Icebergs

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.

Changes

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.

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?

Yesterday

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.

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!

A Nice One

Spotted off the track between home and hospital

I was reminded by one of my friends not to forget to tell the beautiful stories, and I confess lots of my stories are indeed grim. I think that’s mostly because I am here to work at that very place where the stories would otherwise be much worse than grim - they would be your worst nightmares. It’s a grim place to be. Never-the-less there are some beautiful stories and this is one of them.

Shewanesh was pregnant for the first time and like just about everyone else who was going to have a baby in her village miles from Motta she didn’t visit the health centre or have any antenatal care she just waited for the day the baby would come. But one night she was quite sick and she vomited a couple of times so in the morning her family brought her to Motta hospital on a bus. I was leaving the hospital around 1pm as she arrived, and saw a crowd of midwifery students gathering round her as she lay there in her filthy ragged clothing and bare cracked feet, and I decided, on the basis of previous experience to investigate what was happening before going home. “She has vomiting” they said, but no-one was taking her blood pressure or her pulse or even listening for the babies heart beat. There’s one midwifery student who is absolutely the Best – like the Enrolled Nurse you come across in Australian Hospitals who is way better than most Registered Nurses – and I asked him to set up an IV line and get some blood off her, while another went to fetch the blood pressure equipment and something to listen to the baby with.  I tried taking her Blood Pressure, expecting it to be low because of dehydration from vomiting but couldn’t hear anything -  I listened higher – and higher - and finally got a Blood Pressure I couldn’t believe : 200/120.  Just as Aweke got the drip in, Shewanesh suddenly arched her back and clenched her teeth and started convulsing – it was Eclampsia! I was so glad I was right there – we gave her the magnesium, almost immediately – a dose IV and another big dose into the muscle of each buttock - we put in  a catheter, and then some IV medication for her Blood Pressure and she needed heaps of it and repeatedly. She remained unconscious after the fitting stopped as I did a quick scan with the donated Ultrasound Machine. It showed a live baby about 32 week size, 2 months premature and therefore  not mature enough to survive delivery, but that was what was needed if Shewanesh was to survive. Nevertheless I decided to give her a steroid injection that might help the baby if it was actually an undernourished and tiny 34 weeker, a distinct possibility as pre-eclampsia and eclampsia babies are often much smaller than they would otherwise be.

Most of our women have feet like this

I inserted the misoprostol, and six hours later broke her waters and started a drip to get the labour started. She was still unconscious and by then we had our blood tests back – it was terrible enough that she had eclampsia but she had a serious complication of eclampsia called HELLP syndrome, making it even more hazardous ( Platelets were 77, AST 280. ALT 240 for medicos!) The next day was Saturday so they were never checked again but in the meantime I was despairing – how could she survive this? Sometime after midnight I was called back – I had asked them to call me when the baby was being born – a tiny boy, about 1.6 kilograms, still alive. “Wrap him up, keep him warm, look after him” I said, and went home.

In the morning Shewanesh was still unconscious, still requiring additional medication to keep her Blood Pressure down, but had stopped fitting. I couldn’t see the baby anywhere “Has he expired yet?” I asked, and they pointed to the bundle at the foot of the bed. I unwrapped it – and there he was, still alive, breathing  and pink – which means his lungs were working well! “ Oh my God” I said “Hes still alive” And I decided we owed him a chance – all he needed was food.

We found a tube that I poked down into his stomach through his right nostril and we managed to squeeze a few mls of rich colostrum from his unconscious mother but it came back out his mouth – I pulled the tube out and saw it had a long row of holes along the last few centremeters so I cut the tube shorter so there was only one hole at the end, and poked the tube back down. This time the milk stayed down. We also got him a real woollen babies cap, knitted with wool I found in the Flat and gave to one of the cleaners after hearing she was a great knitter – that was after we had used a little cotton bag as a hat  for the first prem we tried to feed.

From then on we fed this one every three hours even though the old lady looking after Shewanesh didn’t seem that interested, much like the family of that other baby I had tried to feed in this manner, a surviving twin that eventually the family let die. Meanwhile Shewanesh was slowly recovering and regaining conciousness, and her blood pressure was stabilising. After two days, I noticed the old lady was taking an interest in the baby so I decided to teach her exactly what to do, with a midwife interpreting for me. She collected the milk in a plastic cup that she had to wash clean first, then drew it up into a syringe and then filled a larger syringe barrel connected to the naso-Gastric tube, holding it just the right height so that gravity would let the milk flow in steadily but slowly.We discovered this old lady was Shewaneshs grandmother, but she was now a “Nun. She had borne three girls but always wished for a Boy! She quickly got the idea, and took on the feeding job, and seemed to be very pleased with herself. She was wonderful really. By now Shewanesh was sitting up with assistance and starting to eat and drink again, and then she also started taking an interest in the baby. I saw her smile one day and she had the most beautiful smile.

Shewanesh, grandma and Baby :Note his NG tube and little red hat

And finally they went home, at their request, still tube feeding him and waiting for him to be able to suck. I asked them to return for a check in five days, and when they did, yesterday, and someone announced Shewanesh was back we all rushed out to see them. Lots of beautiful smiles and hugs all round. Her blood pressure is nearly normal so we reduced her medication, and the boy is still going with his tube and an occasional suck. We’ll see them again in a week. And to think that at one point I thought they were both going to die! Yes, that was a beautiful story.

The Cost of Living

The Donkeys are so sweet

Things were quietening down at work yesterday morning – well that was after I had done a caesarean at about 5am. Mother and baby are fine though the baby has a sore eye because it was poked  a few time during labour before it was realized the baby was stuck in whats known as a Brow presentation. Anyway after seeing all the women recovering from their various obstetric traumas over recent days, all recovering slowly despite their untreatable severe anaemias, I took a walk into town to change some money at the Bank. It’s the third time Ive done this, I change $US100 at a time – so in my first five weeks Ive spent a mere $200 - and I have crisp new American notes that I bought at a Bank in downtown Sydney. There are armed guards outside the Commercial Bank of Ethiopia and they pat me down, either missing or ignoring the contents of my pocket which usually includes my camera and mobile phone,but they usually confiscate my little backpack, keeping it in the sentry box till I return. Inside it looks pretty much like an old fashioned bank except there are lots of staff milling about, and a row of tellers behind a grill, but I am taken behind them to sit at the desk of an Assistant Manager.

He, and several others, somewhat incongruously – given that most of their customers are dressed in rags and have bare feet - are dressed in three piece suits and must get pretty hot as there isn’t any airconditioning. They unlock a storeroom behind the Assistant Managers desk and bring out a dusty machine a little bigger than an EFTPOS terminal, and after plugging it in, feed through it each one of my US notes. The machine is supposed to detect forged currency, and lets off a shrill whistle if the tested note doesn’t pass the test. The hilarious thing is that none of my notes ever do, and they test and retest them until occasionally one might get through without a whistle, but mostly for about 20 minutes, everyone is  having their hearing damaged by the alarm whistle bleeping loudly every few seconds as they madly feed and re-feed the notes through the machine which is clearly “non-functional “ – a term I here frequently round the hospital when I ask why a light isn’t working or why a machine is gathering dust in a corner or a clock not ticking: “Non functional” is the reply. Other Bank workers will come across and look at the machine and fiddle with it and experiment with different subtle techniques of feeding the notes, swapping them end for end, turning them over and back again but on it goes. If someone is foolish enough to retest the one that got through, it will almost certainly fail and the pile of  presumed fakes returns to its original number. It occurred to me, and I wouldn’t be at all surprised if in fact the machine IS functional but they misinterpret the meaning of the “Beep”. Anyhow I sit there trying to look innocent, bemused rather than nervous.

Meanwhile as all this is going on, someone else is copying information from my Passport and  filling out a form in Triplicate with all the details of the currency transaction, the days exchange rate, the number off each banknote  and so on. Eventually he returns with a wad of about 1700 Birr plus a few coins, gives it all to me, I thank everyone for their help, the Forgery Detector is turned off and I head out into the street! Its like a game we play every couple of weeks – I love it!

And yesterday I went next door to the Wubet Hotel for an Egg Sandwich and a St George Beer, sitting in the concrete courtyard outside : Total cost of Lunch : $2.40.

Working

Dirty work!

Ive had an horrendous couple of days at work, and there have been lots more power cuts than usual so there has been no water. Normally water is pumped three times a week to the hospital and then on those days Moges fills my buckets. But right now, at 3 am I think we’ve turned the corner and things are settling down again, nobody is in labour and its raining, so I am collecting rainwater coming off the roof. This is why I am writing instead of sleeping because I am waiting for the small bucket to fill so I can fill up the big ones which wont fit under the downpipe.

Ive just got back from helping deliver a stillborn baby from a woman I think  was probably diabetic. The baby died only yesterday, before labour had begun, and we discovered it when the mother came to tell us her baby had stopped moving.  I induced the labour with a misoprostol tablet which to make a safe dose I had to break into 4 pieces. The baby was born face first, which is a rarity, was very fat, and she weighed 4 kilograms, which is huge for this place, and makes me suspect diabetes. In Australia if we had diagnosed diabetes we would have induced labour 2 weeks early to avoid this very thing, but nobody routinely tests for it here.

Earlier tonight I did a caesarean for a healthy breech baby, and immediately before that did a caesarean and then a hysterectomy on a woman who arrived with the dead babys arm hanging out. The baby had been trying to come sideways, and getting it out was difficult, the result being tears in the uterus and lots of bleeding. This poor woman had now produced eight babies – 4  were stillborn, one born alive died a few months later , and she had three that were healthy! But this is not an unusual story.

And the third caesarean I have done in the last 24 hours was for another dead baby that I wanted to perform a destructive  vaginal delivery on but the head wouldn’t stay in the pelvis when I tried to puncture its skull, for reasons that became obvious when I opened up the woman abdomen – the uterus was torn open  - ruptured -and the baby was outside the uterus , lying free among the  bowels and a whole lot more blood. In her case the  best treatment was  to repair the  uterus but I did a sterilization procedure as well, something we had discussed with her before the operation.

In the last 24 hours we have also induced  labour – again, with a ¼ misoprostol tablet- and delivered a stillborn baby to a mother with eclampsia – she arrived 18 hours after her first convulsion . She hasn’t had any laboratory tests of any kind as she arrived too late on Friday for them to be done, and none are done on the weekend other than emergency blood crossmatching. However her urine looked like coca-cola, indicating dangerous destruction of red blood cells in her circulation, a worrying sign of complicated eclampsia, but tonight she is beginning to wake up, thankfully, and her urine is yellow again, a reassuring sign of improvement. We also have another woman with severe pre-eclampsia at 30 weeks of pregnancy. The treatment is blood pressure medication and delivery of the baby, which will not survive. Delaying delivery to give the baby a chance unfortunately is not an option as it risks the mothers health.

Oh yes, and at the beginning of Friday, before all this hit the fan, because it was quiet, I did a hysterectomy and pelvic floor repair on a women with a degree of prolapse we rarely see in the west but is common here, where – forgive me – the vagina is everted and hangs down  with the uterus behind it between her thighs! The procedure went very well and I was looking forward to a quiet weekend!

At one point today I hurried into the market to get some more bananas and tomatoes, and on the way passed the guys in the photos at last applying the mud/straw mix I had seen being prepared a month ago.



Home Visit

Coffee Ceremony with Shewayes Family Tigeste has a sticker on her forehead and is making everyone laugh with her antics

Shewaye is the schoolgirl  who does my weekly washing in a couple of big plastic bowls outside my flat, usually on a Tuesday. If the floor is dirty she will also wash it clean and do any dishes in the sink, and I give her $3 (50 Birr) if she does both chores. This is good pay by local standards - the junior midwives get about  that much for  a long days work – but Shewaye gives her earnings to her mother, who she says is very poor and is not supported by the father of Shewayes two younger sisters, Tigeste (4) and Mahlet (8) . Shewaye never knew her own father who died for reasons she doesn’t know  when she was a baby. She wants  me to help her with her English and the other day we set up her first email account because she came with the email address of a dutch midwife who worked here recently, and Shewaye wanted to send her a message. She was delighted to get a message back from the midwife but so far that is the only email she has received. I am getting her to write her reply on Word – its taking ages as she hasn’t used a keyboard before –then she will cut and Paste it to her email account.

On the weekend she visited me and asked me to come to her home and meet her family. It was a few minutes walk from the Hospital flat to where she lived, a little closer to town. Tigeste ran to greet us as we approached and held my hand with her own grubby little one, looking up at me and grinning, her  dusty hair in a wild sort of Afro style, and then older sister  Mahlet appeared, along with their mother. 

Their two room home is the middle unit of a row of joined flats I suppose you would call them,  made from that mud-straw mix with a flat corrugated iron roof, 10 feet from the cross street that runs up to the main one. There is a door at the front, one at the back, and no windows. The front room is a sort  of living room about 15 feet by 10 feet, and the back one, the same size,  seems to be for storage and sleeping – they all share a double sized bed  which has a big covered straw mattress on it. In the corner are a couple of large plastic drums of water. The floor is uneven trampled down dirt.  Cooking happens out the back in an open fronted alcove, one behind each flat and all joined together.  The  communal toilet is a deep hole with ragged plastic material making it private. The monthly rent is 150 birr ( about $9, and its all they can afford I am sure)

Shewayes mother at the back door - like so many women I have seen she has a large goitre
( an enlarged thyroid gland - look at her throat)

I thought this was just a casual visit but they had been to a lot of trouble to tidy up, put up some coloured synthetic material on the walls with a couple of posters – one was a very young Brittney Spears – and cooked fresh injera and accompaniments. In fact we then had a coffee ceremony but I was the only one drinking or eating, as everyone sat in front of me and watched. Eventually they seemed to accept my protestations that I had  had enough and couldnt eat any more and the food disappeared out the back where later I noticed the little girls cramming it into their mouths.

Walking back later, thinking about how generous they had been to me despite this families abject poverty, I remembered once giving the last of my daily bread to a scruffy  but charming boy who sometimes visits me at my flat. His name is Ibrahim and he is obviously from a poor family that’s struggling. He thanked me for the bread and set off for his home across the back fence just as an old man appeared out of the long grass, a very skinny and dirty old man dressed in filthy rags – Ibrahim turned back and broke off half his bread roll and gave it to him – and looking at me, explaining what he had done said “He is poor person”