertiary education. His score was enough to get him a place in a University but not at the one in his area. He would have to have gone hundreds of kilometres away to do a course which he hadn’t chosen. He still tries to help care for his older brother who studies at a Government University far away. So he elected to go to night school for some extra points and is taking an accountancy course at a private institution. These are courses which have to be paid for.
The answer is ‘no’ because there have been many attempts to break into his room. (The home is not in a good place). A few months ago he was beaten up and ended in the local hospital. His injury was in the upper third of his face and particularly around his right eye with a lot of swelling and some lacerations. Continue reading “Everyone has a story – Habtamu”
I’m sick of cataloging this afternoon. So here are a few pictures from the past, none medical.
And so it goes on. But enough for one day.
Having a family is exciting! Maybe not all beer & skittles but fantastic!
Modern obstetric care in the ‘so called’ first world countries is on the whole excellent. In quoting statistics one must remember the old adage ‘lies, damn lies and statistics’. The internet tells us that in the best countries the maternal mortality rate is 2/100,000 live births. In Ethiopia it is 421/100,000 live births, and I’m sure that it was worse 50 years ago. Around the world there is apparently an obstetric tragedy every 11 seconds. I cannot find figures for maternal deaths when the baby is born dead. That is the world I entered in 1968. This doesn’t include those who live with vesico-vaginal fistulae, of which there are 9,000 new cases annually in Ethiopia (quoted by the late Dr. Catherine Hamlin); nor those who survive ruptured uterus. I’m sure many of these died before they reached a hospital where they could be operated on.
I took out the figures in Soddo (my second long stay in Ethiopia) over a year period and we had a 95% survival rate of those who reached hospital alive. I had reopened the hospital in Soddo in 1993 after the country was freed from the communist era. I was the only surgeon there. I was on call 24/7. After a while we had an obstetrician there who did the day O&G work and was on call at night every second week for obstetric emergencies. But initially I did them all , and later out-of-hours cases every second week. I was also called in to deal with the situation if there was also a ruptured bladder, which occurs in about 10% of cases.
I shall only mention one case here, as I know medicine isn’t everyone’s ‘cup of tea’. My children say they were brought up on such things around the tea table.
In the countryside antenatal care was almost non existent. We ran such a clinic, but few attended and everyone was so busy we didn’t chase things up as hard as we ideally should have done. Most babies were delivered at home. People didn’t come to the hospital until things were obviously seriously wrong. If you lived, for instance, 50km from the hospital, for the majority, there were neither ambulances nor roads so they had to be carried on stretchers over mountainous tracks and crossing waterways. People were frightened to travel at night; and it took, I am told, above 20 people to carry the patient, sharing the work; so it is not surprising that people arrived late.
My first case of ruptured uterus came within a few days of my arriving on my first time in Ethiopia. I was the only doctor in the place. The story apparently was that the labour made no progress, so the native healer tried to do what we call an internal podalic version. In other words by putting his/her hand inside the uterus they intended to turn the baby to get the feet at the bottom so that they could have something to hold onto to attempt to pull the baby out. I don’t know how but whoever it was managed to tear up the front of the vagina and uterus as well as the back of the bladder from top to bottom, and they still could not deliver the baby. The patient obviously rapidly became much sicker and she was brought into the hospital. The baby was dead, but I repaired the long internal tears and she recovered.
Unfortunately she developed a small fistula for which she was sent to the ‘Hospital by the River’ in Addis. She did well and was later delivered of a healthy child. I’m not sure where she fits into the statistics. Later when I was met with both a bladder as well as a uterine tear I used to bring down some mobilised omentum to separate the uterus and the bladder.