el & marty in hawassa: 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.