Saturday, January 21, 2012

Monasteries Monks and Mountains

St Gyorgis Rock Church, Lalibela
I left Motta two weeks ago and now after long flights via Dubai and Bangkok and two nights in Sydney we are in New Zealand.. But before leaving Ethiopia we made a quick tour of the top tourist spots in Northern Ethiopia – Lalibela, Gonder, the Simien Mountains, the Monasteries on Lake Tana,and Addis Ababa. The  distances between these places are not huge but the road to Lalibela and the road north from Gonder to the Mountains are rocky dusty tracks that even 4WD vehicles struggle along – we went in a minivan, and passed several wrecked ones along the way. Lalibela is famous for the eleven 700 year old churches carved into the solid rock, and on  the Ethiopian Xmas Day  pilgrims flock to them in their thousands. My guide book reckons that if these amazing constructions were as accessible as the Pyramids they would be more popular. It also makes the point that unlike the Pyramids these are still living functioning sacred sites, and believers who get there perhaps only once in their lives leave with a huge sense of rejuvenation and re-invigoration of their faith that can only be felt in  such places. We didn’t see much in the way of organized religious ceremony, but there were spontaneous outbreaks of singing and clapping, open air preaching, praying and personal acts of devotion and worhip at every site, at every icon, at every gateway and altar throughout the site. We saw one man whipping himself – albeit rather languidly – but nothing else that was weird or hysterical. Everyone was dressed in white and on Xmas night thousands gathered around the churches and eventually slept there in the rocks and hollows and crevices round about. When we left, people in our minivan were ecstatic about their visit.
Our two day trek in the Simien mountains left us breathless, not just because of the grandeur of the scenery and the strenuous exercise but also because we were close to 4000 metres above sea level, and at night water in the puddles turned to ice. We also nearly froze. The “mountains” are really a huge plateau that rises steadily to its highest point,  Ras Dashen, but the sides of the plateau which was formed 30 million years ago have been gradually worn away leaving massive cliffs and escarpments falling away to valleys and river flats up to 2km below. The edges of the cliffs are inhabited by Gelada Baboons in their hundreds, and Lammergeyer eagles cruise the updrafts.
The view from our tent
The Monasteries on the islands and shores of Lake Tana were fascinating – well the two we managed to visit in our half day tour were. What I found fascinating first of all was the style of these buildings. They are circular wooden structures hundreds of years old, with a cone shaped roof and 3 concentric walls, the inner two defining the space where believers are permitted to go. A door through the innermost wall gives entry to what they call the Holy of Holies, a place where only priests can go, and which contains, in every such Church in Ethiopia, a replica of the “Ark of the Covenant”, a venerated object that only the Top Priest can ever view, and that happens rarely, perhaps annually. Ethiopians believe the real Ark is in the Holy of Holies in the church at Axum an ancient city  in the far north of Ethiopia.. I asked the guide about the Ark – what is it exactly, how big is it, what is it made of, why is it so sacred – he had no idea, and just kept repeating that only the High Priest has ever seen it – and apparently is forbidden to even  talk about it. This vast mystery in the centre of every church creates an atmosphere of intrigue and wonder that I am sure must heighten and strengthen  the whole religious experience for these believers.

Angels guarding the Massive doors into the Holy of Holies
The other fascinating thing at the monasteries were  the huge wonderfully colourful paintings that decorate much of the interior. These paintings, all crammed together and reaching from floor to a very high ceiling were essentially cartoons of all the Bible stories, a sensible way to get your message across to the illiterate Believers, and they were  frequently surprisingly  graphic and gory – but then the Bible is not all Sweet Baby Jesus in a Manger is it?  Beheadings, mass killings, people being tortured and burning in Hell, the martyrdom of the Saints, monsters and demons, snakes, drownings, plagues, - and lets not forget crucifixion! – I gasped  out loud when I saw the sword plunging into a pregnant womans abdomen with blood pouring down , part of a gruesome illustration of the story about Herod slaughtering all newborns when he heard a messiah was about to be born. The rest of the panel was full of soldiers and dead babies and blood!  Curiously there were also many illustration of events I don’t recall reading in any Bible I was ever familiar with – St George and the Dragon was a popular one – and there were lots of illustrated stories about the life of the Virgin Mary even regular western Catholics wouldn’t have heard – but would probably like – and so I asked the guide about them. He explained that there are many other  Holy Books besides the Bible, and they contain lots of such stories – actually that must be where the story is about killing pregnant women because I couldn’t recall that part of the Bible story  I was familiar with – I thought it was all newborn Boys . These holy books also contain the instructions about fasting and all the other behaviours and doctrines that constitute Ethiopian Orthodox Christianity and that make it so different from the forms of Christianity we are used to in the west. 

Wednesday, January 18, 2012

Last Week in Motta

Feet and Sticks of People standing around wtching Myrte buy some eggs

I had hoped my last week in Motta would be quiet. I needed some time to get things properly organized for Zoe’s arrival and for our tour, for Dr Ruth who was coming to take over from me and fill in a small gap before the next long term volunteer arrived in five days, for all the farewlls and goodbyes, even to have some quiet moments for reflection, to enjoy that peaceful evening rural scene over the fence from the flat one more time – but it was not to be. There was a flood of births, so the place was busy, and then a woman requested a hysterectomy rather than a 3 month trial of medication which I also offered her and hoped she would take – so I had to do that on Tuesday morning – we had another woman collapse with an ectopic pregnancy, I did a really difficult forceps delivery and fractured the babies skull – I thought I must have killed it but the next day it was behaving perfectly normal and the asymmetry of its head had almost disappeared – and then a woman arrived with a dead baby and a ruptured uterus. This turned out to be the most difficult case I have ever managed, because the rupture occurred under the bladder and the babies head tore its way up through the bladder and out the top, creating such  a mess that when I first opened her abdomen, the local Doctor assisting me said it was the worst case he had ever seen,  she couldn’t possibly survive “she is terminal “ he said and he urged me to  just close her back up. “The main thing” he said “ is that she doesn’t die in theatre. You have done your best”  I seriously considered taking his advice because initially, looking into her pelvis and at the bleeding and at the damage I thought to myself “This is impossible for me, Ive got no idea even where to start”  but then again, she was a mother of six living children…..
This looks much less chaotic than it actually is
Eventually I realised both ureters – the tubes that connect the kidney on each side to the bladder – had been torn off the bladder and her only hope was for them to be found and reattached to the miserable remnant of her bladder that I  identified deep in the pelvis. I had seen pictures in text books of this sort of procedure but had never tried to do it before – indeed I had never even seen someone else do it – but I was her only hope. “What we need are ureteric  stents” I said aloud, knowing we didn’t have any in Motta – these are specially designed fine tubes that can be inserted into each ureter to support it once resewn into the bladder – I may as well have been asking for  moon dust. However Myrte, who loved to be involved in everything interesting going on, and had been watching all that was happening, offered to ring her Dutch Oand G colleague Dr Hans who was working In Bahr Dar to see what he could suggest..” If you have any infant feeding tubes you could try those ” he suggested – and yes we did have some and Myrte knew exactly where they were. We were so lucky she had decided to stay and watch. I found the ragged ends of the ureters, trimmed them up and inserted the infant feeding tubes, then refashioned a bladder out of what was left of it and reattached the ureters! All that remained was to complete a hysterectomy, but it had taken over three hours, and she had lost a lot of blood. On the plus side she was still alive and urine was appearing in her catheter bag, but no compatible donor could be found amongst her eight relatives and then to make matters even worse for her I was informed that the Pharmacy had run out of a vital antibiotic I wanted her to have. This kind of thing send me ballistic – its too ridiculous for words for a hospital pharmacy to run out of vital medications – they blamed the Supplier but later I learned that the Hospital in Bahar Dar had stacks of the stuff – it was sheer incompetence and is the sort of thing that infuriates me more than just about anything – the fact that some petty idle unaccountable office worker can lazily subvert all our desperate attempts to keep this poor woman alive.. She – her name was Tiru - would need to be unbelievably lucky to survive, but I knew I had done all I could, and was glad we hadn’t just given up on her.

So when I left Motta two days later I was almost overwhelmed with a sense of frustration and failure and disappointment, that right to the very end all my struggling and fighting and energy had been useless against the inertia of the bureaucracy and a system that seemed moribund, and utterly incapable of change. In the midst of all that Zoe arrived, looking wonderful, and Myrte left, but I was exhausted I had been so busy I couldn’t get to the Bank to pay for our holiday, when Dr Ruth and her husband arrived I hadn’t had a chance to properly clean out the flat for them, the ward was full of difficult patients, and the woman with the ruptured uterus was not expected to live. I was walking away from a mess.

We said our goodbyes and climbed aboard the minivan and without much fuss left for Bahar Dar. My head was still spinning, it seemed imposible it was all over but I was too tired to think about much more than a long hot shower - the first in 14 weeks - and a lovely deep sleep in the Ethio Star Hotel in Bahar Dar, $28 dollars a night for a twin room with free WiFi and Breakfast.

Monday, January 2, 2012

What Happened

Relief after a difficult birth
With only a few days to go before my Shift here in Motta comes to an end Ive been wondering if Ive achieved anything. I know earlier I said I hadn’t come to try and save the world and that I would be satisfied if I had been able to help one or two women. But secretly I was hoping to achieve more, I was hoping to change and improve some of the way things were done, or not done, and especially I wanted to be able to leave thinking the changes, however small, would endure, that they were not happening just because I was doing it, or  were being done just to please me.

When Myrte arrived she also wanted to see things improve – it was shockingly easy to see where change was needed – and she, I think with more energy than I had, struggled mightily to enthuse and to reeducate and to lead  the students and the staff midwives to practice better midwifery, to be more diligent in history taking, in managing labour, in caring for the mother and the newborn babies with sensitivity, in maintaining charts and notes, in communicating with each other, in responding to abnormality and in being responsible.

Today, New years Day 2012 in every other country in the world, but December 22nd 2011 in Ethiopia,  is  the end of my 13th week here, my 91st day of continuous work at Motta Maternity,  and I suspect anyone who could observe the goings on there would reasonably conclude we had changed nothing. When we arrived for our Ward Round at 8.30 this morning there were no midwives in the building, there was only one student waiting , there was a woman in labour but no notes had been made and her name hadn’t been entered on the Whiteboard alongside her bed number, patient files were scattered across the desk in the office and not in the Inbox or the Outbox where they should have been, there was a filthy bed and mattress still waiting to be cleaned from yesterday, the blood pressure equipment was missing from the equipment shelf, and the Bedside Observations charts were not filled in because the Thermometer was missing. Yesterday we found a needle and a syringe in a wastepaper basket.

There was also a mother with a premature newborn baby girl who weighed 1.6kg. She was too premature to suck, her only hope was  to be tube fed but nothing much had happened in the 14 hours since her birth. The mother wanted to take her home and when it was explained the baby would die, she wasn’t concerned, and then with a start I realized I wasn’t either. And then I realized that what had changed over the last thirteen weeks was me!

When I was first confronted with this situation, a premature baby that needed feeding to survive, I tried hard to keep the babies alive, and was mostly quite quickly unsuccessful. I soon learned that premature babies didn’t elicit the same sympathetic responses from Ethiopian families as they do in the west, and that even when successfully tube fed, and go home, the odds are stacked against them surviving infancy, not just because of parental indifference but because of infections that their immature immune systems could never cope with. They go home to houses made of mud, to families of kids with snotty noses, fevers, coughs and diarrhea, without water or sterilizing methods needed to keep their feeding equipment clean( just a cup and a syringe) , to an environment where the concept of cleanliness and of disease prevention is unheard of.  A babies only realistic hope of survival is to be breastfed – there is no alternative – and everyone here, except for me, learned this lesson long ago. Here, if a baby cant breastfeed, it is doomed.This incidentally is why there is no such thing here as being unable to breast feed, a frequent “problem” in the west, where , because it can sometimes be initially difficult, the easy solution is to say its impossible and give up.

So its me who has changed as I have come to see the reality of lives on the edge of poverty. These mothers are not callous and uncaring  -  I  have seen joy and love and caring every day a baby is born here – but, so unlike me and my world, they  are deeply familiar with life and death, stillbirth and infant loss, even maternal death, the struggle to survive, their own history of famine and in the face of all that the need to be realistic and pragmatic.

They must think people from the west have no idea. And I think they are right – we have no idea about reality, about life and death, no idea at all. And I thought I was going to teach them. I am so glad I came.