March 8: Poverty and Power -- Electric and Otherwise

Greetings from Hawassa! March 8, 2012 - Happy International Women's Day!

Hawasssa U. students

Young mother with infant on Hawassa's main street.

Young woman carrying her baby. (Emilia's photo)

From Marty: Rain at last after three months of dry season! The ground was cracked, all grass was brown, the cattle and goats who roam the town and the fields seemed to be eating dust which filled the air and coated our skin and clothes whenever we went out (or stayed in, actually.) Elliot has lived in a desert for almost two years and has never seemed to be alarmed by dry seasons. I am a Midwesterner and a gardener at heart and become anxious with extended periods of blue skies. Actually, neither of us was attuned to Hawassa, where normal is a dry season from November or December to March or April. It is hot and rainless and windy and the animals either graze off what remains or survive on the hay that was cut in December. We have now had 3 days of afternoon and evening showers and are beginning to see the little green sprouts at the base of those lifeless brown floral carcasses. We are both sleeping better, though we worry that the mosquitoes will start breeding again and carrying their nasty little Plasmodia (malarial parasites) from person to person.

Walking back to Guest house, Nathan-Fratkin Residence

Our neighbor pounding hot peppers for berber.

Speaking of which, I am plowing through my London School of Tropical Medicine and Hygiene course (Freudianly initially written “curse”) and am now teaching what I have learned about those evil little parasites (Stop anthropomorphizing!) to medical students. Every day I learn something different about teaching medicine:

1. That it is perfectly ok to answer, “I have no clue whether Herpes Simplex Type 1 is more likely to cause encephalitis whereas Type 2 more likely causes meningitis,” and “I am going to have to check if Cryptococcus causes a rash.”
2. If I am supposed to do teaching rounds on a patient that is in severe respiratory distress (might any minute die from lack of oxygen due to disease) it is not only correct but imperative that I stop what I am doing and help the patient.
3. If I am scheduled to teach a two-hour power point lecture in the medical school, I do have a right to a room, no matter what the room-matron says.
4. When the electricity fails in the middle of the power point, it most likely will come back on.
5. When my students look asleep, they probably are.

I am also learning how to approach teaching all the diagnostic and therapeutic methods that are available in the US context but not in Hawassa. I forge ahead saying: a. These things exist but are not available here now; b. They should be available to save Ethiopian lives in the future and here is how they work and c. Think about how we can secure these important things so you can use them. I've used this approach on everything from sublingual nitroglycerin, cheap and essential for treating heart problems, to a functioning blood bank for patients dying from bleeding, neither of which do we have.

I am excited about my little place as an observer and sometimes an actor and teacher in the improvement in Ethiopian medicine. Referral now can culture urine and stool for bacteria (sorry if you read this as you are eating your breakfast!) and the main problem is making interns accustomed to their use when appropriate. And there is a plan by the lab to start culturing the fluid that comes from around the brain – the CSF – so that we actually can tell what kind of meningitis we are treating.

There is a functioning nebulizer now on the Internal Medicine Ward, though no-one but our chief, Dr. Birrie, knew it existed till this morning – he was gone last week – so asthmatics with trouble breathing can get relief. Again, we need an in-service now to tell all the staff how to use it. The interns do know how and do use the pulse oximeters to tell them if a patient has enough oxygen in his/her blood.

And low and behold, we will start adopting a way of evaluating whether we are treating our patients better – something called Quality Improvement or QI. Dr. Birrie just came back from a week course in Addis Ababa about it. We had already talked about compiling our figures on mortality and other outcomes based on diseases so that we could know if we are improving. I must say that QI in US institutional medical settings is probably the least exciting of any possible undertakings. But in Hawassa? Suddenly it gets my little heart thumping.

Thoughts on all this. I've been reading Paul Farmer's Pathologies of Power which I relate to almost thoroughly. (Though I really respect liberation theology, as an atheist, the God thing is not a functional approach for me. There are non-religious ways to come to the same moral, political, social and medical conclusions.) In many ways I am a luddite who believes that we should, as much as possible, tread lightly on the earth, that carbon-based fuels especially and manufactured chemicals should be used very judiciously. However, I agree with Farmer that the basic, miraculous advances of western medicine should be available to all people, including the poor around the world. Treatment for HIV, multi-drug resistant TB, diabetes, heart disease, but particularly treatment and prevention of the diseases of childhood – malaria, meningitis, pneumonia – are human rights. I am refining and tailoring my rage against the machine. I still ride my bicycle and will do anything to stop war, the most environmentally toxic, unsustainable human activity of our age (and maybe any age). But I've found clarity with Farmer's well-directed diatribe against the lack of inclusion of health and thus economic rights as human rights. In the United States the victims of poverty, the “throw-away people”, those who could not afford adequate food, shelter, clothing, education or health care, are hidden from the mainstream. In Ethiopia they are the mainstream, but hidden from the US and Europe.

Urban children

I agree with Farmer's “preferential option for the poor.” Not news to all my Brightwood colleagues, folks with Arise or Beloved Community Center or Northampton Survival Center, all of whom do what they do because they believe in this brand of human rights. But it is a clarification, a restatement of the reason that I am a doctor.

Farmer's analysis also recasts medical care in a broader sense, the same sense that my beloved boss Jeff Scavron sees it: passing a pill (if that pill works) is good, but health is a complex and contextual matter, and requires nutrition, a home, intact family, running water and sanitation, healthcare and education to guide choices and provide work and sustenance. Almost all Hawassans lack at least one of these things, and probably a majority lack several or all of them. This is both a medical and human rights issue.

Rural children with sugar cane

Man begging on main street in Hawassa

Old man with cataracts in front of his house in Bale Mountains with pile of firewood used to heat and cook.

Enough! I am going to be rounding with the interns and general practitioners in the Emergency Room on a regular basis, at least for this month. This is one of the Referral jobs I like most, a surprise since I was not, by any means, an ER jockey in the States. I also am creating and will be teaching all staff a course on Basic Reading of EKG's (though the ward EKG machine is missing at least one of its leads) and a lecture on fluid and electrolytes to the medical students (though we cannot measure electrolytes.) More on all that next blog.

The Professor on his way to work at Hawassa U.

Elliot’s Thoughts:

We have reached some sort of ‘compromise’ about the electricity with the university, namely that they will give us in the Guesthouse power twice, mornings and evenings. Of course what they need is more power, a separate cable to the guest house that doesn’t make ours run through the water pump for the dormitories. I guess they feared a real riot if 25,000 students could not wash.

I am into the second semester teaching Development Anthropology; I am not as enthusiastic as I was first semester. I must say I am getting weary teaching students of whom only a few speak decent English but the majority of whom brazenly copy papers, occasionally cheat, etc. Marty says this behavior is part cultural – “not to help your friend is shameful” - but it is also desperation. If these students don't do well, or even if they do, job prospects are pretty dim, particularly for Anthro majors. Unemployment is still 50%. The Federal Government's goal of mass education is notable, but they are expanding much faster than they can provide for.

Hawassa U has 25,000 students and they want to double that in 5 years. The Anthropology Dept has just proposed (and was accepted) an MA program, but who will teach these courses is beyond me. The other faculty (there are six of us) have now been asked to teach four courses each per semester (for a monthly salary of $240 or so). I offered to teach another course, but was outright rejected – I think they think that is shameful to use me that way. But at least I am one of the guys now (only female professor is pursuing PhD in Italy), and we can bitch over our beer and Tibs (roasted meat) together. Four other faculty are pursuing their PhDs out of country (in Norway, US, India) so in the long run this will be a strong department. It is the short term that weighs down on us.

Marty seems to have a more satisfying job, even though it seems exhausting. She goes off every morning (by cross town bicycle) and directly engages focused medical students and very sick patients. Unlike us academics, she gets to see the results of her actions everyday - the patient gets better, the patient doesn’t get better and you try a different approach. I am less directly engaged with my students here, much less than at Smith. The students are shy, deferential, and do not come to see me during office hours, although some like to walk and chat with me which is actually the highlight of the day. But I can’t get students to break out of the ‘learn by rote and don’t ask any questions’ mode of education here, something that seems common in developing countries.

While I am not doing direct research, I am becoming very interested in Ethiopia's policies towards pastoralists and agro-pastoralists. The government has an ambitious plan to develop irrigation agriculture, hydroelectric power, new roads and universities, and hospitals. All well and good, and their main strategy is to attract foreign investment, including large scale agribusiness (for bio-fuels, sugar cane, rice, cut flowers), much of it coming from Saudi Arabia and India. But many of these projects are in underpopulated regions of the country, meaning the dry lowlands where pastoralists live. (The government’s base are peasant farmers, which is where the TPLF came from.) For the most part, the government sees nomadic pastoralists as ‘primitive’ and wasteful, and would like to seem them settle down, ostensibly to improve access to health care, education, social services. But this has meant displacing and resettling pastoralist groups from the river valleys being converted to irrigation agriculture (i.e. Awash, Omo, Gambele rivers valleys). Human Rights Watch recently released a report on barren resettlement villages for Nuer and Anuak agro-pastoralists in Gambela region, and the Awash River has had long term displacement of Afar (Danakil) pastoralists for sugar cane production, although their clan chiefs cut their own deals with the main companies for grazing access. Anthropologists are seen as troublemakers who want to "keep people as living museums" rather than “improve” them. I organized a panel for the next year’s American Anthropological Association meetings in San Francisco that will deal with land issues and displacement, something I look forward to writing about.

Cattle in Oromiya

Still, things are not bad here on a daily basis. Had my flat tire repaired on a sidewalk bike stand; Marty and I had pasta and mango juice for lunch at our favorite balcony restaurant on the city’s Piazza – Hawassa’s main thoroughfare, lined with palm trees and bougainvillea. And the wind is pleasantly blowing through our apartment as I write. Cheers for now, Elliot
Here are some photos, just pretty or interesting I think

Calf lying in street. (Ell says never too many cattle!)

Distributing the Coca Cola in Dila

"Motel Muluu" in Shashomenie

Young people on the back of a lorry.

Art shot of Ethiopian baskets in market. (Thanks, Emilia)

Art shot of grains in market. (Again, thanks Emilia.)

Woman selling coffee pots in market. (Emilia, again)

Woman in market (Elliot's shot)

School children in Kenya

Sunset over Hawassa (Marty's reliable sunset shot)