Holiday Greetings from Hawassa

Greetings friends and family,

Christmas in Ethiopia is a bit different than in the states, although we did see a decorated Christmas tree in our favorite restaurant downtown. Ethiopia is a mixed Christian/Muslim country (55/45), with the majority of Christians belonging to the Eastern Orthodox Church. We wake up every morning - early! - to monks singing Orthodox hymns, broadcast over a loudspeaker beginning at 3:30 AM. While this music can be quite beautiful, this religion is quite formal and severe (in Elliot’s thinking). The Orthodox Ethiopians are mainly from the northern highland region (Amhara, Tigray, and Eritrea); while here in the south we see and hear more “Protestant” churches, meaning Evangelical and Pentacostalists. Their churches are smaller and more store-front than the large and beautiful Orthodox churches, and we find their broadcasts (also over loud speakers) more jarring and grating; they are not singing but preaching, and judging from the loud and angry tone of the speakers we suspect they are harsh harangues that the parishioners are all going to hell in an enjera basket! Why do all these religions (Muslims as well) feel they have to loudly broadcast their message whether you want to hear them or not? Marty says it is because each religion feels they have monopoly on the truth and that God speaks through them only. Oy vey ist mir. Speaking of which, Orthodox Jewish settlers in the West Bank also feel it is their duty to drown out the local Palestinian communities with loud broadcasts in Hebrew.

What are our impressions of Ethiopia now that we have been here three months? Well first off we are tremendously impressed at how dignified, graceful, polite, and genuinely friendly Ethiopians are, at least in our day to day work environments at the University and Hospital where we work. It is a very different atmosphere than Kenya where we worked previously, with its rushed pace, money hungry police, and obsequity/hostility to whites and other foreigners. Ethiopia really is different. In part, this must be due to its non-colonial past – they were never conquered and occupied by a foreign power, with the brief exception of Mussolini for five years in the 1930s. Some people here in the south say that they were conquered by the Amhara of the north, and ethnic divisions are still manifest here. But the government (which originated as a guerrilla army in Tigray and is quite autocratic in its rule) are really trying to deliver the goods, so to speak, to all the various regions in Ethiopia, They are committed to a regional/ethnic federalism, where everyone gets resources to develop. We see a lot of building – in town, at the university, on the roads – and a commitment to growth and social development. The government is also committed to the World Bank neo-liberal orthodoxy of free trade and foreign investment, and one sees enormous greenhouses growing roses and lilies for export, owned by Saudi Arabia, Israel, India, lining the roads. But the large land grabbing schemes for bio-fuels and grains seem to be in the low density areas of the western region, and the government really does not want to displace and alienate small holder farmers, its political base.

This week we had a wonderful celebration of diversity at the University, in honor of all the different ethnic groups in the county. Our region, Southern Nations and Nationalities, has 54 different ethnic groups (70% of Ethiopia’s diversity), and each student group put on dances and songs, wearing traditional dress. They were incredibly proud of their tradition, and loved it when Elliot joined in one of the stick carrying dances.

On the domestic front, we have a very nice living situation, located in the university “guest house”, really a five story apartment building in a big field, here we have the “penthouse” view (with two floors to boot). But electricity goes off many times, and we eat most of our dinners in the inexpensive (and generally delicious) restaurants nearby and in town. Marty is braver than Elliot when it comes to Ethiopian food, happily eating her ‘wot’ or ‘fasting foods’ (which are eaten on the 250 odd fasting days in the Orthodox system), while Elliot sticks to his spaghetti and meatballs, although he can dig into a plate of tsibs and enjera (roasted lamb and the Ethiopian ‘pancake’ to eat it with) with the best of them. Elliot, when not teaching or preparing for class (which in truth does not take more than 2.5 days per week), spends a lot of time as one of the three editors of the African Studies Review, reading five or six manuscripts a week and communicating with authors, more than a few from Africa, about how to improve their articles. Marty, when not working at the hospital every morning 8 or 9 – 12 noon, depending on the day, keeps herself very buys, both preparing lectures she gives, and spending as much time as she can (literally all afternoon and most evenings) reading her beloved medical texts on malaria, tuberculosis, and HIV/AIDS. ). She is ‘Dr Marti”, whose hospital chief introduced her, “This is Dr Marti, who does internal medicine and is into Everything!” Elliot is ‘Dr Elliot” or simply “Professor”, including greetings on the telephone. We have a good routine, broken by pleasant walks into town center (about 30 minutes), trips to the lakeside resorts to swim, in the pool, mind you, there is schistosomiasis in the lake – tiny worms transmited from snails to humans, lodging in the bladder or intestine while it merrily multiplies to about 100,000 (Marty – please fact check!)

We have developed friends and colleagues here, including two young Americans, Adam and Emilia, who live at our building and work at the university (Adam in anthropology and Emilia in Public Health), our friends from work (Walelign and his partner Beza, also in anthropology and who live in our building), Rehobeth the daughter of a geography professor who lives in the GH), and friends from work (including good friend the ever polite Mulye Girma, who is applying to PhD programs in the US).

We haven’t gotten out of Hawassa much, saving a trip to a wildlife sanctuary no Ethiopian has ever heard of, but there is plenty for us to do and see here. Hawassa is almost a resort town near the lake, and many conferences are held here, including Eritrean expatriates forming a unified opposition to Issais last week. But the downtown streets are full of beggars intermixed with those with jobs. Poor women with small children are the most upsetting to see, while young boys, who can be incredibly annoying with their calls of “You,You! Give me money!”, but in truth could easily have been our own children if life turned out differently.

We miss our kids, although Leah, recently married to handsome doctor Gavin, is the most communicative. Masaye at Hunter College will answer emails and join us on Google Chat, but Mulugetta is quiet and too into Macalester to write or call, although we can occasionally grab him, where he is surprised we are even worrying about him. Shades of being 20 years old. 

We are posting a whole bunch of pictures this time, of harvest, of birds, of Susy, but mainly of the lovely Hawassan students in their traditional dress, celebrating their own diversity. Some are too beautiful for words.  

Masked marauders, criminals and HAART

Greetings from Hawassa!

A Friday afternoon is lovely in our apartment on the third floor in the middle of the fields from which has sprouted Hawassa University. The corn thresher across the dirt road is active, the cows are still in the harvested corn fields, the funny, gregarious bird with the black mask that loves our porch window is raucously calling us, my work at the hospital is done for the week, it is 80 degrees and sunny and life is sweet.

Went to the ICASA (International Conference on AIDS and Sexually Transmitted Infections in Africa) last Saturday, but ended up returning 2 days early. Became sick in the middle of the night on Monday (I am beginning to think it was altitude sickness, because the same thing happened the last time I was in Addis Ababa) and returned on an overpacked (fifteen people in a vehicle that should hold 12) van with friends Walalign and Besa. It was an experience. There no longer is a bus station in Addis but everyone knows to go to a particular section of the city and wait for the vans to drive by with the young men yelling out their destinations. The van doesn't leave till it is (over-) full. So you can take an hour driving around doing the “collecting”. Then five hours down a crowded, bumpy road filled with lorries, buses, vans, cars, bicycles, people, cattle, sheep, goats and sometimes accidents. At one point we stopped to observe a crowd of twenty or so neighbors and passersby desperately trying to pull the driver out of a smashed-up van. No ambulance or emt or jaws of life or even police or fire department. Volunteer human power, which is usually what Ethiopians must rely on.

Arrived in Hawassa nearly crippled from knee pain from being doubled up in the van, but happy to be home. I truly appreciated the conference. Gazillions of papers and posters on the massive human experiment that has taken place throughout Africa in the last 5 years, the transformation of the treatment of the AIDS epidemic by implementation of broad-based, free highly active antiretroviral treatment (HAART). It has been a monumental and heroic effort to get the meds to every isolated corner of the continent, including Hawassa, so that people whose imminent deaths were considered a foregone conclusion, are now facing the possibility of watching their children and grandchildren grow.

There has been so much data gathered in the course of this incredible ongoing experiment, and a lot of it was presented at ICASA. I felt very fortunate to be able to hear and read about the struggles to reach the most at risk – sex workers, men who have sex with men, immigrants and migrant workers, and the small but growing number of injection drug users. The papers were broad-ranging, from when is the best time to start HAART after beginning a doubly-infected person on TB treatment, to how to follow people's clinical course when you have minimal laboratory capability, to preventing transmission by empowering women through education and employment. All around me different languages being spoken but, the most impressive thing to me, the science was by and large being carried out by Africans in their own countries. And though this may be influenced by sampling error – after all the conference was in Addis – I found the best presentations, the most concrete, data-driven and clinically useful, to be Ethiopian. I was heartened and proud.

The over-arching issue, though, was that of sustainability of treatment. In this last year, the United Nations Global Fund which, with the US PEPFAR, has been the main source of funding of AIDS treatment, had its donations cut by about 10%, which is a major blow to the capacity of the African medical systems to treat the disease. The accomplishments so far have been amazing: reduced transmission and death rates, vastly decreased Mother to Child Transmission, increased identification and treatment of tuberculosis, but all at huge cost. Is this going to be lost to the global recession?

There were political struggles over this question, and it was good to hear them. Many of the true AIDS heroes, Peter Piot and those who struggled for HAART treatment in Africa, demanded that funding continue and expand, while others babbled (editorial comment) about Africa “owning” the funding. This smelled rottenly to me of neo-liberalism particularly when a Nigerian spoke of African nations adopting systems of private health insurance. Wait a minute! Is that not the same system that has left 48 million in the United States without care?

One of the best lines in the conference came from the Archbishop of the Ethiopian Orthodox Church, who was being pressed about his Church's (reactionary) position on condom use and anti-homosexuality. He side-stepped those issues (unfortunately) but instead said that Jesus' main tenet was that the rich should give to the poor. Pretty simple, I would say.

I never had a chance in this crowd of 10,000 to mention that the necessary billions could easily come from the over $800 billion US military budget or from re-taxing the Bush billionaires. They were the elephants in the African room.

I did find myself compelled to react when Prime Minister Melas of Ethiopia gave George W. Bush a medal for his role in initiating PEPFAR. I did not disrupt the meeting. I did not want to get arrested and particularly didn't want to get kicked out of Ethiopia. But boy, that is one disgusting, greedy war criminal! So when folks were clapping and standing, I stood up and turned my back. Interestingly enough there were three African women behind me who did not stand up but who smiled and nodded. I shook their hands and that was it.

I am glad George Bush did PEPFAR, despite his intent through it to further enrich the coffers of the pharmaceutical companies. And I am glad for his new proposal, to detect and treat African women's cervical cancer, which is in many countries here the top cancer killer of women and is associated with HIV infection. Good. But it doesn't make up for hundreds of thousands killed and millions made homeless (subjecting them to risk of HIV tuberculosis and STI's, among other fates) in Iraq and Afghanistan, or his anti-gay and anti-woman and anti-poor policies that all worsened the HIV epidemic in the United States.

Enough!

Back in Hawassa it was the week for clinical testing of the first year medical students. They presented the history and physical exam of a designated patient and I was one of the examiners. It brought back in spades all the anxieties of medical school for a shy and hesitant student. (Yes, believe it or not, there was a time when I was painfully shy!) The Ethiopian examiners are pretty rough and I keep finding myself playing the “good cop”. I am impressed, though, by how hard these young people, who have so little resources, work to learn their medicine. I think I have said in past blogs that I am truly and unexpectedly enjoying teaching.

But I am still upset at the lack of resources. For my clinical friends, we do not have the basics of asthma treatment – no nebulizers! There is one man who is in severe respiratory distress, might have been intubated by now in the States, and is not being adequately treated. I have called all around Hawassa to try to get the machine we need – no luck. The one medical supply store in town says they will order them. I hope he is still alive by the time we get what we need. I have bought peak flow meters, but without the medicine to treat, they are fairly useless.

I will be coming home to Northampton on December 27 and hope to see as many of you as possible. Am going to try to get Elliot to write more, as his work at the University is getting interestinger and interestinger.

In the meantime, I miss you and hope you are well and constantly learning.

Love,

Marty and El

International AIDS Day, Tetanus Again, Cheeky Hornbills

Greetings from Hawassa!

December 1, 7 pm: Listening to Amy Goodman's Democracy Now! Lying on the bed where I have been reading about glomerulonephritis and nephrotic syndrome, diseases of the kidneys that I haven't seen for the last few decades but of which I saw a lot this week and am having to scramble to understand and treat. One young man probably has post-streptococcal glomerulonephritis from a case of impetigo that he recently had. The other has severe body swelling from nephrotic syndrome whose origins are not well understood. These are diseases, particularly the nephrotic syndrome, that are usually cared for by renal specialists, but as I look around the room and the ward and the hospital, I don't find any! And when the 16 year old patient with terrible rheumatic heart disease went into a heart arrhythmia called atrial fibrillation today, again I expected to turn to a specialist but he/she just doesn't appear. So I go to the books, discuss with my very knowledgeable Ethiopian colleagues and take a stab at understanding and treating.

Today we lost another patient to tetanus, which just burns me up. Such a terrible waste of life to such a preventable yet excruciatingly painful death. I told my colleagues at rounds today that I wanted to arm myself with syringes filled with tetanus toxoid and go house to house grabbing people and injecting them.

I feel for the lovely young interns with whom I now oversee “the men's side”. They have had 2 deaths this week of young men because we didn't have the equipment we need and we have 2 patients on the ward with severe rheumatic valvular disease for whom there is no hope. There is almost no cardiac surgery in Ethiopia and it is more expensive than 99% of Ethiopians can afford, and these are young people who developed their disease because they couldn't get penicillin for their sore throats. One man began crying after his echocardiogram, knowing that he didn't have the 125,000 birr it would take to replace his valves. The other is a child – only 16 years old, who looks like he is 11 years old – for whom it is a tragedy to be spending so much of his shortened life in a hospital.

It is now December 2, International AIDS Day. I am preparing to go tomorrow to Addis to the International Conference on AIDS and Sexually Transmitted Diseases in Africa. Found out after I applied that George W. Bush will be there to establish his legacy as the PEPFAR President. When I speak to Ethiopians about him, they say how much they admire him, in part because PEPFAR, which provides Highly Active Anti-Retroviral Treatment (HAART or HIV treatment) to AIDS patients. They say that at least he paid some attention to Africa, whereas Obama, for which they had so much hope, has done little or nothing. Their hopes, which were so high for Obama, have been dashed.

I spent the first night after learning that Bush was coming to Addis thinking about protesting his criminal behavior. I didn't sleep much. But I am a guest in a country I love among people that I respect and honor whose experience of George Bush is obviously much different from mine. The issue of PEPFAR itself is a complicated one. It was a day-late, dollar-short proposal that was a huge gift to the American pharmaceutical companies, because its rules are that all drugs must be bought from the multinationals, not from Indian or African companies. It was also poorly funded: only $15 billion which when considering the high expense of the US pharmaceuticals would not have gone very far. However, it was supplemented to $60 billion and in actual fact, as Paul Farmer has said, has saved many, many lives. I cannot argue that. I am grateful for those meds. And though those meds and the laboratory testing used to apply them have been restricted in their intent – only for HIV patients – in fact there has been dissemination of the benefits to non-AIDS patients. The nutritional supplements meant for AIDS wasting find themselves in the bellies of starving people, the electrolyte testing get used to evaluate diabetics, etc. So that I guess the rising tide is lifting some unintended boats. I am grateful for the lives saved by PEPFAR.

On a lighter note, life outside the hospital is good. We are making good friends and enjoying the harvest time – cattle are gleaning the remains in the cornfields, the donkey carts are loaded with the hay that is sickled by hand from the fields. We became very grateful to those harvesters after they hacked down the weeds and grass right around our guest house. Three of our residents had spotted a large black mamba, one of the deadliest snakes in the world, circled and digesting a small animal right on our front porch over a week ago. Weeds must go! They did. Now only the hyenas remain as a reminder of our vulnerability to wilderness. Whoooo—oop!

This morning El had visitors as he was hammering away on his paper on sorcery. A male and female silver-cheeked hornbill, each 2 feet long, began hammering on our big picture windows that mirror from the outside. They are fantastic. We had seen them in the large fig trees by the lake but never up here. El got some great pictures.

This morning we admitted a man who probably has Staph aureus meningitis, which requires a drug called vancomycin, which our hospital does not have. We sent out the family to search for it at the pharmacies in town. At the same time he needed a ct, but the ct machine had broken. And we just found out that we can get no more regular X-rays because there are no more films to develop them on. So we adapt and do without till we can get what we need. The amazing thing is that, since Dr. Birre and I have started raising issues about the poor quality of the microbiology lab we have begun to get positive results from the staining of the original specimens.

As always, we miss you terribly. We love our wonderful friends in Springfield and Amherst and Northampton and our family scattered around the country.

Please write and tell us your news. On to Addis and ICASA. Love, Marty