The Learning Curve



Etewa and her mum



On Wednesday morning Sebsabe was unwell, Her stomach was distended and tight and she was in pain. I felt sick at the prospect of what might be happening inside her abdomen and cursed myself for not listening to what the midwife had said the day before, not to feed her, to wait till her bowels were working again. Stupidly I had completely failed to recognize the obvious huge difference between my usual post operative patient back home, a well nourished healthy and  vigorous westerner, and a chronically  malnourished, depleted worn out and sick young poverty stricken Ethiopian. One step forward four backwards! And now was she about to pay the ultimate price for my stupid arrogance?

Was an X-Ray possible? “No it is broken 5 months” Oh my God! My heart sank further.

“I’m so sorry, I should have listened to you yesterday” I said to the midwife.

Well, there was nothing more to do except stop her eating and drinking, keep the drip running, give her some antibiotics and wait. Maybe they would pray, but I would not pray to a God who would let that baby come sideways. I would be angry at such a god, but I was angry with myself, and scared for Sebsabe.

But I was not to be permitted the luxury of wallowing in self pity. A woman arrived by stretcher from somewhere out there, she had been in labour a long time, the baby had not come out, and if I had thought Sebsabe was as sick as you could be in labour, I was shocked at how much worse this little woman was. Sebsabe at least could move and cry out, this one was silent and still, breathing quite slowly with deep sighing gasps, barely able to move her head from side to side, or open her eyes. She was almost unconscious. She had no recordable Blood Pressure and the pulse at her wrist couldn’t be felt. The heart beat that we heard was fast enough to be a baby’s, but it was hers, and a scan quickly showed another dead baby. But first of all we had to try to revive the mother with intravenous fluids. Again the midwives proved their exceptional practical skills quickly finding a vein even though she was so severely dehydrated and “shut down” and her arm didn’t move as they searched with the needle. We squeezed the bags of fluid into drips in both arms and then I examined her to see why the baby hadn’t been born. It was a “brow presentation” which means instead of the baby having its chin tucked in, like you do when pulling a tight jumper over your head, it was extended so that a much wider diameter was presented to the pelvis, and it wouldn’t come through. The forehead was all swollen and spongey. Brow presentation is a rare situation but in the west usually recognized in early labour and easily treated by safe caesarean section long before things get to this ghastly state. But here, in this horrible predicament caesarean was not an option. It would kill her for sure.

We took her down to the Delivery Room and placed her on the delivery table. She barely new what was happening. I thought I should try to deliver the baby with forceps if I could somehow change its position but within a few minutes I realized I could not. I looked at Mesaye, a horrible dread in my guts, knowing what he was going to tell me “I think you will have to do destructive delivery Doctor“ he said. And he handed me the instruments.

I have to say that Mesaye and the others there were unbelievable in the way they helped me and assisted me to do what certainly is the most gruesome thing I have ever had to do. At times they wanted to step in – they had already seen me cry once - but I insisted I would do it, it was my job, I needed to learn and I would be OK. And so I was. But the baby went to the incinerator with the placenta, too awful to even look at, and still hardly a murmur or movement from its desperately sick mother, whose family carried her back to bed number two.

But against the odds our patient, Etewa, survived. We had given her 4 litres of fluid in the first two hours and at the end of it a tiny amount of urine appeared in her catheter, as before, mostly blood but as the hours went by the blood was more and more diluted with urine. The next morning she was still terribly weak and unwell but I could feel the pulse at her wrist, and she muttered a few words. Her poor undernourished mother nursed her continuously, feeding her and climbing onto the bed to embrace and support her from behind, in a room where the mothers in the other beds had babies to feed.  At least Etewa had her life, but theres no grief counseling or social worker support for her, no farewells for the baby, just a grim life of poverty waiting for her to return.

Tuesday

I try to get to maternity around 8 or 8.30. Formal “Rounds” – where all staff meet to discuss progress and management planned for each patient  in the office and then at the foot of the bed – don’t seem to have caught on here. Neither have documentation or Filing, so nobody really is sure who is in the unit and doing what, and no individual midwife seems to be responsible for anything in particular. The medical records, such as they are, are haphazardly strewn across the desk and a dusty shelf in the one other piece of ward furniture, a wobbly old book case. Inside the drawers of the desk is a mess of bits of paper, old documents, an empty drug carton, and various other items that mostly need to be put in the rubbish. It’s the same on the bookshelf. Someone tried to get a system going using a whiteboard, which is still on the wall but the markers have all long ago dried up.

So after rummaging about and assembling the files and determining which belonged to women still in the unit and which belonged to women sent home or seen  casually and never admitted over recent days, we, that is up to three or four midwives and myself set off to try and see everyone. Firstly though , on this occasion I gave to Mesaye, the male midwife who I had worked with during the night, the remaining birr to settle the account of Sebsabe..

Mesaye, I should say is quite a frightening looking fellow – he is darker skinned than many, and short, and he is blind in the right eye which is completely white with corneal scarring. However he is an excellent and hardworking midwife and I have huge respect for his experience and wisdom. It has been wonderful the way he has offered suggestions to me at various times to help me find my way – so lacking in ego or a need to engage in any sort of power struggle.

We saw the woman with pre-eclampsia – she was obviously getting her blood pressure medicine and was feeling fine. And next we entered the small room where Sebsabe was. The poor thing was naked but covered by her own coarse and grubby blanket, now trying to recover from the traumas of a prolonged labour, the death of her first baby and major surgery. I felt terribly sad for her. She was still unwell and in pain but her husband and mother and other relatives, all dressed in filthy rags were crowded in to look after her, using god alone knows what resources, but it was their responsibility, and they were doing what they could. Her urine was still heavily bloodstained but otherwise she was stable. I suggested she could have fluids to drink – this is usual practice in the west – but one of the midwives objected. It was my second day at work and I should have listened to her but didn’t – yes she can drink I said, and ordered her antibiotics and a blood test. A lot of talking in Amharic followed, back and forth, and I asked Mesaye what was going on. He had just informed them that I had paid off their account, and with that the old grandmother and a man perhaps her father threw themselves at my feet , wrapped their arms around my legs and started kissing them and crying out. “Please, no” I said and bent down to them, overwhelmed, and couldn’t speak, tears welling up in my own eyes.– I just felt so sad for these sweet caring people. It was terrible that their poverty and their need was so great that  that such a tiny gesture could mean so much and be so gratefully received.  


Bed One



First Night at Work

Women in labour can be carried many miles on homebuilt stretchers like this

I couldn’t really understand what the midwife who called me at 1.30 am was saying – mobile phone transmission seems quite distorted sometimes and also doing their best to speak my language is often only partly successful but it was obvious I should get dressed and go in to maternity, which I did, by torch light

,

When women first arrive they are assessed in an open room that has two more of those clapped out beds in it and even more dirt on the floor because it is right by the front entrance to the unit. I have learned already that if  there is a cluster of old women and men gathered about the entrance to the unit, it usually means trouble within. A further clue as you approach will be an empty jerry built stretcher made of a couple of stout  branches - the men will have carried the woman in distress to the hospital on it, sometimes from many kilometers away, many hours  tough walking along rocky tracks and roads, often with no footwear and almost all dressed in worn out dirty rags.



Waiting outside after bringing a mother on a stretcher, barefooted

And there they were. Inside, a woman was groaning and rolling about on the plastic mattress, the midwife and a relative were with her, and it was obvious she had been in labour for a very long time and was exhausted almost to the point of collapse, with sunken cheeks and her dry lips stuck to her teeth. The real problem was obvious almost immediately – all she had managed to deliver after all those agonising hours, maybe even a day or perhaps two of labour, was the right arm of her baby, hanging between her legs, purple and swollen. The baby had been trying to come down sideways and now its shoulder was rammed down into the pelvis and its head pushed across to one side. The baby was dead and the mother would die as well before too much longer without help. This was something I had never seen before: this scenario just would never happen in a modern country because care would be available right from the beginning of the labour. The abnormal presentation would be recognized and the baby delivered promptly by caesarean section  in perfect condition and both would go home in 5 days probably never really appreciating the fate that had awaited them without modern technology. In fact, if the caesarean scar was a bit crooked or developed a superficial infection as they are want to do – but easily treated with tablets – someone may even have complained!

I had read about the so called “destructive delivery” where to save the mothers life in pre-modern times, a baby stuck like this would be decapitated or dismembered to get it out. Historical obstetric text books had gruesome diagrams and drawings of the techniques and instruments used, but I had never seen them in real life. This womans situation however was of the worst possible kind, and attempting a “destructive delivery” would be more likely to kill her than achieve the desired outcome, especially in inexperienced hands.  Fortunately there was an alternative: caesarean section; but even that is a high risk solution in this environment. The risks are great enough in performing abdominal surgery on a desperately ill woman anywhere, but at a place where there is no blood bank, no anaesthetic  monitoring equipment – not even an ECG machine – and limited surgical equipment – the dangers are obvious. Furthermore, a caesarean will create a serious risk of death from uterine rupture in any subsequent pregnancies, especially if she labours miles away from help. In fact attempting such surgery under these conditions would not be acceptable or even permitted in a modern  country.  But nevertheless it was her safest option, indeed her only option. The family was called and discussions took place between them and the midwife about what needed to be done, and I saw them all rummaging through their ragged filthy clothes and handing equally filthy money over – there are charges for all obstetric services – but after a while, voices seemed to be raised and nothing was being done for the mother – “whats the problem? “ I asked. “They wont pay” I was told “They cant afford” So how much did they have I asked “40 Birr “ was the reply – about $3 between them – and they needed another $8 (130 birr) but it was easy to believe, looking at them, that they had nothing else.

The argument continued a few more minutes but no more cash was forthcoming – so I interrupted “lets get her to theatre and I will settle their account myself in the morning”  I had hesitated because I didn’t want to undermine the midwife or the way the system worked – but on the other hand I thought $8  was nothing to me  – two coffees are sometimes more and we order them without a seconds thought. The woman was dying……

So I did my first Caesar in Africa, and delivered a dead baby from a nearly dead mother. We managed to disimpact the baby from the pelvis without causing any further damage and the operation was uneventful.  The urine draining from her bladder before the operation looked like pure blood, such was the trauma the bladder had undergone during the labour. Hopefully that damage will repair itself but only time will tell : if not, before too long a hole will develop and she will dribble urine  and be constantly wet and smelly.   The baby was dropped into a big old cardboard box and forgotten about till I went to find it and later, it was incinerated with all the other hospital waste.

Am I wearing her pants or has she got my top?

 It had been a confronting and emotional experience for me, and stressful, but everyone in the hospital was tremendously helpful and supportive. I stumbled back through the tunnel of grass now wet with heavy dew and crept back into bed at about 5 am. I just felt glad that at least the mother would survive. Or so I hoped.

First Day at Work



The Maternity Ward Office and (only) Desk

Fritz and his wife left after he handed over the keys to the Ultrasound machine and an envelope of cash from the Barbara May Foundation which was mine to use to assist patients in dire need of expensive things they couldn’t afford, such as urgent transfer to Addis Ababa. Fritz said that in his now completed 5 week stint he had not been called out at night once, and so I was hoping the quiet times would continue as  I went to Maternity to see our one patient : she had been in hospital for several days with very high blood pressure – she had severe pre-eclampsia, a nasty unpredictable disease of pregnancy that in third world countries accounts for many thousands of maternal deaths every year. The only effective treatment is delivery of the baby but the baby wasn’t due for another 6 weeks as best as we could tell. Much of the testing for pre-eclampsia that is routine where I usually work was unavailable, but the plan formulated  when she first arrived was to stabilize her  condition and then induce labour.  She was stable so I ordered the two tests the lab can do and asked  for her urine to be retested. An empty Blood Pressure tablet pack was on the floor – was she still taking her medicine I asked – and after discussion in Amharic it transpired she had used them all up over the weekend. The family had to go and buy more. Basic nursing practice such as taking and recording observations and noting which medications were given and when is obviously not done well here, and is something that will improve, but for the time being I have decided to simply observe what is done and make subtle suggestions. Later we will have formal update sessions on record  keeping. For now I just want to learn everyones name !

I went back to my flat and began the move next door to Fritz’s one – it was identical in size but had a DVD player and  TV connected to a huge rusty satellite dish just outside in the long grass , as well as a small fridge. I  have yet to switch the TV on but I was told there are 20 or so channels including BBC world. It dominated the tiny desk so I decided to swap the desk for the bigger one from the midwives room which was going to be vacant for the next month or more, and shoved the damn TV into the corner. As I frequently do when moving into new accommodation I rearranged the furniture and cleared all the accumulated clutter from shelves drawers and cupboards. The place started to become mine.

 In the afternoon I was informed a woman was in labour but making no progress. No other details were mentioned except for the fact that she had previously given birth twice uneventfully. The midwifes descriptions of what was happening were a little vague so I decided to examine her myself. The room she was labouring in had two almost completely wrecked metal bedsteads against the wall on each side and a fifth one against the wall opposite the door. The linen was ragged and barely covered quite filthy plastic wrapped thin sponge mattresses. There were no curtains. The floor was filthy with mud and dirt , discarded wrappers from examination gloves and other rubbish. I did the examination and we decided to start a drip, because if her labour still didn’t progress she would need a caesarean. . Before long she was in strong labour and becoming awfully restless and distressed with the pain – but there were no drugs available for pain relief, no “Gas” to breathe, no shower to stand under, just this one room and potentially other women and their families to share her ordeal with. Eventually she gave birth to a healthy baby and her smiles were radiant. It was then I was informed she was HIV Positive.

Meanwhile another woman turned up in labour and was found to be almost ready to give birth. She was assisted by her family into the “Delivery” room where she was heaved up onto an ancient and again, rusty, filthy and almost completely wrecked birthing table.



Delivery Room : the Photo makes it look good

I found a fetal heart monitor and checked the babys heart beat – the baby was distressed so immediately the midwife, Semagnew, reached for a “Kiwi Cup”. A Kiwi Cup is a brand of suction device used to extract a baby – they are single use devices but these ones in Motta are used and reused until they fall to bits, as this one was about to, but still   Semagnew managed to get that baby out pretty smartly. The baby boy emerged with a huge flood of blood clots and fresh blood and he looked dead. He was floppy and didn’t breathe or move – I grabbed him and looked around for the Resuscitaire or anything similar on which neonates are usually placed for resuscitation – it’s a special little table usually with towels to dry and rub the baby, oxygen, a warming lamp, drugs and various other items that might be needed in just such an emergency as this –but there was absolutely nothing, no table no oxygen no towels, nothing. I put the baby down on a bench on some old clothes or drapes or curtains – I didn’t care – and started to rub him, give him CPR and called for some extra help. Semenya had delivered the placenta and controlled the bleeding and came across with a little rubber sucker device to clear his airway – almost useless- and a mask that we used to  deliver some fresh air to the baby whose only sign of life for the first five minutes was a weekly beating heart.. Semagnew roughly and vigorously rubbed the babies back, flicked its feet, gave it all kinds of tactile stimuli that would have horrified just about anyone in such a situation in Australia or NZ but then what else did he have to call upon? At 6 minutes the heart beat suddenly picked up and a few minutes later the baby started to breathe. We wrapped him up as warmly as we could in threadbare cotton sheet that looked like old bed sheets torn up for the purpose and gave him to the mother. The next day they went home. I could see that the practical skills of the midwives were amazing, and obviously of much more use than good note keeping!.

I was too worn out to cook  dinner  when I got back home so just ate some biscuits It had been a busy and dramatic first day,  but worse was to come as the run of undisturbed nights for the Obstetrician was about to end.

Sunday Shopping




Shewaye and Moges

I now have worked out when I arrived in Mota : it was  Saturday 20^th of September 2004, exactly a year before I last got married but it really feels like Ive only been here  a few days!  Sunday, my first full day here,  started with  a brief ward round with Fritz, and then leaving him to pack, I decided to climb over the back fence onto the open field  of grass eaten down by cows  sheep goats and donkeys which wander about in small groups, and head past the dwellings on the opposite side to the shops to buy some food.





The view across the Back Fence

I was spotted heading off on my own by Moges, a sweet young man who after a rough start in life has gone to school at age 22 and has hopes of making it to university one day. He lives in one of the overgrown and rundown blocks of units near mine, but his space is a concrete cell just big enough for a bed, and not much more, and so he sits on the floor with a pile of books studying in his spare time. There are common cooking and toilet facilities attached to the block for the other inhabitants of these tiny cubicles, which Moges seems to have been given access to because, for a tiny monthly wage he has responsibility for ensuring everyone has water. When it was connected to a tank his job was to operate the pumps to keep it full, but since the wooden tower holding the tank collapsed, he has had to bring us water in buckets. Apparently for several months now the Tank is going to be replaced next week. Moges is a cheerful and willing worker, and ran across carrying a bundle of empty plastic water bottles tied along a string, and suggested he ought to come with me, and so he did. First though he explained he had to find a buyer for his empty bottles! He got 1 Birr each for them – which amounted to about 45cents in total, enough to buy a few vegetables at least.

Along the wide dusty main street we ambled in the hot sun as Moges did his best to answer all the questions I fired at him about everything going on around us. I walked up to a dense little crowd of young boys playing that table soccer game where you spin horizontal rods to make the wooden soccer players attached knock the ball towards your Goal. I had to encourage them to play on rather than stare at me and Moges.  Further along on the side of the street there was a rickety tennis table but no was using it. A young man with a string of “Scratchies” style lottery tickets approached and after Moges explained what they were, and the cost was 1 birr (ie 6 cents) I decided for fun to buy one. The crowd gathered closer around us as I took the keys from my pocket and made a light scrape across the scratchie – the crowd squeezed in even closer till there was an almost continuous ring of touching heads with mine in the middle, and I looked up – they all sprang back and as soon as I bent over to scratch again they closed in once more as I exposed first one then the other numbers to finally reveal: ….No Prize!  We all laughed!

We eventually bought some tomatoes, green peppers, oranges, 2 limes, a cabbage some rice, atin of milk powder from New Zealand and some little packets of biscuits and returned to the hospital., about 3 dollars lighter. That night I had dinner with Fritz and his wife Anne-Marie – grated boiled beetroot, omelette and boiled rice. They were heading for Addis in the morning by private taxi, and were planning a little sightseeing before returning to Holland. This 5 weeks stay had been their second at Motta and both agreed it had been an extraordinary experience. I thought I knew what they meant but having now started work  I now realize I didn’t really. But I did feel a little nervous at the prospect of being on my own and in charge once Fritz left in the morning.. Apparently Motta Hospital serves the medical needs of over a million people!  Could get busy!

The Hospital and Town

The Main Drag in Motta

Motta was much bigger than any of the villages we passed through on the way, -population of 40,000 according to the information sheet I was given -  and the hospital was at the far end, opposite the prison. My first impression of the hospital was that we had come to the wrong one, as it looked abandoned, with tired cracked and muddied covered concrete pathways  joining  a double line of concrete sheds surrounded right up to the windows by 2 meter high grass. But helpers appeared immediately and my bags disappeared along a  rocky narrow  dirt track  making almost a tunnel through the long grass. I stumbled along behind, and after stepping across a couple of open drains and through a rusty iron gate a cluster of little buildings emerged – each being a strip of 4 small flats. Outside one of them – the one that is now my home till January – a great cheer went up from a small group sitting in the sun  in a strip of cleared grass as we came round the corner – they had been waiting for me. They were also saying goodbye to Diana a dutch midwife who left a few minutes later with her huge backpack, back to Motta and then to the newly opened tiny BMF hospital at Mile, in the Afar region of Ethiopia a few hundred miles east. My stuff was dumped in her room next door to Dr “Fritz” room. He and his wife were leaving on Monday and then there would only be two white faces in Motta, an American Peace Corps volunteer being the other one.

Front entrance to the Motta Hospital




Hospital buildings across a field of Tef

 

My Place with the Blue Bucket outside, and  the Broken water tower

I met two of the three Ethiopian hospital doctors, and handed over to one of them the things I had been given for him by an Australian midwife who worked here for three months earlier this year. He was overjoyed. I explained that the simplest way to pass his exams using  the 5 kg of medical textbooks I had just given him was to simply learn everything contained in them and understand it all perfectly and he would fly through. Fritz showed me round the hospital and we checked on the only woman in the Maternity unit, and later all of us went to the Wubet Hotel for dinner. It was a lovely walk along the wide rough road into town in the late afternoon, and I was hungry. As before there were lots of people on the streets but none seemed to be in a hurry. A number of old women were carrying small charcoal burners and setting up shop squatting in the dust on the edge of the road roasting corn cobs.

                                                             

Now the Wubet is reputed to be the Best in Motta but though  the walls and floor are bare, and the chairs and tables basic, the St George Beer was good and so was my “Spaghetti with Meat Sauce”  The locals among us ordered the traditional meal of Injera, something I knew I would have to try at some stage but given that westerners generally describe it as like eating sodden rotten  blotting paper, I wasn’t really looking forward to it. It is usually served on a plate like large limp dirty grey pancakes, bigger than the largest pizza size,  then torn into portions used to scoop up accompanying sauces and meats which are piled in the middle of it. So I tried it and was pleasantly surprised – it was indeed soft and flabby in the mouth, a little bitter but not very flavoursome, it was probably the texture that was strangest but I ate several portions with no ill effects. I had been worried that if I couldnt stomach the staple local diet, what was I going to be able to eat? Now I thought it might be OK after all.



Yemataw, hospital shoe shine boy having "Fasting Variety " Injera at Wubet

Getting to Mota



Bahir Dar Airport

After over 24 hours of jet travel and transit lounges I finally emerged into the Ethiopian sunlight at Bahir Dar  on Friday 30^th September. The international airport in Addis Ababa was like a huge empty shed by comparison with the massively crowded and glitteringly gross terminal at Dubai, but from the outside at least it looked quite impressive. Bahir Dar airport on the other hand looked like a wreck even on the outside with three quarters of it fenced off with vertical sheets of rusty corrugated iron, and the other quarter propped up with poles and rickety scaffolding made of long thin tree trunks. Our bags weren’t taken inside, just dumped into a rocky dirt roadway, along which I then dragged my two bags and back pack toward a waiting throng of Hotel touts, Drivers and family. One smiling  black face came close - “Dr David?”- it was Birhanu, my contact in Bahir Dar , and he took me to the Ethiopie Star Hotel, room 301.He had planned to take me to a different Hotel but discovered they had no water that day. He was most helpful and friendly and suggested where I might go for dinner, and a couple of sights to see in the morning before he would come back to get me at 7 and organize my transport the last 120 km , to Mota. I objected –could we make it 9? “OK, OK, No problem” I decided to lie down for a rest before dinner, and when I awoke it was after midnight!




Baggage Claim



So in the morning I had breakfast in the Hotel restaurant, and not having a watch or mobile phone I asked for the time at the front desk. “A quarter to one” she said, and then, noticing my stunned reaction “Oh that’s Ethiopian, you want Global time? Its quarter to 7” And that was how I discovered they count the hours differently here, so our lunch time is 6am, and I have since discovered their calendar is different so its only February 2007 or something – still have to sort that one out!. Later, wandering along a busy road and watching the street life I suddenly remembered Birhanus “7 o’clock” which I made him change to 9 – was this really 3pm? He was so polite he didn’t enlighten me…so now we were going to be really late getting to Mota and they were supposed to be picking someone up and bringing them back . But I went back to the Star a bit after 9am just in case, and there he was! I was relieved I hadn’t stuffed it up after all.




Praying and touching the wall around the Orthodox Church

Flying north to Bahir Dar the day before I had been quite surprise at how green the entire countryside was. News of famine nearby and a general impression of Ethiopia as a rocky dry harsh environment had not led me to expect such an incredibly densely cultivated place, every possible piece of land was broken up into numerous small coloured patches, mostly dark or light green, but also black and yellow, and many with a small shed or maybe a dwelling with a tin roof flashing up at me. The entire countryside seemed to be in production. Now, driving to Mota through this , it was even more wonderful to see as there were huge steep escarpments with river flats between and and amazing views from elevated rolling plateaus of distant horizons and the road snaking away below. The unsealed road itself was horrendously rough and rocky, and 40km/hr was probably top speed. The other remarkable thing about the road was the traffic on it – a constant mostly high density stream, not of cars , or motorbikes or 4WDs – there were none at all – but of people, many in the company of overloaded donkeys and mules, or goats with floppy ears  or sheep, many barefooted, all dusty and scruffy and ragged, often carrying a stick  across their shoulders that they hooked their arms over, they were like refugees carrying their belongings but  they were heading to or from markets in Bahir Darr or the many small villages we passed through on the way. 

A quiet stretch of road



On the Mota Road



I had been shocked at the number of Beggars I came across in Bahir Darr, and now, seeing all these people walking miles along rocky dusty roads I started to realize how poor they really are. In India last year I saw many very poor people but there were many poor who cold at least afford a bicycle or even a small motorscooter  but here, no-one seemed to be able to afford even those . Not one! And all that cultivated land, all those plantings and reaping and harvesting  and tilling of the soil – all of it by hand, not a single modern machine to be seen anywhere. I started to realize that they were also incredibly tough.

I will write about my first days in Mota next time