February 3-4: Pastoral policy, pulse oximeters, enthusiasm, Mitt

Marty and El on Lake Hawassa hunting hippos (Emilia's photo)

Black-faced vervet in Arba Minch (Emilia's photo)

Kasech and Serkalme, who clean our apartment

Meskano, Danye, Awoke, Adam, Elliot, Ashinafi and Amalo of the Hawassa U. Anthropology Department

Emilia, students, El and (in front) Awoke of Anthro Department

Professor Lemma, Emilia and Anthro student Dagim

Emilia and Adam on their last day

Yawning hippo (Emilia's photo)

Baboons in Arba Minch (Emilia's photo)

Look close -- vervets in trees (Emilia's photo)

Dorze women making pottery (Emilia's photo)

Woman in Arba Minch (Emilia's photo)

Greetings from Hawassa!

Friday, February 3, 2012

The dry season is here with a vengeance, with its blazing sun and dusty air. It is still pleasantly cool in the shade and the breeze is great, but we find ourselves thinking twice about walking or biking. We plan outdoor things for the morning or evening when it is doable. El saw dust devils stirred up along the road from Addis Ababa this week, a new phenomena, and the mountains become hazier every day.

His trip to Addis was a good one though, as always it seems, he came back sick. The air is smoky and polluted and each of us always has to take several days for our respiratory tubes to recover. He showed a power point to US AID staff at the embassy demonstrating our data on the negative effect of settling on pastoralist women and children. This is a big issue in Ethiopia and Kenya and we need to enter into the debate. The Ethiopian government has a policy to settle nomads, particularly on new irrigation schemes, to “bring them into the 21st century” with health care and education. Sounds good, but if the settlement is not voluntary, it could be disastrous. Our main question is ‘what will they eat? Why take away an adaptive food production system (livestock) and replace it with something the pastoralists are not very good at (farming)? Human Rights Watch recently criticized the government of Ethiopia for settling pastoralists in the Gambelle region to make way for agribusiness. Before El gave his talk he asked who in the room came from a pastoralist family. Four Ethiopian hands went up, so it is not an obscure issue. There was a lot of expertise in the room and Elliot was pleased that the discussion was at a high and knowledgeable level. It looks as though we will be taking the information to the universities at Addis Ababa and Harar. This will give us a chance to see more of Ethiopia – Harar is an ancient walled city in the more lowland, dry, eastern region.

Classes ended for Elliot last week. Like students everywhere, Ethiopians are anxious about their grades, and they will try hard to win an extra point or two by strenuous argument. But Elliot was very disappointed with the widespread cheating, both in written exams and take home papers. Part of this is cultural – one does everything one can for one’s friends – but the main problem is structural. Ethiopia is rapidly expanding its higher education, but neither the students nor faculty are prepared for it. Many of the students speak poor or no English (although their essays are in perfect English, right off the web!). Faculty complain that many students should not be in college, that what they need is intensive remedial and language training, But one must admire the ambitious program the government is carrying out. The universities have many new buildings and furniture, and many programs (including our own in Anthropology) have developed Masters degrees programs, in part to train more faculty. But it feels like community college here, and it gets wearying for Elliot.

We are fast losing our ex-patriot friends here. Adam Boyette and Emilia Biavaschi left Monday, Adam for a one-month trip to pursue his anthropological research with the Aka (forest pygmy people) in Central African Republic, and Emilia to return to the States. They were great friends, neighbors and colleagues. Now our friend Lemma, an Ethiopian-American economist from northern Virginia who had met his wife here at Hawassa many years ago will be returning home in the next two weeks. He voluntarily taught economics at the graduate school level. We will go out with him and other friends tomorrow night to celebrate at the new local brewery, Bira, (beer in Amharic – probably from Italian) to drink their huge liter-glasses of beer. It will be quiet here, but we will be doing more traveling.

We look forward to another Ethiopian wedding on Sunday of friends Beza and Walalign. They are Orthodox but there will be no priest in sight, only endless dancing, eating and celebration at the local hotel. There is the same ritual over-spending on weddings here that there is in the States, and it drives the poor couple nearly to distraction. Walalign was counting off the thousands of birr spent on cars and food and the hall and clothes and alcohol and all the things that parents of recently-wed couples such as ourselves are too well acquainted with. I tried to explain cross-culturally what my father said to me when I was in adolescence – “Here's a ladder. Elope!” It took a long time and I'm not sure that the point made it, but I know that our commiseration did. Of course, Walelign and Beza and all their friends are delighted about their wedding.

Today was a red-letter day, at least for Marty, at the hospital. The hospital finally has its pulse oximeters (Thanks, Jake and Domi!) on the medical ward, but bureaucracy can sometimes be a real drag, particularly when it is coupled with lack of trained staff! Last week Marty's team had two very sick patients that needed to have their blood oxygen tested, but the Internal Medicine Department had followed proper procedure and sent the donated oximeters to the pharmacy medical supply department for redistribution back to medicine, pediatrics, ob and the emergency department. OK. But then when Marty tried to get one back for patient care it seemed that the only person with the key to the medical supply store was at a training for 2 days. Humility and patience. She was directed to surgery where the only other oximeter in the hospital was to be found, used by anesthesia during operations. She had to wait several hours and then cajole and flatter the anesthesiologist (who was actually a nice but protective guy) and promise him our firstborn – sorry about that, Leah – if it wasn't returned. The team got our results, she returned it and Leah is still in Washington with her Gavin. But then, all this week, the donated oximeters still did not appear. Yesterday there were several new sick admissions from the emergency room who needed evaluation with the pulse ox. Marty returned to Pharmacy Medical Supply twice, being told first that one person would come in soon to get them and then that he wasn't the proper man, but she should instead wait for another who would not be there until 4 pm. At 4 pm guess what? No Ato Fukadu! He, the only one with the key, would be in for the night shift. Marty asked the Head Nurse, who now hides when she comes in range, to make sure that the oximeters were obtained on the night shift and then went home in a funk. When it looks easy, it's hard, when it looks hard it's impossible. This morning she started, for the first time, to express her frustration over the bureaucracy to her boss when, low and behold, there sat the pulse oximeters on his desk! The system ultimately had worked. Much of rounds were spent measuring oxygenation of all the pulmonary and cardiac patients on the ward and there now is a system for their use and safeguard.

And, what's more, there now are usable nebulizers in the hospital! There had been four of these for use for sick asthmatic patients, donated by Louis and Clark Medical Supply in Springfield. However, they did not work because, though there were electrical adapters for the plugs, the machines take a 115 volt supply and Ethiopian is 220. After searching all over Hawassa and Addis, a fellow Fulbright researcher in Addis offered us a transformer. Then, the problem became getting it here. After several false starts we finally got an ambulance that had taken a sick patient to the city to bring the transformer back. The whole ordeal took a couple of weeks and endless phone calls but today Marty and her boss tried the nebulizers with the transformer and got this wonderful little machine purr out of two of them! We think that we burned out some part of the other two when we tried to get them to work on the higher current, but batting even .500 is terrific when you are starting at 0.

NOTE: Anybody with any ideas about what to do with the 2 unworkable ones? They didn't smell of smoke – just momentarily purred and stopped.

These minor victories, plus patient care, are the substance of Marty's day. Sorry to be repetitive, but it is hard to describe the frontal assault that disease makes on Ethiopian patients. She rounded in the emergency room with a team of interns led by a general practitioner (a doctor who has finished medical school and internship and attaches to a hospital for at least 2 years taking frequent night call and guiding the interns in their care of patients before going on to residency in a specialty) whom she respects a lot. The first patient had suffered two months of diarrhea and cough to the point that she had not been able to get out of bed for the last month. The team still does not know what was wrong with her and was afraid to hydrate her too forcefully since she was so malnourished. Next a woman with what Ethiopians euphemistically call “acute febrile illness” – fever and headache that could be anything from malaria to bacterial or tuberculous meningitis. Then another woman with new diagnosis – made in the ed – of AIDS infection and tuberculosis in her brain and throughout her lungs. On to a young man with tuberculosis in fluid in his lungs. Another young man whose kidneys were malfunctioning due to something called nephrotic syndrome and he had, again in great Ethiopian understatement, “body swelling”. And the sickest of all, a 30 year-old previously completely healthy lady who suddenly, 4 days prior, had developed a cough and increasing shortness of breath with a horrible disease that is poorly understood called adult respiratory distress syndrome. No euphemism here – she was in terrible distress despite the oxygen and diuretics and steroids that were given her. And there were no beds for the women patients on the ward.

Afterward, feeling as though she had been in a war zone, Marty joked with her gp colleague, Dr. Ole, that she didn't see many patients there with existential angst. Dr. Ole appreciated the comment and laughed and said, “No, and you probably won't.” As Marty got on her bike to leave she watched five men on foot carrying another young man from the street to the hospital. This is the Hawassa ambulance.

The challenge of the work – making the diagnosis as efficiently as possible, helping to figure out treatment, while maintaining compassion for the patient and his/her family – is for Marty very exciting. The analogy to the war zone and her response to it arose again later. We had supper last night with a young British journalist who is establishing a radio at the University. He had worked for the British Army in Afghanistan and spoke of the euphoria of being in the war, the excitement, how he loved it. We argued how hopeless and destructive the war was (gently, it must be said, because he is a kind young man.) But Marty realized that she probably could relate to his euphoria, that it may be similar to what she feels doing medicine in this difficult situation. It was a cautionary note for her own emotions, because that high can carry one, as in war, to do things that are inhumane and flat wrong. It is not enough.

The point was made this morning, when the interns reported that the team lost a patient, a young man with disseminated tuberculosis who had been started immediately on anti-tuberculars and had been at first on steroids. Most of the physicians, including Marty, had agreed that what was known of the disease concluded that steroids weren't helpful in this situation and Marty recommended that they be stopped. After initial improvement, he quickly worsened and died that evening. A knowledgeable and respected internist was critical of stopping the steroids, despite what the medical literature said, and stated he would have continued them since the man was so sick. He may be right. There is so much we don't know. Enthusiasm may lead to arrogance, a treacherous trap.

We are going out tonight for pizza at La Dolce Vita. Life is sweet here, but we need to remember to return before the bajajes stop running at 8 o'clock. The fast life in Hawassa.

February 4, 2012

Addendum: We were awakened last night twice by the whoop of a hyena which was so loud that he seemed to be on the porch right under our window. The second time, Marty couldn't go back to sleep but thought about whether the comatose young man being treated for AIDS with cryptococcal meningitis didn't really have cerebral toxoplasmosis. The CT scanner in town that the hospital uses to diagnose problems of the brain has been broken for 10 days, with no great outlook for its rejuvenation. So practitioners rely again on educated guesses for diagnoses sometimes with tragic results.

This morning we walked to town to buy food. The beggars in front of the bus station were harder to pass than ever. So Mitt Romney is not concerned about the poor? We wish there were a hell for such creatures.

Tonight we will give our thanks to Lemma and tomorrow enjoy the beginning of married life with Walalign and Beza.

Much love to you and know that we miss you.

Marty and El