Tuesday, September 16, 2014

Return to Motta

Motta view showing new Church dome
The person who was supposed to come to replace me in  Jahun didn't arrive. I heard there were Visa issues but I also heard of a high drop-out rate for people assigned to west Africa since the ebola outbreak. So on my last night in Jahun I offered to cover from midnight, so that Dr Goya would get at least half a nights sleep - but as it turned out, I wasn't called. In the morning it was Tuesday and I had my last cold shower in the bathroom that usually had several dead cockroaches on the floor, and on one occasion a rat swimming about in the toilet bowl. After breakfast we headed back to Abuja. the long boring ride south to the Capital and to various "de-briefings" at which I mostly praised the workers in Jahun and mostly was a bit critical of some of the managers..

My return flights were through Addis Ababa and so I had requested and been granted permission to break my return in Addis and have a few days to visit my friends in Bahar Dar and Motta. I arrived late on thursday evening and stayed in a quite upmarket Hotel, and I had two beers and chocolate cake for desert. In the morning I flew north to Bahar Dar on the shores of Lake Tana, checked in to the Ethiostar Hotel - about $20 a night - and went for a wander around the nearby shops. The thing that was great to see were women wearing something other than the muslim coverings - it was not just the joy of seeing female curves again but the realisation that here women had so much more freedom, they were free to express themselves in their attire and hair-do's , in their choice of who they walked down the street with and with  make -up. There was just a sense of being out from under the oppressive domination of religion.

The next day I caught the crowded bus to Motta. The fare is 60 birr, about $3.  Its a very slow 120km ride on a horribly rough and muddy unsealed road through  wonderfully scenic terrain, the most noticeable feature being the throngs of people walking along it. Its a rainy season so the fields were all green and luxuriant in their   acreages of Teff and corn, in one place there were sunflowers and everywhere the wonderful little donkeys. Ethiopia felt quite wonderful after Jahun, at least as poverty stricken but there just seemed to be a sense of freedom and almost of joy in the air.

I had warned Shewaye, the schoolgirl who had been my cleaner and helper in Motta, that I would probably be arriving on September 6th - and I did - but that was the western Calendar date and she was expecting me on the 6th according to the ethiopian calendar - which was still several days away! Consequently there was no-one to greet me when I got off the bus - so I walked through the village to her house and surprised everyone when i stepped up to the door of their two room mud walled and bare earth floored apartment!  But they quickly got the Coffee ceremony going and we caught up on all the news and then I checked in to the local Hotel, called the Wubet, the place I visited innumerable times when working in Motta, for beer and lunches of egg sandwiches or a "burger" of a very rudimentary kind. To my surprise, foreigners are charged double for a room, 500 birr for one with a hot shower. It was a reasonably comfortable bed but there were lots of mosquitoes.

The next day I visited the hospital where I had worked for five months in 2011 and 2012. Ethiopian trained doctors had now taken over the role of Obstetricians and so there was no longer a need for "Farenji" doctors. I met Dr Tenaw who I realised was a much more useful person to have there than I ever was because he had been trained in Emergency Surgery. So he could do bowel resections and set fractures and do various other surgical emergency procedures as well as deliver babies by caesarean when needed. The Maternity ward was full and not as clean as we used to keep it or as organised, but it was functioning and according to the stats on the wall, achieving excellent results. 

It rained on and off during the day, so the streets became muddy quagmires. I got my haircut for  about 40 cents and then later in the afternoon I took a walk with Shewaye  to St Georges church, a large church near the centre of town that somehow I had neglected to visit during my time there. Its the typical circular building in the centre of a few acres of ancient trees. At one edge of the enclosure a new building was under construction and inside I noticed a tall object hidden under sheets and cloth. I asked the armed guard if I could go and look at it, and he let me, explaining that underneath the sheets was the sacred object that only select Priests are permitted to view on certain days of the year, an object that is normally concealed in the innermost chamber at the centre of the circular church. It was out here because a new one had recently been installed and this was the old one, now over 300 years old. He removed the coverings and we beheld this amazing ancient relic with its various shelves and partitions and folding doors. Inside it would have sat ancient Bibles and manuscripts. It was a sort of "Indiana Jones" moment for me, to see this once revered and holy of holiest objects.
St Georges Church, Motta

The following morning I got back on the bus and returned to Bahar Dar after tearful good byes from Shewaye and her family, and returned to the Ethiostar. From there I returned to Addis and caught the night flight to Hong Kong and on to Sydney, arriving at 6am, sleep deprived and jet lagged. I had further debriefings in the Sydney MSF Offices and then had a few days to catch up with family, see my Doctor and an Eye specialist , and repack my bags for Fiji, and Sapphire Breeze.

Friday, September 12, 2014

The real Heroes

My time at Jahun has come to an end. It has been an exhausting challenge made somewhat more challenging by the loss of some of the vision of my right eye and with it, binocular vision up close. I cant read with my right eye any more and I had to make a couple of extra grabs at sutures in surgery on occasion. The side effects of the high does steroids were unexpected and weird as well – my balance was disrupted and I felt a kind of dizziness all the time, and my hands developed a tremor. Now I have finished the steroids these side effects are disappearing. I took them in the hope they would help my eye to make at least some sort of recovery but that hasn’t happened.

But it was the work that was the big challenge.  We would almost always express amazement if on the round of patients in the morning we came across a woman who was in labour with nothing at all wrong with her. More usually our patients were complicated, and often the complications were multiple, so for example a woman with twins might also have a history of previous stillbirths, or anaemia, or malaria, or very high blood pressure – or even all of those things together.  I have never seen so much severe anaemia, I have never seen so many people needing blood, I have never seen so many cases of internal bleeding causing fetal death ( abruptions with IUFD , plus or minus DIC) I have never seen teenage women in heart failure or with pulmonary oedema, cerebral malaria, tetanus ...  What is remarkable is that all these very sick women were managed without ANY of the technology and back-up available in the west, things such as laboratory and radiology services, and the advice of other medical specialties such as  cardiology, or  infectious disease specialists, or microbiology.  All these women were managed with just a haemoglobin check and clinical judgments alone. And while almost all of them survived, tragically there were ten maternal deaths in August , and seven occurred in the 18 days that I was working there.  There had been ten in July as well. Most of these women were under 20, and most were of women who were close to death by the time they arrived at the hospital. They could probably all have been saved by earlier arrival at hospital, or better still by proper antenatal care. The maternal mortality rate in Jahun is therefore somewhere around 1200 per 100,000 women – its 8  in Australia. In Ethiopia around 600.  

The babies also suffered – I saw countless stillborn babies – the rate in recent months has been around 15% -  and  many babies that were born alive but would soon die.  “Fetal distress” is a  common indication for doing a caesarean delivery in the west – but here it was always a difficult dilemma – even a healthy baby had a high chance of dying as an infant, and a sick one even more – but if the baby was born by caesarean it would leave the mother with a complication that would affect and amplify her risks in every subsequent pregnancy and could ultimately result in her own death.

The real heroes out here are my colleagues the Nigerian trained doctors who have chosen to come and work here long term, in a town that has power  poles and power lines but no electricity,  shops that have almost nothing worth buying and very little variety when it comes to food, no out of hours entertainment of any kind whatsoever,  an environment that is hot and humid at best and baking dry in the mid 40’s in the hot season, nothing to offer except the experience of working with an International Aid Organisation, and the unique clinical material that floods into the hospital every day.
Amodu, the team leader, an amazing guy
Drs Ebam, Kedala and Abdul
Jimho and son

They work till after 6pm every day and rotate through night shifts, they are the backbone of the service, and are very good at what they do. I am not sure they will have learned anything useful from me – but I certainly learned much from them, albeit about obstetric catastrophes and complications that I may never see at home, but among other things I should be able to tell when the fits someone is having are due to tetanus and not eclampsia.  These guys, with their midwives and a small range of powerful modern drugs, and a blood bank and an operating theatre really do save countless lives every week. 

To those Doctors, I say Thank You for your dedication and all your excellent work, and for welcoming me and making me part of your team for  short while. You are doing great work for the poor women of your nation.

Friday, September 5, 2014

Something is very wrong

This is a clinical sign of vey low calcium levels: leave the Blood Pressure cuff  on for a few minutes and the hand involuntarily adopts this posture
Imagine you were a homicide Detective and you were sent to work in a precinct you had never been to before, far from your usual workplace. On your first day at work an innocent young pregnant woman dies in a grisly fashion just up the road, the sort of fatality you’ve heard about or maybe seen once or twice  over the years before, but now youre confronted with it again, a tragic and disturbing death, that fortunately is of a kind you know to be rare, but something you have been trained to cope with. Imagine your reaction the next morning when a similar thing happens again – another young woman dies tragically and unnecessarily in similar circumstances – and then, in the afternoon, theres a third, though this one survives, and the next day, another. What on earth is going on? you ask yourself and then you realize you are confronting something ghastly, sinister  and inexplicable, a serial killer in the community. A sense of dread and dismay starts to fill your mind as day after day the toll of innocent victims mounts, young women, some surviving but all devastated and shattered by a relentless serial killer, dead babies and dead or damaged mothers. And the killer is Eclampsia, the unique pregnancy related disorder which manifests as convulsions, unconsciousness and a host of other highly dangerous complications : brain injury, kidney failure, liver failure, bleeding disorders, placental bleeding, feral death, even horrible burns from falling into the fire. Its supposed to be rare but its happening all round you.
Now this little metaphor of mine may sound like hyperbole, but let me tell you, it is not. Every western Obstetrician who has ever come to Jahun has been as shocked and perplexed and completely dumbfounded by what they have witnessed here as I have been.  Even the doctors from other parts of Nigeria are baffled. It is unlike anything we have ever had to confront before, the great deluge of this appalling and devastating disease that damages and often kills unborn babies and their mothers, and is happening in ways and to women that all our text books say it shouldn’t be. Something is very wrong out here.
This woman started convulsing at home and fell into the fire. Hers is the second such case in a week, of burns sustained during eclamptic fits 
The books say that in developed countries Eclampsia affects about 1 of every 2000 to 3000 pregnancies, but they also say that in developing countries like Nigeria the incidence is much higher –  Ive seen estimates of its incidence in Nigeria at 1:235 to perhaps as high as 1:70. That would mean for Jahun, in a month, about 12 cases  – but yesterday morning between breakfast and lunch time we admitted three cases, and there were already four in the ward from the previous 48 hours - a staggeringly high occurrence rate of such a devastating disease that is truly rare in the west.

These syringes are full of Magnesium Sulfate to be given to our many eclamptic patients

The question that occurs to all of us is why? What is so different about this place that this disease has become rampant?  The truth is we know so very little about the health of this population that we can only guess but we do know that poverty and anaemia are rife, high blood pressure and kidney diseases seem to be common – and these are all risk factors – and genetics are always part of the picture. But most interesting is a theory proposed by  Ray, one of the MSF Obstetricians who was here earlier in the year : he believes that its to do with calcium. We already know from studies in the west that giving calcium supplements to high risk pregnant women reduces their risk of developing the antecedent to eclampsia, a common condition called PRE–eclampsia.  Ray showed in some preliminary studies that the severest Eclamptics – the ones who died  when he was here – had extremely low calcium levels.
They say it mostly happens to women having their first baby, and to younger women, and that is what we observe in Jahun where many of the women are thought to be much younger than their given age of 17 or 18 – being illiterate they don’t actually know their age but many look very much younger than that, perhaps 14 or 15, and the local midwives will say so. But many of the eclamptic women have had one or more babies before and are closer to 30 and according to the texts they aren’t supposed to be fitting. 

One of the reasons for the low calcium, apart from the poor diet is that Islamic women are all covered up. Their skin doesn’t get exposed to sunlight, something which is necessary for the production of Vitamin D, and its Vitamin D that controls calcium metabolism. But it must be more than that – there are covered women all over the world, and most of them are not suffering like these women are. No doubt there would be research scientists interested in pregnancy diseases who would be eager to come here and investigate this extraordinary phenomenon if they knew about it.

Even without the research it would seem that giving calcium supplements to pregnant women out here might help to stem the flow of tragedy. Alternatively, my suggestion would be to ditch the Hijab, get a new religion, get educated and do a bit of sunbathing! Incredible to think that sunlight on skin could be all that’s needed.

Tuesday, September 2, 2014

Ignorance is Death

With their babies in Special Baby Care these 3 young mothers have just collected the supplied hospital food 
I saw a headline announcing that according to  millionaire, pot-smoking pop star Miley Cyrus, Google is more harmful to your brain than drugs are. I know I shouldnt take any notice of what vacuous media creations say, but other people will, and if they only read the headline they might think that she was saying that Information is dangerous. A bit like the line from Pink Floyd anthem, sung with gusto by all those English school children “we don’t need no education”.

Those kids, and Miley Cyrus as well, can no doubt read and write, and so if they want knowledge and information or advice they can easily get it. But out here, illiteracy and ignorance is normal. According to the midwives NONE of our patients can read or write, which is why when they have to give consent for surgery, they blacken their finger tip with ink and print it onto the page as their signature.  And when someone comes to take a way a corpse, a dead baby or mother, the parent signs in the same way.

I mention this because illiteracy and ignorance is really the real enemy out here. Knowledge and literacy and access to  Text messages  the internet and Google on their smart phones would change everything for these women. Literacy and education would  have meant life and a future for the  woman whose footwear was left behind under the bed when her family took her home the other day, but instead they took her home to bury her. She was 17.

And why would literacy and education have helped? Well, they would have known about anaemia, that it is common here and more common in pregnancy and that a sign of it is loss of colour in the nail beds and the insides of the eyelids, that it makes you feel tired and weak and breathless. They would have known  something about the signs of  a healthy  and an unhealthy pregnancy . They would have been able to read about  the value of health check-ups in pregnancy, and known to seek help early.

And when this young  pregnant woman over recent weeks was finding it harder and harder to walk about the house, and she was feeling more and more breathless, and her tongue and nailbeds were getting paler and paler – someone would have understood something wasn’t quite right. Whats amazing is that it seems nobody noticed she was  slowly sinking into desperation - they said she had been fine till the night before, but none of us believes that she was “fine”  - she would have been deteriorating for weeks, and more noticeably over recent days.  But nobody noticed, or if they did, nobody did anything till she collapsed. Then it was obvious something was wrong but before that, surely it is mostly ignorance, a plain and simple lack of knowledge that meant nobody recognized what was happening?

So they brought her in, by which time she was deeply unconscious, gasping desperately for air, her white hands and tongue and conjunctivae the give-away to her severe and profound anaemia, her heart racing at 160 beats per minute to try to pump what remaining blood she had to all parts of her body, but failing. Her brain wasn’t getting the oxygen it needed, neither were her kidneys and her heart itself was under massive strain and about to fail. My own Haemoglobin level when last checked was 15. Anaemia is below 10. Serious anaemia is below 5. Hers was 1.8.
Much too late
So we gave her oxygen and called for blood. Her own blood looked like pink water. I did a scan and the baby  had already died inside  from lack of oxygen. And then just as the blood arrived, so did the mother. Her heart just stopped. I did CPR but it was pointless.  She had been in the ward 35 minutes.

I looked  across the bed at the distressed older women who had come in with her “Why didn’t you bring her sooner?” I said in exasperation, almost shouting at them – I just felt angry -  but they couldn’t understand me,  and they said nothing.

And looking past them, on the next bed literally two feet away and watching the whole thing unfold was another pregnant young woman who had come in the day before, breathless weak and tired, she also had severe anaemia and had already received blood. When she arrived, her Hb was 3.4. She was going to alright.