Friday, November 25, 2011

Thanksgiving Hawassa-Style, Hippos, Asmari & Lab Struggles

November 25, 2011

Greetings from Hawassa!

Just recovered from a full day without electricity that made Elliot, more than me, very frustrated. No coffee, no eggs, and no computer after the batteries ran down. The problem has worsened considerably since we came at the beginning of October. At that point we would get spells lasting no more than a half-hour without power. We thought at first that it was the coming of the 25,000 students to the university that put too much strain on the grid, but are learning that this is a chronic problem that occurs in every dry season (winter-spring) when the water levels in the rivers behind the dams fall and the blackouts affect the whole country. The political aspect is that the Ethiopian government is building several large and extremely controversial dams now – one on the Blue Nile that is sure to infuriate Egypt which unilaterally declared decades ago that Ethiopian damming of the Blue Nile was forbidden, and a series of dams that threaten extremely isolated indigenous peoples on the Omo River – which will not supply Ethiopian needs but will provide electricity for Djibouti and Kenya. It's a pisser.

Yesterday the one-hour power failure was the only hitch in what was otherwise a lovely Thanksgiving, Hawassa-style. Our young friend and apartment neighbor, Emilia Biavaschi, from Portland, Oregon, decided we were going to celebrate this holiday about which Ethiopians know absolutely nothing. So we plotted and schemed. There are no turkeys in the horn of Africa. The closest candidate would be the Abyssinian ground hornbill that wanders around our fields (see the first posting), so we decided on chickens for the omnivores. (Emilia and Adam are vegetarians.) Hard to get whole chickens, so our friend Walelign volunteered to buy chickens at the market and slaughter them. As a young man he was the appointed butcher for his family, which is Ethiopian Orthodox requiring adherence to strict rules of slaughtering, similar to kosher and halal. Then we had to find apples for the pies – not raised in Ethiopia that we know of but we suspected somehow available in Addis – and something that resembles cornbread for the stuffing. Ultimately, I found halal chickens at the US embassy in Addis and that put the kabash on the local chicken holocaust and we located some outlandishly expensive apples from Egypt (Go, Arab Spring!) at a stall on the Addis streets. Emilia had trouble finding sweet potatoes at the market, though Wallelign and his wife Beza told us that they are available in Hawassa, so she substituted yams for my North Carolina sweet potato pudding. And having absolutely no luck locating cornbread or corn meal we shredded what friend Helen has called Hibasha bread for the stuffing. Everything except the pies and yams was loaded with garlic and the yams and potatoes were mashed with spoons (no such thing as a potato masher in Hawassa!) after I came home from work yesterday afternoon, and we were well on the way to Thanksgiving heaven when.... you guessed it, no electricity! It lasted for a whole hour while our guests politely drank wine and beer and ate those great Egyptian apples dipped in Ethiopian peanut butter. At a certain point Lemma, our volunteer economist at the University started to describe the difference between what is said over the chicken-slaughterings by the rabbi, the Orthodox priest and the imam and belted forth “There is no God but Allah!” and the lights came on and the chickens began to roast again. Go figure.

We particularly missed our beloved Leah, Mulu and Masaye on Thanksgiving day. Leah and Masaye were at Sister Susy's and Mulu was... hmmm... we're not sure where, but somewhere in the St. Paul vicinity. Mulu, phone home!

I am most thankful that El is home after a 6-day trip to Washington for the African Studies meeting. He worked like a dog there as editor of the African Studies Review and came back pretty exhausted, but satisfied because his book, Laibon, has come out. It was lonely here without him. We have always been a team and, though there are wonderful people here, as Joanie Mitchell says, “It gets so lonely, when you're walking and the streets are full of strangers.” We have no tv so there is no artificial noise in the apartment and the Ethiopian nights are dark.

Before he came back, though, to occupy myself, I went with Emilia and Adam and Walelign for a boating trip to see the hippos on lake Hawassa. They were cool and BIG and the lake was gorgeous. Walelign had spent all his life in Hawassa and had never been on a boat. That night we went to an Amhari (traditional Ethiopian music) club and were the butt of the singers who do Ethiopian version musical stand-up comedy. My children will be relieved to know that I refused to dance. 
El came back to Addis on Monday and I rode up to meet him and to attend a command performance orientation for Fulbrighters at the American Embassy. We were dreading it, but it was actually very informative. There was much to learn about Ethiopia and much to learn about what the American government thinks about Ethiopia and its government. The Ambassador denied that there had been an army invasion of Somalia last week, that it was just Ethiopian-backed Somali militia. And they denied that there were armed drones at Arba Minch, though they really did not deny that there were drones. We will try to find out more about both. We heard and talked a lot about the Ethiopian policy of “massivization” or “flooding” of education. There are so many young people, and they are being funneled into higher education programs that lack sufficient resources or staff, overloading the professors but, at the same time, creating the educated young people that will become the future professors. It is a bold but sometimes outrageous undertaking by one of the world's (if not the world's) poorest countries.

We attended a reception at the home of the Public Affairs Officer and his male partner and wondered about whether DOMA allowed federal benefits to his partner. But most important I got to talk to the CDC representative in Ethiopia about the problems at the Referral Hospital Lab, which are monumental. There are no bacterial, tuberculous or fungal cultures, the microscopic analyses are unreliable and we usually ignore them, and we cannot get basic chemistries, called electrolytes. I was pleasantly surprised when, at the cocktail party, the CDC man not only took my issues seriously but helped me make what seems to be a plan to try to address them.

The hospital work has been challenging. Before I left for Addis I had worked long hours preparing a 2-hour power-point lecture on hypertension for the first year medical students. I have some power-point phobia so, though I was promised there would be both computer and projector, I brought my own computer, my own projector and my own thumb drive just to make sure. And then 1) my computer wouldn't communicate with the Hospital's projector; 2) the Hospital's computer couldn't read my thumb drive and I knocked it over trying to put the drive in and 3) I couldn't use my projector because I hadn't brought its wire! So I “wung it” for 2 hours, actually enjoying the chance to be more Socratic. The interesting thing was that the small group of women medical students all sat in the front row and knew all the answers, allowing me to tease the male students for their lack of bravery.

I am participating more in the morning patient conferences, when the interns present the patients that they have admitted and that have died. I find myself caught. There are problems with patient evaluation and care. Students and interns know very little about cardiovascular disease and tend to give everybody antibiotics, specifically ceftriaxone, which is a pretty potent med. I find myself questioning management decisions, but try to do it in a way that outlines the basis for how those decisions are made. However, as was true in my own training 35 years ago and was true when I worked in Eritrea, questions about management can quickly turn into a “pillory the intern” session, that is humiliating and, in my experience those many years ago, leads to very little learning and instead to a lot of anxiety and anger. I cringe when staff do that – it was particularly bad this morning – and need to figure out how to deal with the patient care issues at the same time paying heed to the pedagogical ones. Appreciate any suggestions from my colleagues and anybody else who has an idea.

After morning patient conference went with the head of internal medicine (who found out by glancing at a memorandum on his desk in my presence that he had been transformed into the acting Medical Director of the Hospital while the official Director was out of town) to interview the chief administrator of the Hospital Lab. He is a young guy, 30 at most, who told us about lacking equipment, having old equipment without technical support or ineffective technical support, about lacking reagents, culture media and other supplies, of receiving specimens many hours after they were obtained, delivered by the patient's family, not by hospital staff. Of the frustration of requesting needed supplies from the pharmacy but never receiving them, of being expected to apply for the (newly-instituted) World Health Organization-derived laboratory accreditation and knowing that there was no way that he could fill the deficiencies in the lab's procedures because he simply didn't have the equipment. My heart went out to him and we are writing up a report to give to a representative of Johns Hopkins with an office actually in Referral to see if he can give support – technical, resources, training, whatever – to improve it so that the clinicians in the hospital can begin to rely on lab testing rather than treating each patient empirically.

I write this as much to see it on paper because it is so different from what I usually do and what I expected to do, and I find the issues more complex than I think I am prepared for. Forgive my ramblings and let us all be thankful for our families, our fragile and beautiful world, the amazing accomplishments and incredible tomfoolery of our species, and our solidarity with one another.

Love, Marty

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