Saturday, December 31, 2011

A Sad Day

Once I had passed the halfway mark on my 2200nm solo sailing trip to Tubuai earlier this year and everything had progressed smoothly to that point, numbers of people congratulated me as if I had already arrived and suggested from there on it would be a piece of cake, plain sailing, all downhill, no sweat….But of course then the wind went round to the wrong quarter, and strengthened, and the seas developed into something quite wild and so the last week turned out to be the toughest week I had  ever endured sailing.

Something similar seems to be happening here, as my last week begins, and the event I had been dreading since arrival, the thing I am here above all to try and prevent - maternal death - finally happened. To be honest at times Ive felt lucky that it hadn’t already happened - Ive felt like a lone and inexperienced goal keeper leaping this way and that to keep out  a furious barrage of  attacks, but that it was only a matter of time before one would get through. Never-the-less as the last week approached I started to hope that maybe on my watch, none would – but that all changed yesterday: a mother died ; her name was Erteban, she was only 23.

I wrote early in my stay here about Etewa who arrived looking dead, with a dead baby stuck in a “Brow” presentation. We performed a so called “destructive delivery” on that baby, using an instrument to penetrate its skull so that its contents would be expelled and the head collapse making vaginal delivery possible. Erteban arrived looking as dead as Etewa did, with no recordable Blood Pressure, semi conscious, dehydrated and the  babies head stuck in the birth canal. It was dead. We found out that she already had a healthy toddler and this was her second pregnancy, that she hadn’t had any antenatal care and had been in labour at home and had been trying to push the baby out for six hours . Then her pains all stopped but by then it was midnight. In the morning they carried her for four hours to a road and caught a bus to Motta and she arrived just after lunch. As is typical here, she had on a horrendously filthy dress, her arms and legs looked as if they hadn’t seen water for months, her feet were dry and cracked with souls that were as thick and hard as a layer of bark on a tree, and she could barely lift her head up. One valuable but ominous sign that  Ive learned to recognize, is that in someone who has previously had one or more babies , if contractions stop after thay have been in strong labour for a long time, and now the baby is dead, it probably means the uterus has ruptured. And when that happens there is a massive internal bleeding. It seemed very likely that this was what had happened. So, whereas for Etewa major abdominal surgery was avoided by the destructive delivery, Erteban was going to need it, even though she was in shock and desperately ill. Without surgery she would soon die from ongoing internal bleeding,  and infection carried into the abdominal cavity by the baby expelled ther from the birth canal.-but the operation by itself could kill her – but it was her only hope.

We took her to theater and it took an hour and a half to deliver the dead baby – quite a large baby for a small Ethiopian woman – and to repair  a huge tear in the side of the uterus. We guessed she had lost close to two litres of blood. At the end of the procedure it was still not possible to record her blood pressure, her pulse was racing at about 150 beats per  minute, her breathing was still fast and shallow but there was urine in her catheter, the only reassuring sign. We tested all six of her accompanying family members to find someone with compatible blood, but were unsuccessful, and she was too unwell for transfer to Bahar Dar where there is a blood bank.. We were doing all we possibly could, which was not very much.

I couldn’t imagine how she would even survive the night, but she did. In the morning she was still desperately unwell, but blood pressure could be recorded, she spoke a few words, and her temperature was normal. On the other hand her pulse remained close to 150 and her breathing was very fast. She struggled on all day as we watched for some sign of improvement but it took hours for our one daily set of limited blood tests to come back, and the X-Ray machine has now been unfixed for eight months, so it was impossible to see if she had heart failure or pneumonia – so I treated her for both. In fact nothing we did seemed to make much difference and her condition worsened with a rising temperature, increasing restless ness and then unconsciousness. Infection was setting in. Late on the second day, when it was clear she would not survive the night, her grieving brothers and husband decided they would like to take her home. Tears ran silently down their faces as we removed the catheter and the IV lines that had given her the fluids and antibiotics and other medicine that had prolonged her survival to that moment, but now there was no denying it, it was too late for her. Hopefully she would survive the road trip and being carried in the middle of the cold night along that four hour track to her village, where the rest of the family could comfort her for however many hours remained. It was moving to see how much they all loved and cared for her, and how dignified and how true was their conduct. It seemed worse to me that these poor ragged farmers who already had almost nothing should have even their young mothers and babies taken from them. Strangely I felt more numb than sad, and I thought about everything I had done and  wondered if there was something I could have done differently. In fact numerous things suggested themselves to me, and there are some things I would do differently next time, though I am not certain the outcome would have been different . However I do know that if they had made that four hour trek to the road at the beginning of her labour rather than at the end, it would have been: but how were they to know?  Mother nature can sometimes be a very cruel midwife.

My (Late) Xmas Message

When it was Xmas day where you are, it was December 15th  2004  in Ethiopia– and  December is the 4th month so the date was 15-04-04. Obviously therfore  nothing out of the ordinary was happening that day, and certainly there has been no counting down of the remaining shopping days to Xmas. I am glad to have missed all that ghastly commercialism that everyone professes to deplore, piously blabbering on about the true spirit of Xmas, when in spite of all that deploring and sanctimony, and not to mention how ghastly it is that we might have to pay more to save the world from the warming caused by our own pollution,  people still manage to find  obscene amounts of money  to spend on  Xmas presents and feasting. And if that wasn't enough in Australia they have Boxing Day Sales where I read the other day in the Sydney Morning Herald its estimated just over 14 billion will be spent in shops over the xmas and new year period, and in London on Boxing Day shoppers spent 50 million pounds!

Religion isn’t big in New Zealand or Australia and so, because its in Summer for most of us antipodeans Xmas is about getting presents and having time off work with family and apart from shopping - and spending 14 billion dollars- heading to the beach, swimming, fishing, sailing, recharging the batteries. Quite a few will make their annual token visit to Church, enjoy a bit of Carol singing then head home for a massive meal. The Ethiopian Orthodox Christians celebrate the Xmas season in a way that seems a bit more in keeping with the Christian story of birth in a cow shed, by fasting till lunch time every day for the month before, and when they do eat they avoid eggs milk and meat – I couldn’t persuade Moges to eat a lolly the other day because he thought milk or eggs might have been used to make it!  I keep telling him its time to get a new religion, and whenever I am asked about mine, and I tell them I don’t have one because  there is no such thing as a God like the one christians and muslims talk about, they think I am playing a huge joke on them and find it hilarious, and just about split their  sides laughing. Its amazing how easy it is to accept without question that something is an undeniable fact when nobody ever challenges it!  And should someone ever do that, well they have got to be kidding right? Notwithstanding the language barriers, I know it would be pointless to try and explain why I no longer believe in a god so I dont bother,- I just laugh along with them.

Xmas will be celebrated here at the end of next week, but Myrte and I decided to have our own western Xmas celebration anyway.As usual I left my Xmas Shopping to the last minute, forking out on a present for Myrte yesterday at the Market that set me back 60 cents. I thought to myself "Shes a good person, shes come way out here to help these poor people all at her own expense so hang the cost, go all out and get her something decent ". So I did but as there were no Xmas cards in the Market  I made her one.

The day started busily, with an emergency Caesarean but after that not much else happened at work, so after lunch we went to Shewayes home and the kids there watched the Lion King on Myrtes Laptop computer. We had popcorn, orange drink and Injera. The weather was beautifully warm during the day and there was no wind, but at night temperatures fall to about 8degreesCelsius. As the day ended we sat on our plastic chairs in the roughly cut long grass outside the flats and sipped  Sundowners that Myrte cleverly assembled from locally produced Spirits, mint, lemon sugar and ice – a Mochito! It was quite special to sit there as the sun went down and to watch the cattle and the sheep eating their piles of straw across the fence, the locals in their traditional dress going to and fro, a setting that  would only need a baby in a manger to make it the perfect Nativity Scene, and have you believe that maybe  Peace and Goodwill toward all mankind is possible after all.

After sunset, Myrte prepared a lovley soup, and then we had spicy fried chicken ( the last three pieces of the chook we killed about three weeks ago )  with boiled and herbed new potatoes - all beautifully prepared by Myrte - and boiled cabbage beautifully prepared by me. Lastly she made crepes - well we decided that was the closest description of them - with a  sweetened raisin and cinnamon filling. We worked out that our Xmas dinner had cost about $4.80, and the raisins had been the most expensive item. It was a Xmas Day to remember.

PS Apologies for the long delay in getting my Xmas post onto the Blog.  For some reason access to it, and to any other blogspots from my Computer is impossible, though I have no trouble accessing email or any other  website I want to. However I can access my blog  from Myrtes computer,  and I can still Post to the Blog but not view it., and uploading photos is impossible. Can anyone suggest why I cant get to my Blog from my own computer? (Ive already changed my Browser - to Chrome - deleted temporary Internet files, defragged the computer etc etc..

Friday, December 30, 2011


A Short message : Sorry but I am having trouble this week getting my Posts onto the Blog. If this Post gets up then I may have found a solution, in which case I shall post again soon.

Thursday, December 22, 2011

Third Time Lucky

She is very happy but there is good reason for the sadness in her eyes
This is a story which nicely illustrates, among other things the difference made by  having someone in Motta who can do a cesarean section., and is about a woman I saw in clinic about a month ago. She was sent to me so I could do an Ultrasound scan and try to work out when her baby was due. As usual I asked if this was her first pregnancy and was told it was her third. “And how did the first two go?” I asked. “Both alive but no any more” – a tragic and too common sory round here, for someone to have children which subsequently die, usually of infectious diseases. But I dug a bit deeper and found out that they had both been delivered here in Motta and one died within a few hours and the other in a few days of  their birth. The only other detail I could get was that they had both been delivered with forceps, and the mother described what sounded like some sort of a head injury to at least  one of them as a result. None of this was recorded in her notes because the old file was lost and as usual the midwife filling out her new one didn’t make any attempt to find out what had happened to her children other than recording there had been two. Inadequate history taking is one of the deficiencies in antenatal care that Myrte and I have both identified but to date we have been too busy dealing with acute clinical problems in the Maternity ward to have time to get to the Clinic to do something about it. The “History” we were taught way back in Med School will give you 80% of the diagnosis, and its no different here.

Now there are many possible reasons why her babies could have died, varying from prematurity, infection and haemorrhage to birth injury and congenital abnormality, and so to try and prevent her losing a third baby we needed to find out as much as we could. The Medical Records system here –and elsewhere in Ethiopia – relies on the patient remembering the unique hospital record number  which is written on a small piece of cardboard and given to them when they first enter the system. If the patient loses the card or cant remember the number  - both are much more likely than the card being kept - it is impossible to find the old file and a new one is started. In this case however I was able to track it down by looking in the Birth register for the day  a couple of years back when she said the second baby had been born. I should have expected it, but after the excitement of finally tracking them down, the notes were a disappointment, and contained almost no useful information. The brief description of the labour and forceps delivery contained not even a hint that it was all anything other than routine. Indeed just about every “Delivery Summary” is usually the same three or four sentences with only the sex and weight of the baby changed!  So I was no further ahead but I wrote in her now combined old and new notes that I wanted to review her in three weeks and that I was to be notified immediately when she came to maternity in labour.

The usual "Delivery Sammery"
In fact I didn’t see her again till she was a week overdue, last week, when she returned for a check up.  Simagnew, an excellent senior midwife who had been away when I first saw her, recognized her immediately  because he had been present when the second baby was born – he described a ghastly horror of an instrumental delivery that was hugely traumatic to the  mother as well as the baby whose head was barely in the pelvis when the forceps were applied, and the babies death was no surprise to him.  The poor woman had been through this twice, and her husband - a teacher at a distant rural school - actually used the word "killed" when describing the births of their first two children to me later. The  only other option on those two occasions would have been to transfer the mother to Bahar Dar, by which time the baby may well have succumbed, and possibly  the mother also from a ruptured uterus. And in Bahar Dar forceps delivery may have been attempted with the same results both times - its impossible to know.

Obstetric Forceps : Scary but Life-saving instruments usually
However I suspected that this womans pelvis was just too small for safe normal birth, but to be certain I had wanted to see her in early labour,  when there would be time to arrange a caesarean if the head wasnt fitting nicely into the pelvis . However , here she was, a week overdue and when I checked, my suspicions were confirmed - this babys head was what we call "floating", not showing the least sign that it would fit into the pelvis. Sometimes its difficult to decide if a caesarean is necessary but this decision wasn’t and the next morning we delivered a healthy baby girl.

Saturday, December 17, 2011

Managing Help

"Condom Ball"= inflated condom sewn inside cloth patches: surprisingly robust football
When I heard last week that a delegation of the senior managers from the Amhara Health District were going to be at the hospital I asked our local medical director if I could meet  them to discuss the “human resources” problems we were having in Maternity.  I was told there was a meeting at 10 the next morning I could come to, but when I went it had been deferred to later in the day. I waited for a call but nothing happened for the rest of the day or for the first part of the next morning so I went looking for them, because I knew they would be heading back to Bahar Dar later, and I didn’t want to let them get away without hearing what I wanted to say to them.  I gate crashed a meeting they were having with the supplies and store managers, introduced myself and they agreed to meet me at 11. And they arrived in Maternity at 12.30 just as I was starting to think maybe they had got away after all!

I told them that in the year before volunteers like myself and Myrte started coming to Motta – about 18 months ago – there had been less than 700 births at Motta, which was staffed by 8 midwives. Since then two midwives had left and not been replaced, but birth numbers had increased to over a 1000. Were the two midwives not replaced because now there were two “Farenji” working there for free? Of the remaining six, three were “Degree” midwives and three were “Diploma” midwives and of the senior “Degree” midwives, two were away getting training most of the time and the third had been formally warned about his attitude to work and was today, as usual, not at work though he was supposed to be – I told the bureaucrats I wanted him replaced as he had already had his three formal warnings and nothing had changed. Of the three junior “Diploma” midwives one, an excellent guy, had gone to work in a private clinic in Bahar Dar for triple the pay he got at Motta. Why would he return to work really hard in Motta for half the pay of the lazy one? He was a real loss but I had every sympathy for him. Of the remaining two diploma midwives, one was away again training somewhere and the last remaining midwife I had just sent home as she had worked alone – except for students and myrte and myself – all the previous day and the night just gone – she was exhausted. There were no employees  left, so Myrte and I were once again the only trained staff in the unit. What I wanted from the bureaucrats was a commitment to replace the lazy one and to bring staffing levels back to eight. Then, I said , midwives would still be able to attend training and education courses, but this would  have to be done in a co-ordinated way, and staffing levels could always  be maintained at a safe level without individuals becoming exhausted and disenchanted with the local system.

Lots of agitated talking in Amharic followed, and the leader of the delegation thanked me and expressed his concern about what had been happening and apologized. He promised “action” and seemed genuinely concened, but then he said something that worried me, not about replacing the lazy one or finding more midwives but about punishing the ones who had taken unauthorized time off, and about the local managers having the authority to deal with these problems – it sounded as if they were washing their hands of the problem. 
Selling corn
Now I am afraid all Ive done is make things worse for the midwives who are already here, who possibly regarded the ability to go and get more training as a benefit that made staying here bearable. The reality is that Motta is a backwater, and most of the  doctors midwives and other staff are here because  by working in such  a place they work off their free education sooner than they would if they stayed working in the bigger centers. And once they’ve worked it off they can go wherever they like and work for whoever they like – all the doctors here cant wait to get back to Addis and do further training and “get rich” as one said gleefully to me a while back.. Its disappointing to realize they are preoccupied with their own advancement and aren’t  all that interested in the terrible problems of rural Ethiopia, but then again they are just ordinary people, and have the same desires, strengths and weaknesses as all  of us.

So  they know they can get rich  by working in “Private “ clinics and for overseas Aid organizations -  NGO’s – which, thoughtlessly and needlessly often pay  rates which are as much as 5 and 10 times higher than what local medical personnel would otherwise get. This clearly, in the context of  such extreme poverty and dire need, is obscene and it completely distorts demand and supply, and undermines the ability of the public system to function except with the “left overs” that the NGO’s and Aid organizations didn’t want. The NGO’s of course then have the problem of staff who see themselves as being on the “Gravy Train” of western aid - I have heard that not far from here, in a hospital funded by overseas donations to a famous charity, massively overpaid local specialists with 4WD vehicles, Laptops and Mobile Phones supplied are working hours and at a pace that suits, and doing very well for themselves thank you very much. Its easy to imagine how donors in the west would respond if they knew how their funds were being squandered on a gravy train for already well off doctors. Meanwhile in the understaffed public hospital a few minutes away, a hospital from which those on the Gravy Train were lured, women are literally dying in the corridors. And this is happening right now.

This aspect of the way in which “Aid” can undermine and corrupt an indigenous system struggling to take root, and create a cargo cult mentality and dependence rather than self reliance and independence is really the very opposite of what aid should be about.  In that context “Aid” is more like a salve to a guilty conscience for the west and a nice little earner for a privileged few in the third world, with the added benefit of some direct assistance to a few of the underprivileged. In fact “aid” should be about enabling those needing it to take charge and deal with their problems themselves. This is what we are trying to do in Motta, and I think progress is being made but it’s a long slow process and there may well be setbacks on occasion. If the “action” that the managers here take is the easy option of punishing individuals and not remedying the underlying staffing problems, my recent efforts will have to be counted as a blunder and we will have to think of a better approach and try again.

Monday, December 12, 2011

Ive had better days

Alternative Uses for staff Toilet in Hospital with no running water
On Friday night I woke about with a sore back and I remembered how earlier in the day I had been helping shift a semiconscious woman off the operating table. There are no theater assistants so anaesthetic nurse, scrub nurse and doctor have to do the transfers.Usually this isn’t hard as most people here are really thin, but on Friday the patient was heavy. I rubbed my back for a while and gradually the pain eased and I went back to sleep. A couple of hours later I woke with the pain again and it seemed worse so I took a couple of paracetamol tablets, but this time couldn’t get back to sleep. In fact the pain seemed to intensify. I couldn’t lie flat in bed so I got up feeling restless and uncomfortable, pacing round the room but that didn’t seem to help much either. Eventually the pain was so intense I started to throw up, and then I realized it was coming in waves and was centred over my right kidney: it was renal colic!  They say the pain of renal colic is the nearest a man can come to experiencing labour pain – so I tried to tell myself this should be a useful learning experience, but really I just wanted it go away, and to hell with learning experiences. Just after 8am Myrte appeared as usual, because we usually go across to maternity together but I was on the floor with  my head in a bucket – I explained what was going on and asked  her to go over to maternity and bring back some diclofenac, an anti-inflammatory analgesic – I was tempted to ask for a narcotic but I recalled that they can make the spasms of pain worse – and she duly returned and injected it into my backside. An hour later my pain had subsided to a dull ache, and by the end of the day I felt washed out and tired but the pain had gone completely and has not returned.

Fortunately there were no dramas in Maternity on Saturday until about when a woman in early pregnancy arrived in severe pain. I had never diagnosed a ruptured ectopic pregnancy with ultrasound before but even with my limited ability the blood inside her pelvis and abdomen was obvious. My initial thought was to send her to Bahar Dar – bleeding from an ectopic can be massive and can kill, and we have no blood bank – and I felt pretty wrecked myself. We tested her only  available relative and his blood wasn’t compatible, so I felt I had a watertight case to send her away but then we discovered the hospital vehicle was out of town taking the medical director to a meeting!

(In fact with him out of town for the weekend it meant that I was the only doctor in Motta! I probably shouldn’t have been surpised that all 4 medical doctors had the weekend off together because all but one midwife was also rostered away for the weekend – in Bowral where I used to work in Australia, there would be at least six rostered over the weekend and there we only had medium and low risk women, and about 2/3 the number of babies. How on earth did they expect Mintamir to cover maternity on her own for 72 hours? In fact what we did was send her home on Saturday and Sunday during the day and Myrte and I covered the place, as we had done  the previous weekend when the same rostering farce was in place : more on this later)
Stacks of teff harvested by hand as far as the eye can see; Hospital bottom right

But now I was stuck with this patient  – I really had no choice but to operate then and there – I reasoned the sooner I did so, the less blood loss there would be and the less need there would be for blood. I explained all this to the woman and her husband using Mintamir as my interpreter – she  had just returned in time – but the woman would not agree to surgery. “Alright” I said, “we will keep you here on a drip overnight and if your condition remains stable we will try and get you to Bahar Dar tomorrow. But if your condition deteriorates  we may have no choice but to do the surgery, blood or no blood”

I kind of like it when patients refuse to let me do something I don’t really feel like doing, but this was not really sensible. Fortunately, a little while later they got me to speak on their mobile phone to a relative  in Addis Ababa, and though I had no idea what the guy on the other end was saying, such was the quality of his pronunciation and of the mobile phone signal, at the end of the conversation she agreed to have the surgey right away.

In the west this procedure is usually done as “Keyhole” surgery and is usually fun to do, and often the patient can go home in a few hours. In Motta however we don’t have the expensive equipment needed to do it that way, so we do it the old fashioned way, which means making a 4 inch incision in her abdomen. In fact removing the damaged and bleeding fallopian tube was quite straightforward, and though we mopped a couple of hundred mls of blood and clotted blood out of her pelvis she did not need a blood transfusion, but will need a couple of days in hospital recovering before going home.

When I went home I was pretty worn out so it was lovely that Shewaye the schoolgirl who does the cleaning, had made me some very nourishing soup. She had arrived in the morning  when I was writhing around on the floor and spewing into the bucket waiting for Myrte to bring the injection. The three of us were planning to go the market, but in the end Shewaye went on her own while I lay on my bed slowly recovering, and Myrte went to the hospital and saw all the patients without me. Shewaye returned from the market later and made the soup that was waiting for me when I got back. It had been a memorable day for sure – I had never been so unwell, ever - I need to increase my fluid intake to stop it happening again. It’s the sort of thing you dread ever happening when youre on your own at sea.

Friday, December 9, 2011


This Orthodox Christian Priest often visits the Hospital and is highly regarded by all
Its easy to write stories about my successes and about the things that turn out well, but I have to tell you , not everything does. In the interests of balance and a more accurate perspective in relation to my work here I should tell you about some of the bad decisions Ive made, and the one the night before last was a horror.

I was woken about 1.30 and asked to come to maternity because a woman had arrived in labour with twins, and the first one was coming bottom first  (breech presentation) and one foot was already out. And indeed that was what I found, when I got there. In fact she was a woman I had seen about a month earlier, when we estimated she was around 30 weeks pregnant, and noted both babies were breech. I gave her some steroids then – two injections dramatically improve a babies chances of survival if born early - and indeed, as is common with twins here she was in premature labour. I used the ultrasound  machine to check on twin 2 – I saw one head above the other and concluded Twin 2 was also still in the breech position. However, at that time both babies seemed well and the labour had been progressing well, and ,given they were about 6 weeks early, they were small and ought to come out easily, probably in the next hour or two so I didn’t  see any reason to deliver them by caesarean section. In the back of my mind I also thought it would probably not be a good idea to do a cesarean on  premature babies that might not be mature enough to survive anyway.

Well, as expected before long the mother felt the urge to start pushing her first baby out, and soon both legs popped out, and then the bottom appeared. With her next push we expected to see the babies abdomen and for the arms to come but they didn’t – they seemed stuck so I felt around to see why – and almost immediately realized twin one was about to die, and there was nothing I could do about it. Such a  sickening and horrible feeling is almost impossible to imagine, but it filled my guts as  I realized that what I could feel near the shoulders of twin one was not twin ones head but the head of twin two, and it was never  going to be possible to get twin ones head past it.  Twin two had not been in the breech position at all but was actually in the usual position that babies are in when they are born, with its head down, and I had  failed to recognize it. The head that was uppermost on the scan was actually twin ones and as it descended, it forced twin twos head before it and into the pelvis, and now they were all stuck there, so-called “Locked Twins”- look at the number “69” and think of twin One as the 9 with the circular part being the head and the tail being the body and legs - and twin Two as the 6 – if you pull down on the tail of the 9 you might be able to imagine how the circular head of the 6 might get pushed down by the head of the 9 if it cant squeeze past…and as the enormity of my blunder descended on me like a cliff toppling onto me, twin one died!

Meanwhile the poor mother was consumed by an overpowering and irresistible urge to push the rest of her baby out and kept squeezing and pushing twin two down and trapping twin one even tighter and I was momentarily paralysed with indecision, not having ever faced this situation before or even heard a story from someone else who had and not knowing what the hell I should be doing. It takes an hour to organize a caesarean and I had previously had the debate with myself about doing one and decided it was a bad idea – so how could I get Twin 2 out?  “I think destructive delivery is better” said one of the midwives and I quickly searched the instrument collection for something to use – a large knife, some powerful scissors – could I decapitate Twin 1 so Twin 2 could come out past it? Or would I have to decompress Twin 2’s head – empty its skull of contents – at least I had done that a few times before - so Twin 1 could be delivered? “Oh my God” I kept thinking to myself “this is the worst horror-“. The mother crying out, a dead baby hanging by its neck, another one trapped inside….At times like this you regret  and curse every little thing you ever did that got you into this mess, you regret ever coming here, ever doing obstetrics, ever doing medicine, you regret not being an accountant or a school teacher or a librarian or anything that lets you sleep all night and not have to be involved with life and death and have people thinking you know what the bloody hell you’re supposed to be doing, and looking at you with fear and confusion on their faces, people who trusted you and thought you would help them and now here I am in this horrendous disaster and its all my fault….”shit shit shit” is what I kept saying to myself, my mind spinning wildly.

And then suddenly I realized what I should do – Twin 2 was still alive- there was no way I could kill it and decompress its skull - we should do a Caesarean and try to get it out before it too was dead. I woke up the theatre staff and the anaesthetic nurse, urging them to be as fast as possible, and they responded well but it still took nearly an hour . I opened the uterus quickly and grabbed twin ones head and pulled her out – she was long dead, but Twin two followed and she was alive and remarkably vigorous, requiring  virtually no resuscitation at all. She was warmly wrapped and taken back to the family and her husband waiting in the cold air outside maternity, a large group of people I had to walk past on my way to theatre, feeling like a mass murderer – hopefully they would be kinder to me now. But once the operation was over and I went back to maternity, I discovered the baby weighed only 1.5kg meaning she would be lucky to survive – she was too small and too premature.
In Theatre
And so, at the end of it all, she had the caesarean I didn’t want her to have but it was unavoidable, and she lost the twins she had been unhappy to discover she was carrying when I first met her and did the scan a month before. If I had been a bit cleverer and realized twin 2 was not a breech, we would still have had to do the caesarean, but it wouldn’t have been preceeded by all that horror and pain and misery for the mother, and panic in the family and hospital staff including me – albeit momentarily. And after the caesarean Twin one may also have succumbed to her prematurity and low birth weight as did Twin 2 eventually,  but at least she would have had a chance which I regret she was denied because of my blunder. It was a miserable way for a baby to die and a horror for her mother – but fortunately she is young and tough and I expect will return in a year or two to try again.  Certainly by doing the caesarean this time she avoided the likely natural outcome of locked twins for the mother, which is death, so it hasn’t been all negative. We have given her the chance to eventually end up with an obstetric history something like that of so many of the women we see here –  after perhaps 7 pregnancies, 2 stillbirths and 1 infant death : 4 live and healthy children. And I daresay they give thanks to God for them.

Tuesday, December 6, 2011

The Honeymoon Phase

Courses can be a great way for an NGO to use up its Budget, and they sound good in the Annual Report
I’ve just finished reading “Three Famines” by Tom Keneally, an amazing author who might be best known for the book that was made into the movie “Schindlers List” I downloaded “Three Famines” to my Kindle before I left Australia. The three famines he compares and contrasts are the famous Irish potato famine of the 1840’s, a famine in Bengal around the time of the second world war, and the famine in Ethiopia barely 25 years ago. In relation to Ethiopia he mentions Bob Geldof of course but not my father, which is not all that surprising though he also was part of the world wide response to that famine . My father, a marine engineer, came out of retirement in his mid 70”s to be the “Chief Engineer” on a ship called “Ngahere” which with an entirely volunteer crew sailed  from port to port in New Zealand collecting the tons of  food, clothing  and equipment that was donated by Kiwis. It then sailed to Port Sudan in the Red Sea to unload it all. But I digress.

All three famines were utterly devastating and horrific.- "well yes David they were famines! " I hear you say! Millions of lives were lost and it was ghastly to read about people being reduced to eating grass,bark, rats, dogs that fed on corpses, and even the corpses themselves: cannibalism. The view expressed by Keneally and many others, which was new to me was that in all these famines , domestic extremes of ideology and political interference was not just an impediment to the relief of famine – something we probably all accept – but to a large extent it was a cause  of the famine in the first place. Thus for example in Ireland – which was controlled from London – food EXPORTS continued to England where politicians either refused to believe there really was a famine in Ireland, or else believed  that market forces were at play and shouldn’t be interfered with. In Ireland starving people who couldn’t pay their rent were kicked out of their dwellings which were then pulled down so the occupants would leave the estate they had lived on, so they died of starvation and exposure in ditches and on the roads. In Ethiopia the psychopathic communist dictator  Mengistu destroyed the traditional way of life with a policy of soviet Russian styled Villagisation, and then when it failed, denounced news of famine as anti-government propaganda. Much western aid was diverted to feed his army and his support base in Addis Ababa, which was defended by troops who brutally turned back the thousands of starving who tried to go there for help.
Monument erected in Motta during the reign of the psychopath Colonel Mengistu
I know this is a fairly long bow to draw but its occurred to me lately that in a similar way its not so much the reduction in resources that’s the problem in our hospital but the way in which the resources are distributed and managed, and I am sure it will be the same for most if not all hospitals here in Ethiopia. In Australia the huge difference that a good manager makes to the way an organization like a hospital functions is obvious, even though resources there seem unlimited, but here, with so few resources I am beginning to realize, excellent managers are vital. Unfortunately so far I haven’t found one.

Take bed sheets and blankets for example. And yes, I know this is a long way from cannibalism and death in a ditch but we continually run out of clean sheets and blankets. On a recent cold morning on the ward round I came a cross a woman and her baby lying huddled under a thin cotton garment on a cold plastic mattress – no sheet, no blanket – and the baby had been born at about when lately the temperature drops to about 10 degrees at night. I asked myself what kind of hospital doesn’t have a sheet and blanket for a mother and newborn baby? The point is we do have these things but the laundry system is dreadfully inefficient  and the staff utterly resistant to changing its work rate and practices, with the result that  over the weekend, and at night piles of sheets and blankets are locked up in the .laundry and inaccessible. The reason I know they are inefficient and resistant to change is because I went there to find out why we kept running short – everyone there started shouting at me at once, waving their arms around and shaking their heads and when I shouted back and told them all to shut up I just wanted to talk to their Boss – well that got me nowhere as well!

Another example : Staffing. I think I may have already mentioned that there are six midwives on the books, three junior and three senior, one of whom almost never bothers to turn up – so effectivley there are five. There always used to be eight but the acting Hospital Manager tells me they are not advertising for replacements – and then, when the already depleted staff request leave for study courses or whatever else, they seem to be given it almost automatically and without any regard to who else may or not already be on leave with the result that on occasion we have had only one staff member in the entire town available to work. And if someone or someones baby dies because a single midwife can only do six things at once – is the manager going to accept responsibility for allowing the hospital to be so depleted of professional staff that it was inevitable?

The other day the hospital had no water! And Ive already mentioned the fact that the Xray machine has been “non-functional” for now 7 months. And for the last three weeks  the Lab guy tells me hes been waiting for the chemical reagents needed to enable him to do Liver Function tests. Well my question is why did he run out? In maternity if someone needs an IV cannula for fluids, or medications or a urinary catheter, a midwife has to write out a sort of shopping list, and while we wait a family member has to be found to take it to the dispensary and buy it all and then bring it back to us . Why, I have asked, couldn’t we have a supply of everything we  might need in maternity so we can have immediate access to it and then later have the family replace what we’ve used?  No-one seems to know!

Initially when faced with these unusual ways of doing things, one tends to find them curious and quaint but eventually the cuteness wears  thin and they just seem absurdly inefficient wasteful or ridiculous. Yes folks, the Honeymoon is definitely over!

Thursday, December 1, 2011

The "Global" Financial Crisis - yeah, right

Waiting for something?
I watch less and less of the BBC World Middle East Edition these days because I am getting a bit bored with the Global Financial Crisis, this imminent Eurozone catastrophe that’s about to affect the standard of living of so many Europeans, so many Italians, Spanish , Portugese and the Irish.  I watched a man being interviewed about how it was going to affect his business, and how he might have to lay off staff.. In the background of his bookshelf lined living room an open Laptop could be seen on an elegant looking desk, and he walked past a huge Flatscreen TV  to look out the window and lament the outlook for living standards in Portugal. I looked out my window and saw a bare footed woman in a filthy green dress bent double under the weight of firewood she was carrying home and turned off the television. I suppose it must just be the lack of a global perspective that makes people fear having only one car, or fewer holidays abroad, or even having to use public transport, or even having to be sustained by government handouts. And I don’t doubt people do find it hard to adjust to having to step back from a lifestyle they had enjoyed or were expecting to continue. And yes perhaps their standard of living will drop, but to what level? – to something well above real poverty I am sure. I cant see that millions of westerners are suddenly only going to have one pair of trousers, no shoes, no running hot and cold water, chronic malnourishment and no radio or TV, oven, fridge or internet access.

From here its so blindingly obvious that the entire “west” is living way beyond its means, way beyond a level at which all basic needs are reasonably met, way beyond a point that in the face of reality in the third world could reasonably be justified, that the feared “Austerity Measures” could perhaps  more accurately be described as a “reality check” . It seems – no it IS  - wrong, surely, that on this now tiny planet there are people wealthy enough to employ a fulltime crew in uniform to look after their mega-yacht worth tens of millions of dollars, while millions and millions of their fellow human beings try to survive on $2 a day.  In the west there is an “Obesity Epidemic” for gods sake, and people pay extra to buy jeans that are pre-ripped and pre-aged, trying to act poor when in fact they have so much money they barely know what to do with it. If they are trying to identify with the poor of the world, let me tell them that people round here wouldn’t even dream they could have something as nice as your precious pre-faded and pre-ripped jeans. Come here and I’ll show you what ripped and faded jeans are REALLY like!

Well patched shorts, commonly seen
People have written to me and said after reading about Motta they feel bad about the way they live, and yet I know these are decent ordinary people living average lives in the west. I don’t believe any of us need to feel bad about where we happen to have b een born,  I am not writing this blog to make people feel bad, and I don’t want to sound like an old Testament Prophet calling down fire on the west.. The truth is the west is my home and I think its absolutely wonderful.  Well, mostly.

The truth is that without the “west” and the fabulous advances made by science I would have nothing to offer these people, no special knowledge, no medical training, no way of even getting here, no antibiotics, analgesics, anticonvulsants, surgical instruments or anaesthetics, there would be no vehicles to get them to Bahar Dar, no blood transfusions or fluid resuscitation, no ultrasounds or  even forceps to deliver their stuck babies. Life would be “nasty, brutish and short” ( I forget whose words they are ) 

Todays Lesson :Living on $2 a Day 101 :Cant afford a new plastic bowl? Stitch the  wrecked one together!

The reality of our lives in the west is that we are privileged and remarkably rich, even without a mega-yacht. The Media however encourages us to  be preoccupied with what we want but don’t have, to keep the wheels of advertising and commerce turning, constantly comparing our lot with those freaks of celebrity and movie stardom  whose gross lifestyles are shared by almost no-one  on the planet. Instead I think we ought to be preoccupied with how much we already have, and celebrate all that’s wonderful about the “west”, not just all the amazing advances given us by science, and our comfortable life styles but also the “ideas” that have flourished in the west, ideas of freedom of thought and religion, of equality and the rights of women, the democratic institutions, the right to an education and to work – so much that’s extraordinary and too often taken for granted. But if you are going to have to put up with “austerity measures” remember that for most of the people in the world, life under even the harshest of the Eurozone “Austerity measures” would be a wondrous blessing by comparison with the deprivation and poverty of their present lives. I think we ought to rejoice in the good fortune of having been born in the developed world, make the most of the opportunities we have been handed, take nothing for granted and where possible at some stage in some way, whether big or small, give something back. Psychologists believe that this is the most likely pathway to true happiness and contentment.

Monday, November 28, 2011


Myrte, Dr Merawi and Kipur
The day before yesterday walking away from maternity ward I saw a small boy with a shaved head and baggy pyjamas walking slowly along the covered walkway by himself. As I passed I looked down at the top of his head and saw it was covered in horrible sores and pustules – “no wonder he's in hospital” I thought to myself. Today I met him. His name is Kipur, he is 11,he was infected with HIV at birth, he has Tuberculosis and the reason he came to hospital – if all that wasn’t enough! - was because  a month ago, when he was admitted to the childrens ward, he was starving to death : he weighed 12.5 kg, the average weight of a 2 year old in Australia! Underneath those baggy pyjamas he is just skin and bones, the skinniest human being Ive ever seen, his arms feel like twigs you could snap with two fingers. And to think that only yesterday I wrote that the famine wasn’t affecting these  parts of Ethiopia.

I also wrote that the people here are living on the edge and he illustrates how close, because with an immune system depressed by HIV, even though he receives the anti HIV medication, infection has been robbing him of the little nourishment he gets at home and he has been slipping further and further behind. In addition to being fed, Kipur is getting antibiotics for his infections, cream for his infected scalp, and 3 packets every day of PlumpyNut, a chocolatey sweet and nutrtitious nutty paste specially formulated for the treatment of malnourished HIV +ve patients. Beside his bed is a standard razor blade for slicing open a corner of the PlumpyNut packet so he can squeeze it into his mouth like toothpaste. Hes been here a month and can now walk again, and has put on 4kg. It’s worrying to think that even though he was in a fully funded programme for HIV positive people, apart from dishing out medication no-one seems to have been monitoring his health. Its also worrying to wonder about how many other kids are out there like him ; there are probably hundreds, maybe even thousands…..but I don’t think anyone really knows.
Like superstrength Peanut Butter
The reality seems to be that in Ethiopia the organized health services treat only a very small proportion of the total need, the merest tip of a massive iceberg of disease and disability. In the pediatric ward today, for example there are 4 children, an absurdly low number even just for Motta township, reputedly home to 40,000 people – there are undoubtedly many many more sick kids out there, and many are dying – the question is why aren’t they in hospital?

As far as women having babies are concerned, its been estimated that our hospital is the nearest one to a population of over a million people, and if that’s true something like 30,000 women are giving birth in our area every year, but we only see 1200,  about 4% of our potential work load. The sad implication of that statistic is that even if all our mothers were to have perfect outcomes, and all their babies were to survive and be healthy, the effect of all our efforts in Motta would not be noticed in the ghastly statistics that describe the outcomes for mothers and babies in this region where the huge majority of births occur out in the country, out of sight, out of mind and out of contact with anything that resembles modern medicine. Having seen the misery and horror of the few who manage to drag themselves in  to Motta, I shudder to think of the scale of  suffering and of injury and loss happening hour by hour  as near as perhaps 30km away but who may as well be on the far side of the moon for all the help we can be to them.

Ive heard that plans are afoot to seal the road between here and Bahar Dar beginning as early as next year.(next year, 2005, starts in September in the Ethiopian Calender) If so it will dramatically improve the ability of huge numbers of people to access health services, and potentially have a much greater impact on Maternal and child health outcomes than any  piece of modern equipment, drug or foreign volunteer doctor programme. However, the services  currently in place will be completely overwhelmed and utterly unable to cope unless huge improvements in hospital infrastructure and  especially medical manpower are in place in time for when the road is sealed. Discussing this with Myrte the other day I said “ I am starting to feel what  I think the iceberg might have felt when it saw the Titanic heading for it”

I am not really discouraged by the fact that a road will have a bigger impact on health than all my efforts, or that my contribution wont make even the tiniest blip on the statistics, because I always knew I wasn’t going to be changing the world. However every now and again here in Motta something I do makes a big difference to the life of one poor family, a difference that might not have happened if I wasn’t here, and that’s enough for me.

Sunday, November 27, 2011


Stacks of Teff
Ive been here eight weeks now and for the first six was the only foreigner in the hospital, but now I have been joined by Myrte the volunteer midwife from Holland and things certainly have changed.. We have been very busy with difficult patients and complications, but there has also been time for the introduction of a plan to make the place better that I had been working on before Myrte arrived  I had written it up as a  Power point Presentation and after working on it with Myrte I presented it to the midwives and the 14 student midwives a few days ago. Essentially we wanted to improve communication and organization within the unit, quite simple changes which we felt would enhance the care and the outcomes women would receive. My idea was that we would outline the plan and then work steadily on implementing its  eight points over the next few weeks. Myrte however had other ideas - she was expecting it to all be implemented right from Day One, something I felt would be too much to expect. One of the changes we wanted to make was for every patient to have their vital signs recorded  and entered on a bedside chart every morning at 8am, and then for everyone to meet and do a “Round” of all patients together at 8.30. I also wanted to assign individual students to particular women, to give them some personal interest in the case and take on some of the responsibility for caring for her. In the “west” these activities have been a normal part of hospital practice probably since Florence Nightingale and hardly seem revolutionary but here, they are foreign ideas which my predecssors have also tried to introduce but without success. The practice of  midwifery here is largely  what I call “reactionary”, that is to say nothing is anticipated or prepared for , nothing is done until something else happens to prompt it – and this is true for things like running out of stationary and batteries, and for managing labour in someone for whom it could easily be anticipated that there could be problems.
The morning after we made our presentation, to our amazement every bedchart was filled in by  8.30 and every midwife and student  was present for the ward round. After the round they split off to do the tasks needed for their assigned patients instead of milling round like a mob of confused sheep getting in the way, and later still, when the work was all done Myrte gathered them all together for a discussion about care of the newborn. She has got tons of energy and is full of enthusiasm for midwifery and for improving the lot of the women here, and that I think is why our little plan just might succeed.

Cutting the Teff
Meanwhile, the fields of teff have been harvested. The rocky track to the Hospital passes through the middle of  one of these fields which cover the rolling hills in all directions around Motta, so it was easy to watch the harvest. I was amazed at how quickly a line of 17 men with small sharp curved sickles moved across and cut it all down,  in a sort of self induced frenzy, shouting and yelling encouragement to each other , then stacking the bundles to one side as other men with pairs of bullocks ploughed up the ground where only hours before  fields of golden teff had been growing. The tiny seeds from the teff are the base ingredient for Injera, the staple food of Ethiopia. It was the failure of these crops because of drought – and also because of inhuman Government policy, including massive expenditure on arms instead of health in the 1980’s - that led to devastating famine in the region. It was the trigger for the first “Live Aid Concert” and that catchy “Feed the World” song. The famine currently happening in the “Horn Of Africa” is affecting  mainly neighbouring Somalia , as there clearly isn’t a crop failure in Northern Ethiopia where I am, but its easy to imagine, seeing how poor and on the edge people are here, that crop failure would rapidly see famine re-emerge.

Tuesday, November 22, 2011

Driven to Drink

Anyone who has ever visited a predominantly Muslim country will have heard the calls to prayer that start at some ungodly hour in the morning and carry on through the day at intervals. Ive always resented being woken by these calls, quite apart from not being a Muslim,  but especially because, as in several countries where Ive endured them in the early morning, not only are they are amplified and horribly distorted by loudspeaker to reach way beyond their traditional range, but they are usually recordings rather than live. In fact the Immam and local muslims probably sleep through the racket, much as people living near railway tracks eventually don’t notice trains thundering by in the night, and the people disturbed by it are visitors and non muslims for whom the calls are irrelevant.

Here in Motta there are several Mosques and they do indeed broadcast their calls to prayer, and they are bearable. However, something I had not come across before is similar broadcasts from the several Christian churches in Motta, and these are absolutey horrible. The Muslim calls last ten or fifteen minutes but the Orthodox Christian ones go on literally for hours every Saturday night and on various other  “Holy Days” and believe me there are way too many of them. The monotonous wailing and howling in three unmusical, irrythmical semitones utterly ruins a lovely peaceful afternoon and sometimes goes on all night. Every so often theres a short break and I always fall into the trap of saying to myself “Thank God its finally finished” at which exact moment it starts up again - I don’t know how anyone puts up with it. I lie awake dreaming about a gun and blasting the hell out of the loudspeakers, and the tape recorders, and …well no I wouldn’t shoot the orthodox priest but maybe a few shots into the dust to get him fleeing down the road to Bahar Dar would be satisfying. I am sure no self respecting God would permit such an abomination to be performed in His name : ipso facto, there cannot be one! But oh the relief when it finally stops....

Whatever was wrong with a few nice church bells on a Sunday morning?

Thursday, November 17, 2011


Vultures in a field ploughed 6 weeks ago, now sprouting green shoots
Theres a movie that I haven’t seen called Ground Hog Day, but I believe its about someone reliving the same day over and over again – an eastern concept I suppose, the cycle of birth and rebirth turning over and over until somehow or other, one escapes into a better place. But work here is very much Ground Hog Day, pretty much the same thing day after day, always challenging and too often dramatic and tragic but that same mix of poverty, chaos, frustration, blood , dirt and death.

Yesterday was a perfect example: we have only six midwives here – one took leave last week, but was not missed as his contribution was never more than minimal. Another took annual leave for two weeks starting two days ago, and yesterday three more left to go to a 3 day course on contraception, leaving one midwife and myself plus, luckily, a new volunteer midwife who arrived from Holland 5 days ago.  But this sort of mismanagement of staff is common – slightly less annoying was when they were all at a conference at the Wubet Hotel every day for a week – at least when we needed someone we could call them back!

During the morning,  the hand held device for checking a babies heart beat stopped working because the battery was flat. Fortunately the midwife who controls access to the Store room had left the key to it with me – I insisted as previously the key went with the midwife and we couldn’t get needed supplies – grrrrr- so I went to get  another battery – but there were none ( of course ) Eventually, it was decided that someone coming back from Bahar Dar  today would bring one (!) – I insisted they should bring at least four! It will be interesting to see what turns up – the wrong size perhaps?

Meanwhile a woman gave birth to a very small baby from an abdomen that looked like it should have had a much bigger baby in it – and fortunately Myrte the astute Dutch Midwife realized the other possibility was an undiagnosed Twin pregnancy – and so it proved to be, our sole remaining working local midwife confidently delivering the second one as a breech, as I watched. But of course, sadly these two little boys were  doomed, far too premature to survive anywhere in Ethiopia except perhaps in the big hospital in Addis, though at 1.2 and 1.5kg, in Holland or Australia, given their vigorous health at birth, they would very likely have survived and developed normally -not always of course, even in the “West” bad outcomes will still result despite every effort – and there will be up to date figures on the likely survival of twins of that size published somewhere – but my guess is at least 75% will go home eventually in near perfect health. Instead, we warmly wrapped the two little boys together and they were embraced by their mother who lay there with them until in a couple of hours, they quietly “expired”, a single tear in their mothers eye. And then her poor family took her home.
The One Birr Note ( = 6 cents )
Later, at about 9pm, I gave up squeezing fresh air into the lungs of another baby we had just delivered, hoping it would start to breath but the only sign of life was his beating heart. His problem was the opposite of the twins, he was born after a long labour well past his due date by the look of his skin and all the meconium he was covered in at birth. The student midwives  looking after him had said the  babies heartbeat was “fine” in labour, which really just means “present”. We don’t have the sophisticated machines we use in the west which record the exact rate and the pattern of its responses to contractions,  information which can alert us to the possibility of the babies distress. But when I checked it myself it was very fast, an indicator of probable distress and so we accelerated its birth with a Kiwi  Cup– but it was too late. Even so, the husband and grandmother tearfully embraced me and hugged my legs when after 20 minutes I decided to stop trying to keep the baby alive. He had a very sweet face that baby….

A typical Motta house
In amongst all those dramas, and with the mostly useless  student mdiwives getting in the way all the time we had a couple of women arrive bleeding with miscarriage, other women needing scans, we diagnosed a urinary fistula in a woman who had given birth to a dead baby at home about a month ago, and we brilliantly managed the labour and delivery of a healthy boy to a woman having her first. She was a sister of one of the midwives on leave so everyone was very concerned and there was an enormous throng of family and friends and other hospital staff in attendance, and at the beginning of the labour things looked challenging as the baby was in an unfavorable position, not nicely settled into the pelvis.Even I, forever the optimist about womans ability to give birth naturally, had warned that she may need a caesarean. In this situation, with all that family and colleague pressure, its easy to think of a reason to do one, but there are only two bona fide reasons for a Caesarean in labour – obstruction, and fetal distress, neither of which were present. The tendency in the west is to delude yourself, and think that you can predict the future, and advise gravely,  that if labour continues, one or other of these conditions will develop, so the caesarean may as well be done now ( rather than later, and interrupting golf perhaps? ) This dilemma is sometimes rather duplicitously – if that’s a word - presented as a “choice” between a caearean now and contunuing - which is the strictly correct thing to do -with a subtle message that the baby might be harmed if not delivered  immediately – and which frightened confused and anxious mother is ever going to turn down the wise counsel of her trusted obstetrician? Hence a caesarean rate of around 30%.  And millionaire obstetricians.  The obscenity of it all seems stark from this place.

Sunday, November 13, 2011

Market Day

The Markets
Every Wednesday and Saturday is market day in Motta, and the population swells by hundreds as country folk flock to a large dusty open space surrounded by local buildings in the centre of town to buy and sell and I daresay to catch up on the local gossip. Walking there along the road crammed with mules pulling loaded carts and donkeys piled high with sacks of  grain or firewood and lots of women struggling along with huge loads in hand made baskets on their backs is a great distraction from the frustrations  and disappoiontments and stresses of work, and I soon feel a sense of excitement and fascination with the foreigness of it all. People with like products set up their stalls, or spread their wares out on a sack on the ground near each other but in a disorganized sort of way, and there they sit all day in the hot sun, occasionaly under a makeshift awning or umbrellas, crowded together, no doubt hoping  to sell off their produce sooner than later and head off home early. If its  been raining of course theres slippery mud and puddles everywhere.The Saturday market is the bigger one, the crowds are shoulder to shoulder, its standing room only as you thread your way through looking for the best onions or coffee beans or tomatoes, cabbage, green peppers, beetroot, ginger, spices, salt, herbs, corn, beans, eggs and live chooks, handcraft, oranges, sugar cane, bananas,  and all sorts of other produce some of which I do not recognize. There are also people selling cooking oil, kerosene, old and new clothes, traditional cotton garments, sashes, empty containers, barley, and rice, bundles of firewood, dried cow dung for fuel, and at the periphery rows of tailors making alterations and patching up clothes on old treadle sewing machines. Nearby people with hot coal clothes Irons are waiting to press new pleats into your skirt or smarten up your best trousers. Like this kind of market everywhere it is dynamic, full of colour and smells and noise, and great to pick your way through

Shit for Sale
Most of the people here are very poor and its quite pathetic to see someone sitting in the dust in the blazing heat trying to sell a few miserable vegetables or some empty cans or plastic bottles. At the edges of the market like carparks round a supermarket, are collections in various places of mules with attached carts,  and clusters of donkeys, scores perhaps even a hundred or two altogether, usually immobilized by being tied to each other or to a post or by having their two front legs bound together.

Initially I went with Yemataw or Moges , but now  Ive been several times on my own to buy fresh vegetables. I can count to ten now so can usually work out the price being asked, and as there doesn’t seem to be any kind of bargaining, and prices generally seem fixed, its quite simple to look about for someone selling nice looking produce and grab  a kg of potatoes or a cabbage, or some bananas. I try to time my trips on Wednesdays and Saturdays to fit in with a stop at the Wubet  on the way back for lunch of  beer and an egg sandwich, and then back towards the hospital I call in at Jamals shop for a top-up card for the Internet and things like  macaroni, sugar, peanut butter and bottled water. So far I havent been called urgently back to the hospital from the midst of my shopping expeditions but I suppose inevitably one day I will be, but I'm not looking forward to a 2km dash in the heat with a load of veges in my back back. And eggs!