Timkut, family affairs, germs and pastoralists

Greetings from Hawassa.

Timkut

A hot, blazingly sunny day that is really feeling like the dry season (which should go from December to April, but started late this year) in Southern Ethiopia. The ground is gray and hard and all the grass has dried. The mountains on 2 sides of us are hazy with the dust and smoke from fires. The nights are cool and breezy and the hyenas (jib) still sing their songs. It is the tail end of the harvest with many fewer donkey-drawn haycarts on the roads.

This weekend was Timkut, and despite our best intentions, we never made it to the celebration. It is an Ethiopian Orthodox holiday in January celebrating the Epiphany – different from my memory of the Epiphany as the time when the Angel Gabriel told Mary she was going to have a baby whose father was god. Ethiopian Orthodox Epiphany celebrates the baptism of Jesus by John the Baptist and the revelation was to John that Jesus was the Son of God. In Hawassa, there is a procession of thousands from St. Gabriel Church at one end of the main street, Piasa, to the lake at the other end. All women (and many men) wear traditional white dress and at the lake all are baptized the next day from a fount. That was Thursday night and Friday. Then on Saturday, another procession took place from the Lake back to St. Gabriel's Church bearing the tablet of St. Michael, because it was his saint's day.

It is a time of public and family celebration, and the streets were full of folks. On Thursday El and I walked down to and then on the promenade along the lovely Lake Hawassa, where many people had gone after the religious celebrations to sit, drink soda or eat and take a vacation day. Men fish on handmade small reed rafts, pulling up small tilapia. The birds wander among the reeds and lily pads and at one point there was a gaggle of young boys swimming.

Going home I walked with friends Rhobot, Adam, Emilia and their visitor all the way to the extremely fancy Haille Resort, at a certain point leaving the promenade to walk with about 30 children from the adjacent fishing village up to the Haille Road. The contrast between the elegant Haille and the poor fishing village where women were processing the local false banana (ensete) to eat while men stood barefoot on their rafts was fairly striking, as happens with so many contiguous phenomena in Ethiopia.

Family Affairs

Yesterday we had visitors from Addis Ababa: Mulugeta's birth-mother Genet and his brother and sister Ermiyas and Meron and nieces Miriam and Iba (ages 9 and 5). Elliot and I were both conflicted about it, worried if we would have anything to say to each other; if we would be able to talk across that ocean of language and culture and history that divides us about such a sensitive issue as our mutual son; whether we would know what foods and sleeping facilities to offer!

The upshot was that it was a wonderful visit. There is a reason that our kids are as wonderful as they are, and it is not just their American upbringing. We have known Masaye's sisters for a long time, and they are fairly remarkable young women. The more that we know of Genet and her Ethiopian children, the more we are able to attribute much of Mulu's success in this life to his birth family as well.

We spoke extensively of the kind of poverty that most in America do not ever have to see, fortunately – hunger, homelessness, disease and violence – that many Ethiopians are way too intimately acquainted with. It is this desperation that drives families apart and frequently is the source of international adoptions.

The talk was moving and revealing in a new way for El and me. (We thank Rhobot and John for their compassionate and empathetic translation.) We were and are invested in this story. We cannot walk by it as part of the Ethiopian scenery, but felt the pain of parents whose children have been torn from them by a harsh society.

Prior to this, last week I had been yanked around by a moment in the hospital when I had found myself looking in the eyes of the mother of one of my very sick patients. Her despair stopped me in my tracks, the tracks of a clinician there to do a job. Her unflinching sorrow held no blame or embarrassment, yet it spoke to me more powerfully than any contact I had had here that I JUST CAN'T FATHOM WHAT PEOPLE HERE SUFFER AND ENDURE. From that moment I saw myself looking at the street children and the crippled beggars and the old women carrying huge loads in a different way.

I discussed it with El and I think we were a little better prepared to talk to Genet about her suffering and the limited choices she has had in her life, all of which she tried to make with the best interest of her children in mind. I had also started reading Paul Farmer's Pathologies of Power in which he speaks to just this issue. I thank him for his insight and recommend that all of you, my friends, read it. He is pissed on behalf of the poor. He is right.

Germs

The last two weeks at the hospital have been full. I have started to teach medical students on a scheduled basis. Before, my work “schedule” had consisted of walking onto the ward and doing whatever I was told for the day. I now teach bedside diagnosis a couple of times a week to a class of about 25 students. Other days I round with the team of interns and a general practitioner who treat the male patients on the ward – they call it the “male side”. I have been struck with the amount of tuberculosis that we see. Potts disease – infection of the spine – is, if not normal, certainly not rare, and tuberculous meningitis is the diagnosis of exclusion in most cases of fever and headache. We have been fooled when diffuse disease of the lungs presumed to be caused by fluid from heart failure has turned out to be tb.

My respect for my colleagues continues to grow. Their willingness to argue medicine on the basis of science is quite remarkable, given how difficult it is to have access to that science. And their experience far surpasses mine in many fields, especially, of course, infectious diseases. Humility – hard for an American – is an important commodity, as is the willingness to hit the books.

Which I will do this afternoon, helping the interns prepare a lecture on diagnosis and treatment of opportunistic infections of the brain and spinal cord that come with the AIDS virus. Deadline Friday.

There are some major breakthroughs in expanding the lab. We expect the microbiology lab reagents to come in this week (finger-crossing or prayer – whatever your forte -- is appreciated) which would mean that, just maybe, we will be able to start culturing specimens and no longer best-guessing diagnoses.

I have been asked to help institute a serum test – detecting the malarial antigen, not just seeing the little devils in the red cells under the microscope – for malaria. The microscope test is very useful but is not sensitive if the tech a. is not well-trained and b. does not take a whole lot of time searching every field for the little malaria forms on the smears. Thus, again, we more often than not treat empirically. In such conditions, the antigen test (which is used in isolated clinics where they don't have microscopes but not at the big hospital, where we do) is more likely to be positive. If we get a positive antigen test a. we can feel more comfortable treating with quinine and b. we can go back to the lab tech and ask that another look be given to know how heavily and with which species the patient is infected. Am visiting the local Malaria Consortium and talking to my teachers at the London School of Tropical Medicine (online course in Malaria) about the best test for us to adopt.

The struggle to get the nebulizers (to treat severe asthma) to work is ongoing. We THINK that perhaps tomorrow we will receive a transformer from Fulbright friends in Addis Ababa via an ambulance that transferred a patient from Hawassa. All that looks easy is hard and all that appears hard is impossible in Southern Ethiopia.

The nebulizers were to have been a huge breakthrough, but they work on 115 volts and electricity here is 220. Most computers are easily adapted, but we tried all the usual adapters, without success. Finally, we resorted to searching for the kind of transformer that El and I used in Kenya more than 25 years ago, and hope its arrival here tomorrow will mean that some people, literally, will breathe easier.

The irony was that Thursday a big deal, with photo-op, was made of our donating the medical books and supplies, including the so far-useless nebulizers, to the hospital. Hopefully, by the time I teach about asthma to the medical students on February 8, we will be able to demonstrate their use.

Pastoralists

Elliot presented our research about the effects on maternal and child health of settling Northern Kenyan pastoralists in towns. Pastoralists live by raising livestock -- camels, sheep, goats and cattle -- in drylands where they are forced to move from place to place to find pasture and water. Our research found that women and children suffer hunger and malnourishment when these groups of folks are forced to stay in one place because they are separated from their animals and don't have milk to drink.

We are excited about going back to Northern Kenya in February to visit El's adopted brother Kanikis and his family. By bus to Moyale and then and then south to Marsabit district. It will be another huge adventure.

We plug along, encountering so much that we never expect and, ultimately, feeling exhilarated and thankful for health and family and friends and amazing opportunity. We, like Paul Farmer and so many of you who know the score, remain pissed and trying to figure out how to be so effectively.

Please write.

Marty and El in Hawassa