Monday, March 19, 2012

Black Water, Breakthroughs and Background

Marty and her admirers by Lake

Greetings from Hawassa!

Elliot is tired of talking about Kony2012 because it diverts from our experience of Ethiopia, which is neither mad killers with guns or helpless victims. It is life in a highly social and complex community that is difficult and challenging but engaging and frequently fascinating. It is not violent or frightening though poverty and need constantly raise questions of resource allocation for the common good. The issue of international resource redistribution is what drew us here, not men with guns.

Lovely little girl in Tyiqur Woha
We took a nice bike ride on Saturday, heading north on the main road, with the Lake to our left. After crossing the little creek that divides SNN region from Oromiya, we saw a dirt road off to the left through a cluster of houses and headed through a small village until we reached the northern part of the Lake. We drove by a man plowing his field with two oxen – a common enough site in Ethiopia, but Ell really wanted a good photo to use in his anthropology classes. He stopped his bike and asked if he could take a photo, and offered ten birr (.60 cents) which probably wasn’t necessary but polite. Ethiopia is one of the only countries in Africa (south of the Sahara – excluding Egypt, Libya, Morocco, etc) that uses oxen for plowing – it sure beats the tractors that World Bank and Green Revolution constantly peddle.

We biked further and got to the shoreline of the lake. Here we saw naked boys swimming, older boys (teenagers) with cattle in the water, and men on narrow reed boats fishing with long poles, occasionally pulling up the small (but delicious) tilapia to sell in town.We asked an old man if this area was Oromo (people) as we were no longer in SNN (which was mainly Sidama people near Hawassa), and he said it was Oromo.

Ibis in cemetery
Goliath Heron with lily pads.
We proceeded left to see if we could find any hippos. The bird life was spectacular, as usual on Lake Hawassa. We saw a male and female Goliath Heron (possibly the biggest herons in the world) plus egrets, plovers, and others. We met a young man who spoke good English, told us his villages name was Tyiqur Woha (“Black Water”) and we were welcome. It was a nice end to the week

The week for Marty has been full to overflowing with teaching. She prepared one lecture for her colleagues and interns about interpretation of electrocardiograms. She planned it for Wednesday but there was no electricity(!) at the hospital. When she finally presented it on Thursday, it was overly long and she expected glazed looks on all faces but was surprised that folks seemed to be into it. It was encouraging that there was consensus that the effort should continue and one of the other internists agreed to take over tachyarrhythmias (thank god!) while she would do heart block. There is huge irony here: Marty has never seen herself as a medical instructor and has shied away from medical academia. To pretend she is a cardiologist is over the top, as any colleague at Brightwood will understand.

Even more shocking, on Friday she presented TWO HOURS of fluid and electrolytes for the medical students. Ugh. Every physician's nightmare – hypernatremic and hyponatremic hypovolemia. But she pounded through it for a week's preparation until she felt that EVEN SHE maybe understood it. And the students, fortunately, had studied well and were able to follow her, though they have no tools – can't measure sodium, potassium, bicarb or chloride – to measure what she was talking about. She is growing extremely fond of them and feels as though it is becoming mutual. They are so young and earnest and clearly shocked and pleasantly surprised when she acts out the role of a confused and frustrated red blood cell rejected by the left ventricle and finding itself back in the left atrium after having passed through a regurgitant (leaky) mitral valve in the heart. Her colleagues are seemingly a little more formal.

She has been playing her favorite role in the department – rounding in the emergency department. She is still amazed by how ill the patients are. It is not uncommon to treat patients empirically for cholera; the staff still does not routinely culture for severe gastroenteritis at Referral, though she is impressing on the general practitioners and interns that they need to and informing them when and how to do it.

This week brought a major breakthrough. There are huge numbers of patients with what is called (euphemistically) AFI for acute febrile illness. They have fever, headache and may have associated seizures and coma. In other words very, very sick. Marty has written before that the hospital's capacity to diagnose them so that they can be treated properly has been very limited. The major decision to be made is, Is this malaria or is this meningitis? And the answer has usually been, Who knows? The doctors do their best, but 1. The microscopic tests of the fluid taken from a spinal tap are poorly done and unreliable. 2. Ditto the microscopic test for malaria, and 3. There have been no cultures for bacterial meningitis, which is what most doctors in the global north ultimately rely on. So, usually Referral doctors have treated, as her boss says, “gunshot”, or for both. But that is expensive and exposes the patient to drugs that are not without side effects, and they may be missing an entirely different alternative.

Marty's colleagues, Drs. Tariku and Andergow.
For the first time this week, the Department was told that it could get CSF (spinal fluid) cultures! It is supposedly for “research” only, (our wonderful lab supervisor winked as he said it) and only under certain circumstances, but it is a wedge through which it is hope a truck shall be driven. Hallelujah!

There may be a second breakthrough, soon. Marty is working with administrators of the Ethiopian Malaria Consortium to see if the hospital can obtain a. rapid diagnostic (antigen) tests or b. further training for lab staff for the routine blood film test for malaria. She and her boss are doing a stealth attack on that flank, with the full support of the rest of the department, the pediatricians, the lab supervisors and, probably, if they were asked, the patients.

She is struggling mightily with Amharic, amazed that one language can be so difficult and take so many syllables to say something fairly simple like “I walk.” Eyeterameudkuny no.” Seven syllables, no less. And both vowels and consonants are a constant challenge to the tongue. But another breakthrough. On Thursday she was able to ask a patient whether she had a cough or fever. She expected the poor patient to look at her in mystification, but instead, she readily answered, “No.” Shocking to both Marty and her colleagues. Keep hope alive.
Speaking of which, Marty just finished Congressman John Lewis' Walking with the Wind and it provoked a lot of thought and discussion about how social change takes place. John Lewis is one of the primo nonviolent organizers of all time, leading the way over the Pettus Bridge in Selma in 1965 and getting his skull fractured by Alabama police, but that was the culmination of constant door-to-door organizing with SNCC for the right to vote and to be free of violence. We both feel tremendous admiration for his radical ideas about democracy – especially economic justice – and the eloquence of his nonviolent stands and his god-awful stubbornness and tenacity. His story reminds us of and challenges our own radical past. Marty wishes, particularly, that she had known more history when she was organizing in North Carolina thirty some years ago.

The anthropologist at work
One nice thing about living here, and having a lot of spare time when not teaching, is that Elliot is doing a lot of reading and talking to people about Ethiopian culture, society, and history of surely one of the most interesting places in the world. Like most African countries, Ethiopia is a hodgepodge of different ethnic groups, some large and powerful, some small and isolated. Ethiopia has over eighty groups, the largest being Oromo in the south, and the Amhara and Tigray in the north (and the related to Tigrinya in Eritrea). In addition there are Somali and Afar (Danakil) pastoralists in the east, Sidamo and Wolaita coffee growers in the south west. To the west and southwest near Sudan and Kenya are truly tribal people including Mursi, Suri, and Bodi on the Omo River (they wear the large clay lip plugs) and the Nuer and Anuak in the far west (Sudanese cattle people who are very tall and dark). By far the two most important groups, who shaped Ethiopian society and culture as we know it, are the Amhara and the Oromo. They are almost opposites of each other in culture and society – Oromo are egalitarian cattle herders and agro-pastoralists, organized by age grades without any chiefs or true centralization. Amhara on the other hand are a very hierarchical society with (in the not-too-distant past) feudal lords and Orthodox Christian bishops at the top (these are the people whom Haile Selassie comes), followed by a huge majority (90%) of farmers who raise teff grain with their ox plow agriculture, and low caste blacksmiths and wood workers at the bottom. Amhara inherited the high tradition of what they call the Solomonid Dynasty – the belief that all their kings and emperors descend from Menelik I, the illegitimate but beloved son of King Solomon and the Queen of Sheba. According to their national epic the Kibre Negest (written in various forms between AD 600 and early 1300s ) Menelik came to Ethiopia, “God’s intended and favored country,” bringing the Ark of the Covenant (with the ten commandments) with him. It is believed to this day that the original ark is hidden in a church near Axum in Northern Ethiopia.

Black Madonna Axum Cathedral
High culture of Ethiopia began with the Tigray whose kingdom of Axum was a trading empire that dealt with the Mediterranean, Indian, and Egyptian worlds through the port of Adulis (that our archeologist friend Daniel Habtemichael studies) between 1000 BC and 700 AD. Axumites had a written language (Ge'ez, which is the script in use here).After the spread of Islam in 7th century, Axum was isolated from the Red Sea trade by the formation of Islam and the spread of Muslim culture and networks. The Axumites were early Christians, adopting the eastern Orthodox religion from Syrian priests in the 4th century and forming one of the world’s oldest Christian communities.

Axum at Tsion Festival
The Ethiopian Christians built Lailibella (with its eleven churches carved out of rock and connected by tunnels), they even sent Christian knights to fight in the Crusades. They built Gondar, a medieval town of castles and monasteries which was the center of the Zagwe Dynasty which reached its zenith in the 15th century and spread Amharic language and culture throughout the north. By 1520, however, the Turks, the greatest military power in the world at that time, expanded their influence to the Red Sea and helped arm Muslim Somalis and Afars to launch jihad against the Solominid Kingdom. Under the charismatic leadership of Ahmad GraƱ (“the left hand”) from the walled city of Harar, the Muslims reached the highlands where they were stopped by a combined army of Amhara and Portuguese troops.

Menelik II
 By far the strongest of the Amhara emperors was Menelik II (1844-1913, taking his name from guess who) who expanded from the Shoa highlands in the center to the south incorporating Oromo, Somali, and southwestern cultures under Amhara dominance. It was Menelik II who, at the urging of his wife, created Addis Ababa (“New Flower”) at the turn of the 20th century. It was Menelik who defeated the Italians in 1896 in the Battle of Adwa. The Italians, who had colonized Eritrea and southern Somalia, tried to add Ethiopia to their colonial conquests. Defeat at Adwa was a great humiliation to the Italians, and Mussolini tried to avenge Adwa when he invaded Ethiopia in 1935, bombing Addis and setting up colonial rule until 1941 when the British forced them out. In 1936 Haile Selassie went to the League of Nations to plead for intervention by the Europeans, but like the Spanish Republicans fighting their own fascist Franco, his pleas fell on deaf ears. “I ask what measures do you intend to take? What reply shall I have to take back to my people?" France and Britain were too afraid of starting a second world war with Germany and Italy, so they sat on their hands until the war came to them three years later.
Selassie at the League of Nations June 30, 1936
 Haile Selassie came to power in 1930 following an interregnum after Menelik’s death in 1913 where power was held by Menelik's wife (some say Selassie, tired of waiting, suffocated the queen mother ( - the same fate that Selassie himself met at the hands of Mengistu in 1974). Haile Selassie means “Power of the Trinity”: his real name was Tafari Mekonen, and he was called Ras (head or prince) Tafari – hence the origin of Rastafarians in Jamaica who saw him as the Lion of Judah and leader of all Black People. Selassie's reign and the remnants of Ethiopian feudalism were overthrown by Mengistu who set up a pro-soviet regime – he is remembered for returning land to the peasants but also for his murderous rule that killed hundreds of thousands of people opposed to his regime, including Marxist students in the 1970s and huge numbers in the liberation movements in Eritrea, Tigray, and Oromo in the 70s and 80s until his downfall in 1991 by combined national (i.e. ethnic) liberation movements of Tigray (TPLF) and Eritrea (EPLF), with additional movements in the Soamli region (OPLF) and Oromo area (OLF).

The Amhara, who until recently constituted the most educated and powerful group in Ethiopia, have been characterized as individualistic, hierarchical, beholden to both Orthodox priests and feudal lords, taciturn and, in the past, the group that could rule others. Under Menelik, Amharic culture spread by force to the south, south west, and east as Menelik expanded Ethiopia to its present borders, in part to keep out the British (in Kenya and Somalia) and the Italians (in Eritrea and Somalia).

In contrast to the Amhara, the Oromo are non-hierarchical, bound by their kinship groups and age grade system known as Gada but lacking in kings. They remind us much more of the Ariaal and Rendille people we know from Kenya. The Oromo are livestock keepers – they own the majority of cattle in the country and much of its goats and sheep (camels are the domain of Afar and Somalis in the eastern lowlands); the most nomadic of the Oromo are the Borena, and probably all Boran were pastoralists 400 years ago (now many farm maize and other crops as well as keep livestock). The Oromo were fabulous horsemen of the past – they probably gave Menelik II his divisive edge over the Italians at Adwa. These were the people we went horse riding with in the Bale mountains a few months ago. In the 16th century the Oromo spread to many regions, including the Shoa highlands in Amhara and into Kenya as well. This Oromo Expansion assimilated other groups so that today they are 55% of Ethiopia's population.

When Menelik conquered the Oromo areas in the 1890s, he imposed an Amhara feudalism over them, rewarding his officers with land in the south and making the conquered people pay tribute including several months labor each year. The Oromo have felt dominated by the Amhara much of this century, including during the Derg time of Mengistu (1974-1991). Mengistu was overthrown by both the Tigray Peoples's Liberation Front (TPLF) and the Eritrean EPLF in 1991, the TPLF leader Meles Zenawi became president. But because he believed in ethnic sovereignty, Meles established a federal government that gave some autonomy to different regions, and Oromo have stepped up to the plate as equals to the Amhara. There still are resentments and ethnic favoritism played out all over the country including at Hawassa University, but we believe that most Ethiopians seek a greater Ethiopian identity than just that of their own ethnic group. Amhara is the national language, but the music and cultures of all regions are promoted, at least according to the music videos on national TV. Most Ethiopians see themselves and their country – its history, customs, and peoples- as unique, and we do too.

 Mengistu Haile Mariam (ruled 1974-1991)                 Meles Zenawi (1991- present)

The final and mandatory cow picture
 We miss you, as always, and will return in late June.

Marty and Elliot


  1. Marty, great to hear that you are working with the folks at the Malaria Consortium. It sounds like you are continuing to make positive changes at Referral Hospital. Thanks for the excellent photo of the goliath heron! I really appreciate the blog as a way to feel still connected to the goings-on in Awassa. We miss you guys and we miss that place, but the photos and stories help.

  2. Great to hear from you, Emilia. It is 2 pm here (simint sa'at keu qanu)and so probably 4 am your time. Are you still in California, or did you return to Portland? Did Adam make it back safely? Job situation? Stay safe and we miss you, too. The Chinese gentleman in your apartment is not nearly as fun.