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…

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.

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

We were headed an hour west into remote Ethiopia, close to Sudan’s border, where an under-stocked, dilapidated clinic waited our arrival.

Satellite clinics within this mission based hospital cover over 100 miles of deforested valleys and hills, reaching areas forgotten by governmental planning. Desolate regions far from public transport and markets, people so poor that second-hand clothes and shoes remain unattainable. Many are barefoot, carrying heavy loads of wood or water to their distant villages.

The red dusted window played like a foreign film sans subtitles as Islamic holy men herded zebu humped long-horned cattle and sheep with matted, twisted tails slowly through rows of thatched huts supporting coptic religious crosses.
Fields of seasoned mangoes and avocados fell heavy from trees into villagers hands where they lined the dirt tracks selling fruit, charcoal and sugar cane.

A narrowed path turns into a village where a lone yellow acacia tree towers in the dry heat, its lower branches gone, a telling of fate as firewood is sparse and nothing goes unused. Children race to the car, pointing and howling, ‘ferengi,’(white foreigner) as we unfurl ourselves into the new surroundings, our clinic for the next several days.

A little girl, perhaps five, with crazy hair and a makeshift dress races between my legs, shrieking. She grabs my hand and slaps it into hers, triumphant. We eye each other curiously, making faces, slowing our pace to the clinic.

Towering above these children, I notice their heads, or in this case, compared with Tanzania, the lack of fungus on their scalp. It has changed, how I look and interact with the environment.

Past her smile, I notice palms that are peeling and skin on her extremities cracked, her fingers clubbed with deep nail ridges. A little boy running to catch us has a swollen belly with a protruding umbilicus, his reddish hair is sparse and brittle. We pass women squatting over charcoal, large goiters protruding under scarves. While malnutrition and deficiencies are evident throughout Ethiopia, so is the panacea. But the abundant wheat, fruit and vegetables grown as cash crops don’t find their way into the local diet. There are no government subsidiaries for vitamin or iodine supplementation.

Patients arrived early, miles away they came in droves, sick children and elderly in tow. Emanual, my interpreter of twenty-three, shouted for our first patient. An anxious young husband, wife at his side, an infant nursing under the head scarf, I had yet to sit down, no chance to organize my stethoscope, paperwork, they spoke hurriedly as he deciphered this Oromifa dialect. Weaving a tale of night sweats, lesions and infections, he finally motions his wife to uncover the child- feverish eyes look over her breast as a rotting odor engulfs my senses.
A moment of panic struck, what was I doing here in Ethiopia? Hours away from a hospital and people too poor to travel any distance were asking for help. I found myself struggling, wondering how I could help this family, one among hundreds waiting outside the broken blue door?

Experience builds confidence, until one day you reach Africa and everything changes. What we learned from medical books and mentors in the western world suddenly means very little. His face covered with small, irregular raised bumps, many secondarily infected with impetigo gave way to to large bulbous abscess draining from the neck and back of his head. Tight curls atop his head matted with virescent pus.
Lifting his weak body, she moved his small head aside and pointed to a clustering of new pimples on her arm. I had no idea what this strange mix of lesions could be, nor the illness taking over his body.

I had to get this boy to a hospital, IV antibiotics, fluids started. Without proper treatment, he would die. Urgently, I made my way through the crowded clinic looking for Shumate, my new colleague, an Ethiopian nurse with years of clinic medicine in the rural villages. I urged her to come quickly and see the boy. While distress covered my face with desperation and fraught, she glowing, entered like an angel, touching the child and his parents, quietly asking questions, a sense of calm.

She turns to me and in soothing English, explains what it could be- autoimmune, HIV, end-stage Syphilis, TB, fungus, bacterial… She agrees the child is septic and perhaps he will die. Pragmatically she continues, “There is nothing the family can do to change this, they can’t afford to get to a hospital and they can’t afford treatment, and we can’t help everyone because many children die in Ethiopia, that is the way.”

I sit back down, defeated.

Holding back tears, I watch as she takes over the grim situation, gently picking up the child encouraging the family, offering everything we have brought to help- injectable Penicillin, antibiotics, Tylenol, she offers a prayer, her smile holding strong, reassuring the family that life is a cycle, they are calmed by her efforts.

Her steady hand to my shaken heart, she leans forward, wisdom trickling from her soul, “You must help those whom you can and help those whom you can’t, you must offer hope, this is Ethiopia, that’s all there is to it.”
Those who could afford hospital visits had done so months ago, these are the remaining few from an impoverished country of 80 million, with nothing left.
I look around and see for the first time the raw humanity around me, hope riding on the shoulders of sickness, poverty and malnutrition. Seated upon wooden benches, soothing one another’s discomfort all waiting to be seen: malnutrition, whooping cough, lost pregnancies, deformities, infections, burns, epilepsy, AIDS, prolapsed uterus, scrotal hydrocele and the list goes on. Simple vaccines, surgery and proper treatment could treat most of the conditions, but funds, resources and education are lacking.

We are all they have, and once a month this organization offers them assistance with medical supplies, comfort and hope to those who are the poorest of the poor.

The boy and his mother were treated with our meager supplies and then the father, not wanting to take up resources as more sick families arrived, bundled up his family and began the long walk home to his village.

I remain conflicted about the roles and funds of NGOs, International Aide and Medical Organizations in the third world. I am still struggling with the many poor and critically ill patients who received our palliative care, but were unable to obtain further treatment or hospital admission.

Who am I to judge and in a world of such prosperity, why do so many still suffer?

village church

pharmacy

pharmacy

Gimbi hospital

surgical sheets

Iodine salts

out-patient clinic in Gimbi, mine was first door on the left

rash 1

Rural clinic

Rural clinic

Rural clinic

used eye glass center

This is the first of two videos I was tasked with making and the imagery contains pictures of terribly disfigured feet due to an ailment called podoconiosis. If you do not like medical imagery, consider this before watching the video or viewing the gallery. The video was made to support the work of Gimbie Adventist Hospital in Ethiopia and I would especially like to thank Monica Barlow, who among many other things, is the compassionate narrator.

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