There is an adage in Africa that with film and video, it’s best not to linger too long. The gear is expensive and a temptation and over the past few weeks, we’d had it out far too much. There are other, now amusing circumstances as well, better shared over a beer at a later date, but ultimately, it was decided that we needed to get the gear out of this small town and into Bahir Dar. Joni and I were leaving first thing the next morning.

It was my single biggest disappointment of the trip. I did not want to leave Darlene, I had just found a seemingly ideal translator and photo enthusiast in one of the hospitals midwifes, I had plans to watch futbol with an Ethiopian doctor who’d become an increasingly good friend, and, perhaps most important, I was invited to play on the hospital team’s volleyball tournament that Sunday.

We packed all the gear into the land cruiser and set out. About twenty minutes out of town the road starts winding down a breathtaking canyon to a water crossing thousands of feet below. It was market day, again, and the line of merchants streaming into town was also crushing in that I wanted stay in Mota. My heart sank as donkeys, goats, sheep and shepard were all on foot marching toward town. Men and women and children in their gabis and wares, many barefoot, the march of walking sticks and the donkey carts. We head down the canyon and I texted Darlene that we were beyond town, freely on our way.

Freely, that is, until we started to climb out of the canyon and the back tire blew. I’d never heard a tire blow like that. I’m more accustomed to the slow leak.

A local boy helped change our tire, which included he and I rocking the vehicle back and forth so Mulu could wedge the jack in under the body. We eventually gave him a birr for his troubles.

I inspected the remaining tires and found that though the spare was completely bald, it was not the worst one. The rear driver-side tire had no rubber at its center and we were two hours from Bahir Dar. The road is a never ending stretch of packed gravel with washboard grooves and sharp loose rocks. It wears a heavy coat of fine grain dust that gets everywhere and as I gazed out into the hot day ahead, I was preparing myself for the inevitable bus ride rescue.

But this is Africa, as they say, and somehow all the pieces more or less held together and after another hour we still had four tires full of air. We pulled into a little village where we patched one of the spares. Once again on our way and forty minutes later, we finally crested a small rise and saw Lake Tana and Bahir Dar spread out before us. It was beautiful. The lake expanse felt like the sea and the town of tree-lined avenues swayed in the breeze. By now the back seat and our gear was full of dirt from the dry countryside and we were looking forward to soothing our sunburned skin under cool, running water.

As we wound down toward town, we crossed a long flat stretch and slowly, the car decelerated. I pointed to a building under construction as the car rolled to a stop. “What are they building there?” It’s a new hospital, he said, pulling out his cell phone. He apologized, “it is my fault, I forgot when we were in the village, but I will call my friend and he will bring more petrol.” We were seven kilometers out of town and completely out of gas.

POSTSCRIPT: Though I left Mota four days before Darlene, she arrived here with me yesterday. On her return trip, the rear driver-side tire went flat and Mulu received four new tires that afternoon.  Her four days remained challenging in terms of the medical condition of Mota Hospital and it’s patients, but rewarding in the nature of her stay.

Chapter Three

A small unlocked Nokia cell phone with an Ethiopian SIM card floats between the white pockets of Dr. Philippa and myself. The number is scribbled on paper taped in the maternity ward. We are on call 24 hours a day, 7 days a week for almost four weeks. Other medical teams before us have stayed for three months, a feat I find holy.

Nurse midwives and doctor’s names fill our phone lists and tonight it is Abraham* who rings us two hours before midnight. ‘There is a woman in the delivery room, we have tried a vacuum delivery twice and still the baby doesn’t come out, there is fetal distress, can you come and help us?’
‘We are leaving now, right away, be there in 5 minutes.’ I pull on my pants, grab my head lamp and retrieve Dr. Philippa from next door. In our tiredness, we stumble over the dark path, rushing to get to the hospital.

Once inside, the scene is portrayed and everyone rushes to play their part. She is on the stirrup table, her legs shaking from long hours of pushing. One defeated midwife holds the vacuum attached inside the mother, another leans into her protruding belly counting the fetal heart rate, 140 beats per minute down to 80, there is fetal distress, this baby needs to be delivered immediately.

I turn to Dr. Philippa, ‘A C-Section, forceps, what shall we do?’ Calmly, she reassures the team, examines the patient and announces the head is transverse, lying sideways and therefore wedged tight. The goal is to turn the head so delivery can happen. It is too late for a C-Section she informs me.

With fifteen years of experience, she works with her hands, the vacuum, limited tools. An episiotomy opens the narrow passage further and within several minutes a head, with cord wrapped tight about the neck, is pulled through the canal. Deftly, Dr. Philippa reaches for clamps and scissors, releasing the cord. She turns, handing the blue, lifeless baby to Malsaman and me.

‘We should order a Neonatal Resuscitation book and leave it at the hospital,’ Philippa mentioned to me in passing a few months back, I took her recommendation to heart and three days later Amazon delivered such a book. I devoured the algorithms, protocols and ratio of compressions to breaths, the book is for high end facilities with oxygen tanks, neonatal bed warmers and medications.  Everything our hospital in Ethiopia is lacking.

Malsaman and I grab the floppy baby, its eyes closed, mouth open, and rest it on the table. An eternity churns before I understand what is before me. ‘I feel a heart beat, its slow, but its here,’ Dr. Philippa presses the umbilical cord, searching for a pulse.
The race begins, from the smallest of compressions, 1 and 2 and , two finger tips thumping the frail chest, the lungs have yet to fill with air and the tiny oxygen mask is held in place, I try to keep the airway open, jaw thrust up. It swollen lumpy head lists to the left, making the ability to maintain an airway difficult. For thirty minutes, I don’t give up, I can’t give up.
A cough, a gasp, the heart beat quickens, we push air into her lungs, ‘come on baby, come on, you can do it,’ my mantra begins. Then it happens, her little chest begins to rise, she takes a breath and then another.
Turning to Malsaman, we are ecstatic and dance around, grasping hands, overcome with joy.

The mother watches from the delivery table, her feet in stirrups as Philippa delivers the placenta and sews beautifully her torn body back together. Finally, the family is allowed to enter, husband escorts his wife back to bed, there are no wheelchairs. The baby is brought to her side, she is surrounded by four other maternity beds in a small room. Here, there are no monitors, machines or oxygen tanks to keep life viable, only the mother. For she will keep watch, infant at her breast, and hope the spirit of death passes over.

Not much later, the cell phone rings, another midwife urgently inviting us back. ‘Another baby is stuck, she has been in labor since yesterday, we should go quick,’ Philippa informs me, grabbing her white coat and we walk the well trotted path together. The story parallels the first, only the cord is wrapped around three times, strangling any chance of survival. This time our attempts are futile, the little face is malformed, perhaps a chromosomal defect, an incomplete cleft palate, perhaps it is from pushing, its face lodged against the canal bones for too long.

I can’t fix the oxygen mask, air escapes before passing into underdeveloped lungs. The ailing heart pulses through the cut cord, ‘thump …….. thump.……..’ instead of a healthy 120 beats/min, there is only one every five seconds. More compressions, more oxygen, the heart beat slips further into the heavens, we try and try again. ‘Come on baby, come on, you can do it,’ my mantra begins, only this time no one is listening and over 30 minutes the little soul leaves us.

Looking into Malsaman’s eyes, a wave of defeat overcomes the room. I want to cry, but no one cries in Africa, there is too much sorrow for tears.

‘We have saved the mother,’ he touches my shoulder, now they can have more children, healthy children.’

* names have been changed

to be continued…

On the way home we took my favorite street, past the mosque and imams house, and like a child I peered thru the slotted wooden fence to the large golden wheat fields that makes up the eucalyptus lined yard. The men in the field across from ourhouse sift teff from hay and drive their cattle in circles to mix it up. Donkeys bray from somewhere out of sight and children run the dirt packed avenues with homemade pinwheels spinning in the wind. The hospital was quiet with two new births, the sun was present and ready as always.

Darlene spreads across the chairs in the yard, dark glasses on, reading a novel as the heat of the afternoon soaks her clothes with warmth. Our pails are full of water, as today is a water day. At the stadium, the hospital futbol team tied in a tough match and Manchester United, the town favorite, won on the tele. It seems the perfect day.

Chili

Video

Darlene relaxes.

A mosque

Fuel - dung and wood

Weaving

Merchant

Chilis

Spices - hot berbere

Potatoes

Garlic and Onions

Mingling

Tailors

Potatoes

A quiet corner

Hospital Team shoots

A view back toward town and the hospital

The streets of Mota

Kai Wat with Yamatan

Our rooster chicken

Notice the yellow converse that the team wears

Kids play ball at halftime

The Imam's house...

Chapter Two

Without running water, sterility is difficult and conservation is everything, even during surgery. Faded green gowns and drapes, homesewn lap sponges, recycled tubing, everything in the operating room is used again and again. We enter building 24, the operating theater. A clear plastic apron, battered from use, is placed over our heads and tide in the back. I run my hands under trickling water from a bucket, passing the soap to Dr. Philippa, we scrub for surgery. A sweet smelling purple alcohol dries our fingers.

Putting patients under general anesthesia at our Hospital is an amazing feat undertaken only by one, a recent graduate of the nurse anesthetist school. Without the ability to monitor blood pressure, oxygenation, blood count or really anything else during our case, he does an exceptional job of keeping our patient stable. I’m in awe of what little maintenance will keep a patient alive. I feel this is what surgery must have been before technology or electricity.

Fingers across her taught belly, a lateral incision is made. It is now obvious the uterus has ruptured just as the midwife Abraham had predicted. We pull gently, dislodging the lifeless baby from her torn womb and pass it to the nurse. A quietness overcomes us all.
There is little time to be sad as we shift our focus to the mother, Samanesh. Working quickly, Dr. Philippa’s nimble fingers stop the bleeding as she removes the uterus and repairs the vaginal wall. Dr. Frantilal, a young local General Practitioner, his dark eyes concerned behind the mask, ponders our decision to save her right ovary, ‘I have never seen this done before.What is the use of this?’
‘Wouldn’t you prefer I save a testicle if I could?’ asks Philippa.

In remote rural areas, there are no roads, only narrow foot paths. Sometimes a six hour walk is required to reach a bus stop. And then they wait, wait for an overcrowded bus to transport them to the district hospital. During the rainy season, foot bridges are washed away, roads eroded, making the journey even more arduous. Often without shoes, these women labor on route.

Samanesh’s forehead perspired, she was familiar with birth, this was her fifth pregnancy. Her ‘pushing down pains’ began at home, surrounded by family, far from the hospital. Hours passed as the baby’s head wedged high in the birth canal, unable to slip into position for delivery. Labor stalled. A sense of urgency, something was wrong, her life was now in danger. Her family began the long procession to the hospital. Hours later, Samanesh arrived exhausted, bleeding and the baby no longer kicking in her belly.

Poverty, lack of education,  malnourishment and the devaluation of women are obstacles in developing nations for a safe delivery. Once these are rectified, one issue remains at hand- access. While numerous health centers are within hours from each other, the hospitals are few and far between, once you reach a hospital there may be no physicians on staff,  not to mention no operating room or surgeon. The WHO reports there are more Ethiopian doctors in Chicago then there are in Ethiopia. Lack of transportation and lack of roads are a standing problem for these women.

Early mornings we walk through the rusted blue hospital gate to make rounds, the maternity ward, building 28, is just waking, newborns crying out to suckle, birds chirping, staff yawning. We check our patient’s vital signs, looking for infection, any signs of decompensation. Samanesh’s devoted family remains at her side, they feed her injera and chai, change bed sheets and sponge her tired body clean. Days later her fever resolves and we stop the intravenous antibiotics. A week passes, her incision heals, she is able to return home with her husband. She returns a sister, a mother, a wife, a daughter.

Operating Theater

Operating Theater

Morning Rounds

Morning Rounds with Midwife, myself and Dr. Philippa

image by Joni Kabana

image by Joni Kabana

Hospital Reception

Hospital Reception

Thru the gates and on toward the hospital

to be continued…

‘You want a picture?’ he asked as we drove to the edge of the desolate canyon.

‘How about now? You don’t have camera?’

‘Later,’ I told him, ‘When we come back, when we return home.’

‘You sure? You sure you return home?’ he laughed.

That was a good question since I was wondering how this rusted jalopy, bouncing and speeding through curves, almost colliding with buses, was going to get us to Mota at all. Knuckles white, seizing a broken door handle, I watch as the broken speedometer oscillates anywhere from 0-120km while the gas gauge hoovers over empty.

‘We make the hospital in no time, maybe three hours.’

The only two story hotel in town is painted pink, Hotel Wubit, and sits midway along the dirt highway stretch of 240km, the original eastern through-way connecting Addis Ababa with the North. Asphalt has yet to see this part of the world.
‘We are here, this is Mota!’ he smiles, pulling into the hotel parking lot, ‘Now we should have food.’ Inviting the driver to lunch, we collapse into wollen couches and share beyainatu, small portions of vegetarian food dumped over injera. We scoop potato, shiro, cold french fries, lentils and cabbage into our hungry mouths.

Road signs adorned in blue Amharic script line the road, we turn off towards the Hospital in search of our new home.

Blue and white paint coat the walls, colors of hospital and government. Only open for ten years, age prevails over the compound- a building has fallen, walls cracked, overgrown weeds and trash decorate the compound. An aluminum latrine sits downwind, but meandering the paths, one must be mindful of human scat.

Only in the last year has the hospital come alive- a water tank, the opening of an operating theater and a mini medical library. Water is pumped from the ground four mornings a week into the tank and keeps the plastic buckets in each ward filled. The small library houses a surprisingly large assortment of medical textbooks with two wooden desks filling the room and one dial-up computer with a lineup of staff waiting to check Facebook accounts.

Episodes of MASH come to mind passing through the aluminum doors into the operating ward. One room for minor procedures stays busy removing lumps and draining wounds. The main OR, reserved for gynecological emergencies, is open 1-2 times weekly. My visa and papers are stamped with such purpose, Dr. Philippa and I will become quite familiar with these quarters.

The morning of our first day, a daughter recovering from childbirth is carried home by her family, she rests atop a wooden bed strung with goat skin. At the same time, another daughter arrives, supported by the arms of her father and husband. Her pregnancy is full term, but her labor has stalled. Abraham*, a quiet, unassuming midwife, his second year working at the hospital quickly recognizes her distress- a ruptured uterus, the baby has lost its heart beat.

To the untrained eye, her stomach bulges on top and bottom, a valley between- twins, a mass, a fibroid tumor? Instead, Abraham teaches us, it is the sign of a ruptured uterus bulging atop and the dead baby bulging below. ‘The mother will die if she is not operated on immediately.‘

This is why we have come, this is the purpose of the Foundation, to train local medical doctors to perform emergency obstetrical services.

We are here to teach, but we have much to learn.

The story is complex, these young women are often malnourished and under developed. Their pelvis is small, creating a problem for childbirth. The nurse midwives, three females and four males, are incredible talented at using their hearts and hands delivering even the most difficult of births. But their magic ends once a baby becomes stuck in the birth canal, the mother’s survival precedes the baby’s. A Cesarean Section vs. removal of the fetus through the vagina. There are no perfect solutions.

*Names have been changed.

Delivery Room

Delivery Room

Delivery Bed

Hand Washing

Safe Abortion

Costs

Jay and Philippa at Hospital Cafe

New Water Tank

Patient Transport

Operating Room

Operating Room

Minor Procedure Room

The Team

Image from Joni Kabana

Dr. Philippa and Darlene leaving for Mota, Ethiopia

Town

Town

Town

Mota

Mota

Picture by Philippa

Mota

Well in Mota

to be continued…

Along the way I hooked the lavalier microphone to Philippa and tested the audio levels, an excellent sample given the bump and jolt of the old minivan and the chaos of horns and street commerce. Joni configured her cameras for video and together we honed our questions to respect Dr. Hamlin’s time.

Dr Hamlin’s presence is graceful and enchanting. She fills a tall, composed space in her hospital whites surrounded by a backdrop of large window panes framing the extensive flora on the hospital grounds. As we prepare to film, a group of tourists come in to greet her. They are at once speechless and giddy with respect before this humble, grandmotherly presence.

I hoped to ask five questions in about ten minutes, but the tape started rolling as she talked about her gardens, how there were only two trees on the property when they purchased it, and how she personally planted each and every plant and tree. She spoke in long, thorough narratives and my five questions became a dialogue on women’s health and access issues that lasted for almost of forty minutes.

After our interview she gave us a more personal tour of the plants and trees that document her tenure here. Amid the chaos of Addis Ababa she has cultivated a garden, a hospital, and a system of support where rural women can begin finding peace and building a new life after the horrific, isolating trauma of fistulas so common in rural Ethiopia.

Our first visit

The grounds

The interview

The connection

A book signing for Philippa

KEEN shoes

In her garden

See that tree...?

In her garden

In her garden

With these hands...

Photos by Joni Kabana

NOTE: Two duffel bags of KEEN shoes were delivered to Dr. Catherine Hamlin, who couldn’t have been more sincerely appreciative. Darlene and Philippa delivered two additional duffels to their clinic in Mota. The shoes are a big success and we’re working with Dr. Hamlin to transport more to her clinic, but there are so many more to deliver and we continue to look for delivery options.

Soaking in the bustle of morning, a chaotic paradise surrounded by mountains and high risers. Goats awaiting fate with their brethren chickens anchored by the side of the road. Christian and Muslim families alike make their way through the city. So begins our journey.

Stumbling over broken Amharic, laughter erupts from all sides as we try to assimilate our ferengi smiles into warm and welcoming crowds. The faces seem familiar as we return to our old hotel.

Last night in Addis, dinner was shared with old and new friends from Gimbi. Jay was excited to hear about the Street Boys he spent so much time with. The Podoconiosis project he filmed lives on and many of the first patients now have normal size legs, ankles and feet.  We spent hours talking about medicine, Africa, the pros and cons of humanitarian efforts and the realities of poverty. I am exhilarated to be back, where my passion for medicine and Africa fuse, this is where I belong.

The roosters have been crowing, waking before the sun, bringing the city slowly to life. Our Ethiopian coffee sludge awaits, I must remember to ask for bunna weuteut, coffee with milk.

Nine months ago we left Gimbi Hospital in Western Ethiopia with a desire to return and further our volunteer efforts. Since then we have joined forces with Joni Kabana and Dr. Philippa Ribbink in FootSteps to Healing. Our purpose is multiple, including volunteering for four weeks in Northern Ethiopia with the Mota Governmental Hospital teaching Emergency Obstetrical Services to local doctors, health officers and mid wives. Jay and Joni area heading south to the Omo Valley to document the tribal medical facilities and services, as well working on a film project for Merci Corps.

We are thankful to everyone who has donated to FootSteps to Healing, Darcelle’s raised over $5000 and combined with other efforts we now have over $ 11,000, nearing our goal.

Families humbly stake space around the crumbling bush clinic in Southern Ethiopia, half a morning passed and the line still snaked around back through town.  My translator pulled me aside after our first 15 patients, whispering “People are becoming upset, you are not treating them properly. You are not offering them marfey.”

Since the 1920s medical volunteers have come to these bare villages, treating known and unknown ailments with local tinctures, antibiotics when available and always with marfey.

Sensing my confusion he explained families walk for days to come and get the ‘injection’ cure.

Was there something I had missed in my schooling, had my tropical medicine training in Tanzania been so far off, what ‘injection’ were they talking about?

Gimbi’s Hospital pharmacist smiled in agreement, “Don’t worry its only sugar water, but they feel so much better.”

Seven months have passed and we are ready to return to Ethiopia, back to the places, the people, and the fascinating world of tropical disease and third world medicine.  In January 2011, we will join FootSteps to Healing. As a team of four, we will be working with the Ethiopian Department of Health to train rural health officers in emergency obstetrics and neonatal resuscitation and documenting the health care plight of these women. Read our Newsletter.

You’re Invited:

Come join our Fund Raiser at Darcelle’s in Portland on Friday Dec.3rd at 6pm. The irony of these show-women raising money for their less fortunate sisters born in rural Ethiopia is beautiful and powerful. We look forward to seeing everyone and send a warm thank you for your support.

Fundraiser Efforts To Date:

Joni Kabana, a friend and professional photographer in Portland, has been working extensively to raise awareness of health conditions in Ethiopia.  In the process, the video was included in her presentations and as a result, I’ve learned that 918 pairs of shoes have been donated to Gimbie for the patients suffering Podoconiosis, courtesy of KEEN.  We are currently looking into avenues to get them there and I am extremely pleased that video played a role in helping the people who’ve touched me so deeply.

I’ve re-attached my video and a photogallery of Monica and Binyam delivering shoes to rural Ethiopia in April 2010.

showing up for their appointments

waiting for wash basins

bathing

proud

healthcare

soaking

the ailment

the ailment

also known as mossy foot

the patients

cleaning

washing

caring

together

on her way

a young woman

the look

awaiting good health

the patients

a patient

patient

beautiful

a nursing student donates his lunchtime

battered shoes

tattered shoes

the queue

shoes are abundant

more shoes

an impoverished land

In Casablanca, the mosque is built over the sea. A bastion of faith on the old sea wall, the tides and waves curling into its foundation. Inside the fortress, a pocket of calm. From end to end a small channel carved into the marble floor, where water flows, cooling and soothing with its unique whisper.

I stand barefoot on carpet, my sandals at the entrance with two men silently abuzz in arabic murmur. I am at ease in the peaceful inner décor of mosques. I am afloat and untouchable. There is a coolness to the marbled protectorate and a calming in the patterned mosaics. Calligraphic inscriptions of the Qur’an ring the columns and trace the contours of the sanctuary. I cannot read the arabic verses and so, uninterpreted, I am alone to inhabit my own story and welcomed to do so. I look inward, but feel expansive, heeding every breath.

In Damascus busloads of Iranians descend the old city on this stop of their hajj.  All in black, men in fine western suits and women draped head to toe. They are immaculately dressed, the women sharp in their embroidered burkas, fine slacks and leather shoes of the latest european fashion. Amongst themselves they hum with anticipation behind black sunglasses, but outwardly, they have all but removed themselves as anything more than a physical holder of the space they occupied. It is at once both eerie and oddly beautiful in its mystery and anonymity.

Darlene kneels on the soft divide between the muslim and christian halves of the mosque, a shrine for a prophet shared by both faiths. She is cloaked in a borrowed hood, yet her golden curls betray her. Families approach, smiling, and offer forth their children. Disinclined, but gracious, she accepts them and the families come to her and take photos, fathers and mothers with their children, collecting memories.

Walter and I enter a neighboring mosque early one morning. There is only a hint of the surge of pilgrims that will later fill the streets and halls. It is a persian mosque with a martyr’s tomb. A slain child, daughter of a caliph, bloodline of the prophet. The tomb is adorned in gold beneath a dome of glass mosaic. Women in black huddle and cry softly. Families lean tightly together, reciting the qur’an amongst themselves. Tears of faith and belief for the little girl, as one by one, men and women enter the hall and press themselves against the tomb.

We are on the floor by the marble columns of the entrance when an elderly gentlemen steps forward. After a moment, he turns and comes to us. I look up into his eyes. “I am Iranian,” he says and extends a welcome. In turn he shakes our hands, touches his heart, then turns and walks to the tomb, where he presses his head against its side and closes his eyes.

In occupied Palestine, we cross the square and stand at the open door of the mosque named for the second Caliph. Atop a flight of stairs a small, venerable gentlemen in a conservative, gray western suit and stocking feet, waves us up. He is the muezzin, the man who sings the call to prayer, and he invites us to join him.

The prayer hall is a large, humble space on the second floor where we are joined by several men who joke about the merits of sons and daughters and share with us the extent of their own families. When the time comes, we are invited downstairs into his station, a simple room with a microphone and stereo system wired to the minarets loud speakers. With us seated beside him, he smiles, stands, and turning to the microphone, he sings.

The adhān covers the entirety of Arabia.  By design, this call to prayer penetrates every nook of the city. It is intentionally loud and often tinny. However, on that afternoon in Palestine, when the muezzin sang, we heard that call in its purest form. We shared the intimacy of his song, his heart, and his pride. The complicity of organized society confounds me the world over, but the gifts of an individual does not.

darlene in casablanca

darlene the dervish

umayyad mosque, damascus, syria

umayyad mosque, damascus, syria

Sayyida Ruqayya Mosque, damascus, syria

Sayyida Ruqayya Mosque, damascus, syria

Sayyida Ruqayya Mosque, damascus, syria

Sayyida Ruqayya Mosque, damascus, syria

al-Aqsa Mosque on the temple mount, jerusalem

the muezzin, bethlehem

mosque of omar, bethlehem

casualty mosque in the golan heights

casualty mosque in the golan heights

courtyard of the alabaster mosque, cairo

courtyard of the alabaster mosque, cairo