Life boxes in action

The lifebox is a portable oxygen saturation monitor designed specifically for resource poor settings. They were donated be Little lives an Edinburgh based childrens charity and lifebox, a UK based charity which aims to get similar equipment into all hospitals in the developing world. The lifeboxes help identify which patients need oxygen.

End Game

So with my final few weeks in Ethiopia disappearing quickly I have started planning for home. My final report for VSO is complete and just requires submitting, I have finished off writing exam questions for the medical students and I am now trying to complete my "clearance" - another wonderful bit if Ethiopia bureacracy which sees me requiring a signature and purple stamp from every single university department even if I have nothing to do with them before they will write the necessary letter for me to get my exit visa. Its a long and painful process and doesn't exactly help make you feel sad about leaving.

What does make me a little sad is the mass exodus which has taken place from Haramaya University over the last few weeks and will continue over the next wee while. One by one, most of my freinds and colleagues here are leaving. Some of them - the expats and other volunteers I will likely see again in Europe (or at least there is a real chance of it if week make the effort). My Ethiopian friend though, I will probably only ever see if I return to Ethiopia. Even if we paid for their flights to visit the UK, the chances of being allowed a visa would be slim. One of the university professors here has had a paper he wrote accepted for presentation at a conference in Glasgow this summer but so far he has not been granted the visa to travel to the UK to take part. So it feels a little bit like saying good bye forever and that is pretty tough.

On top of all the preparing for home, there is still plenty of work in the hospital with regular teaching sessions and plenty of attempts to consolidate everything I have tried to do in the last year. I do worry slightly that anyone following in my footsteps will wonder what I've done all year as the changes are barely perceptible and there is still so much to do.  I sometimes wonder if I had gone about it with a completely different attitude and been a little more forceful with my views and opinions whether i would have made a more of a difference. I distinctly remember some consultants of mine  waving sets of patient notes around until all the loose sheets fell on the floor to make the point that you hadn't filed things properly. As a junior doctor I filed things properly fairly quickly after that to avoid scrabbling around of the floor picking up all the bits that had fallen out. I do wonder if taht kind of approach might not have made more of a difference. In the end though, some thing I accepted fairly early on, and still know is true, is that there is no way one person can fix everything here in a year. Fortunately there is meant to be another paediatrician following me next year, so hopefully she can continue to bang on about good note keeping, and hand washing and the importance of doing regular vital signs etc. At least I think that because of my year here there will be alot of nurses and midwves resuscitating babies more effectively and (with the help of all the baby hats and blankets) keeping them warm, and that alone feels worthewhile.

Arba Minch Photos Part 2 - Nechisar park

Arba Minch Photos - part 1 Dorze Vilage

 The view

 Traditional Dorze House

 Spinning Cotton

 Making Enset bread

 Weaving

 Pottery Lesson

 Important Game of Marbles

Dorze Lodge

cream teas Croc and Catholic Priests

Cream teas, crocs and catholic priests

Calum has just left after his two week trip to Ethiopia, which is means two things; firstly I have lots of exciting holiday type stuff to write about and secondly I’m on the home leg with only 6-7 weeks left in Ethiopia.

We spent the first few days of Calum’s trip here in Haramaya, catching up with friends and enjoying life on campus. I was also able to take the equipment Calum had bought down to distribute to the hospital. I have had 3 Life boxes, which are oxygen saturation monitors designed for resource poor settings donated by Little Lives, an Edinburgh based children’s charity run by one of my colleagues at Sick Kids. They help the help to detect hypoxia earlier than clinical signs can and are especially useful for patients undergoing anaesthetic. Initially I wanted all three from the paediatric ward but after discussion with the medical director we decided to put one in the OR, one in “intensive care/ recovery” and one in paediatrics. I made them promise to reassess how much use they are getting and redistributed if they are not being used, although whether that will happen is anyone’s guess. Calum had also brought 24 child/neonatal ambu bags with masks courtesy of Dr Morrice (also back in Edinburgh) and which will go into the labour ward paediatric ward and also to some other hospital and health centers so that the staff should have no excuse not to put into practise all the brilliant resuscitation skills we’ve taught them. They are desperately needed – only the week before I found another apnoeic, bradycardic baby on the neonatal unit. I asked the nurse to get the ambu bag, but she couldn’t find the usual one so appeared with another old thing but said she didn’t think it worked. I decided to give it a go but when I squeezed the bag the baby almost got a mouthful of cockroaches instead of a lungful of air. Needless to say we abandoned that particular ambu bag pretty quick.

Our original plan had been to stay in Haramaya for a full week, but then we were invited to the British Embassy to a garden party to celebrate the jubilee. Since we had been planning to fly to Addis anyway on the Saturday we decided to bring the flights forward to Thursday and go to the party that afternoon. It wasn’t so much the patriotic need to flag wave the attracted me, more the pull of pimms, proper wine and pastries. However there was to be no cream tea for me as we were bumped off the flight at the last minute in favour (we think) of the US ambassador who’d been at Haramaya the day before to open a radio station. Gutted is not the word. Still we ended up with some extra time in Addis and filled it very nicely by swimming at the Sheraton in their lovely heated outdoor pool, and spending the night watching Ethio jazz at the Taitu hotel which was fab.

From Addis we flew to Arba Minch which is in the South of the country. It’s totally different to any other part of Ethiopia, set in the heart of the Rift Valley with two great lakes which almost meet, separated only by the “Bridge of God” a narrow, but mountainous piece of land which forms the Nechisar national park. On the other side of Arba Minch from the lakes there are mountains covered in lush vegetation including enset and banana plants and mango trees. Its very green and tropicl feeling in comparison to other parts of the country which generally are looking much more barren at this time of year.

In Arba Minch we stayed with Father Paddy at the Catholic Mission. It was recommended to us by other volunteers but I have to admit to being a little apprehensive about it as my previous impression of the Catholic church has been one of a slightly intimidating, stuffy, out-of-touch institution. Would they mind that Calum and are were not yet married? Absolutely not! Father Paddy and Father Dennis are so hospitable and great company. They (and the fridge full of beer) really make you feel at home, and I think between them they could definitely convert the masses. Apart from the great accommodation and food they also generously provided us with use of the mission’s 4X4 to visit Dorze Village up in the mountains and Nechisar park, where we saw the biggest crocs ever! (Photos to follow). They also took us to visit Arba Minch Prison where they do a lot of development work, improving the inmates accommodation, and health care services, and providing workshops and equipment to allow them to learn a new skill and keep occupied while in prison. They were visiting the prison that day with a group of Irish Musicians on a fund raising visit, and the plan was to put on a concert. After a couple of tunes though, it was felt the locals didn’t really get the Irish music and maybe some irish ceilidh dancing would help, except they only had 3 people and needed 4. Next thing I know I’m being dragged up to do my first ever Irish ceilidh dancing in a Ethiopian prision cheered on by 2000 inmates. Thankfully they totally “got” the dancing and were very enthusiastic in their applause! It was a brilliant experience.

Thats all for now. More photos later.

Thoughts turn to Home

Oops - its been a while. Another period of dodgy internet access I'm afraid. the joys on living in Africa!! Wrote this post last week......

Last week I travelled to Addis Ababa for the VSO leaver’s conference. This is a one day work shop held to inform anyone whose placement ends in the next 6 months about the procedures and paperwork necessary before you leave. There’s quite a lot to do but it all seems fairly straightforward and I still have at least two full months to get everything finished off.

The workshop also gives you a chance to reflect on the highs and lows of volunteering and what you have achieved in your placement. It was interesting to hear everybody’s stories, good and bad. It seems that although most people have had many challenges and frustrations along the way, no one has regretted making the decision to volunteer with VSO. For me it has been a brilliant year and I am so pleased to have had the opportunity to do it. It has been incredibly tough at times, especially at the start when I really missed Calum and had no permanent accommodation which made getting settled so difficult. However I know that if I hadn’t come to Ethiopia I would have always wondered what it would have been like and wished I’d been able to find out. I have also learnt a huge amount. Not just about paediatrics in Africa (which is  an entirely different job to paediatrics in the UK in every way imaginable) but also about things that have never been part of my job before, like writing project proposals, preparing and managing budgets, running training courses, and implementing changes and new protocols. I have had a huge amount of teaching experience and have discovered that I actually quite like it and maybe medical education is something I’d like to explore more when I get home. So on the whole a year well spent. There is still sooooo much to do here though, and I will never be able to change all the things I would like. The good news is that there may be someone following in my footsteps so hopefully a new volunteer will help keep up the momentum.

After the leaver’s conference Susan and I headed West of Addis to the town of Ambo. We had a brilliant night out on the town and then went to visit Wenchi crater with a whole gang of VSO vols. Wenchi crater is an extinct volcano with a fresh water lake, and it’s absolutely beautiful. We walked the 1 ½ hours down to the crater lake then took a boat to the island in the middle on which there is a monastery. Afterwards we rode horses back up to to summit where our minibus was. It was so lovely to get our in the country side and there was hardly any hassle so it was a really relaxing way to spend the day. Photos to follow......

Mission NLS complete

The last two weeks have absolutely rocketed past. We have been super busy with our NLS course, running another 3 rounds, and training 80 people in total. The courses seemed to get better and better and it was really lovely to have our local trainers on board, able to translate into Amharic. I’m sure it really improved the understanding of some of the participants who really didn’t speak much English.

I particularly enjoyed working with the local trainers because most of them were young women, and women still have a pretty subservient place within Ethiopian society. There are very few women in positions of power here and the traditional culture is for the wife to serve her husband. Consequently a lot of our female trainers were really apprehensive about the idea of standing up in front of colleagues to give presentations. However with a bit of encouragement and the reassurance that we wouldn’t have asked them to do it if we didn’t think they would do a really good job, they all did us proud and seemed to really relish the opportunity, to make things a bit better where they work. A lot of them seem to have gone back to their hospitals and health centres really motivated to improve things which makes me feel like we’ve achieved our aims.

We have already visited one of the hospitals at their request, and made plans to spend an afternoon there, making sure staff are confident to use the equipment they have that was not covered in the NLS course. The Helping Babies Breathe newborn life support posters which were donated by UNICEF Ethiopia and given out at the first course were proudly displayed in frames on the walls about the newborn resuscitation station just as they should be so some things are working!

The next step will be to ensure all the senior staff have been trained. This was requested by one of our local trainers, who said that she was delighted to have learnt about newborn resuscitation, but had come up against some resistance from senior colleagues at work who still think the best way to resuscitate a baby is to swing it upside down by its feet (seriously!). We’ll need to tread carefully with this one so as not to cause offence and are working with the University to devise a plan.

Finally I’d love to be able to persuade the regional health board that they should fund this training to be run every few months with local staff so that all the health care workers who regularly deliver babies update their skills every couple of years. This might be a long shot be we’ll see what we can do.....

NLS success

Every now and then I get a day when all the difficulties of volunteering seem worthwhile. This week I’ve had a whole week! It has been brilliant and it’s great to finally feel like you are doing something that might actually make a real long lasting difference.

When Susan and I first started working in the hospitals, one of the things we noticed is the complete lack of confidence most of the nurses and midwives have in resuscitating a baby who does not breathe at birth. This is a really critical part of a midwives job, but our direct observations were that it was done badly or not at all. Partly this is due to inadequate staffing, space and equipment but also it’s due to a lack of awareness and training. More than the basic resuscitation, we also found that the care of the newborn was often really poor.  The babies who are admitted to the neonatal unit are frequently hypothermic, and they may not have been fed for hours and hours.

We decided that this was something we had to try and improve, and so since Christmas we have been preparing a newborn life support course for the nurses and midwives working in Harar. We applied to VSO for a grant to fund the project, and spoke to the regional health bureau who asked us to train health centre staff as well as hospital staff, and agreed to ensure that the government institutions have the basic equipment necessary. Then we prepared the course material we wanted to teach, based on UK newborn life support guidelines but also adapted to the WHO/ Ethiopian Paediatric guidelines.   As well as basic newborn resuscitation we have includes sessions on ethics and document keeping ( as the quality of note keeping here is generally pretty appalling), and essential newborn care which covers how to support mothers in breast feeding and keeping babies warm amongst other things. Finally we persuaded UNICEF Ethiopia to donate the neonatal resuscitation training equipment in the form of 4 neonatalie complete kits!

The course is happening in 2 stages. The first stage started this week and we had participants from every hospital and health centre attending. We did two days training on the theory and practice of newborn resuscitation and then a final day discussing methods of learning and teaching, and asking our participants to think about how they would take what they have learnt back to their place of work, share it with their colleagues and put it into practice.

The course was really well received and all our feedback was extremely positive. On the 3^rd day we asked our participants in groups to prepare a micro-session explaining and demonstrating a particular aspect of newborn life support, and it was so lovely to see them demonstrating what they had learnt and explaining it to colleagues. The candidates who we thought were strongest we have asked to come back and help as instructors in phase 2, when we hope to train another 60 of their colleagues by running 3 more similar courses but without the third day.

The final part of the plan is to speak to the regional health bureau about setting up an annual professional development programme, where they run similar training regularly throughout the year so that all of the staff here get the chance to update their skills on a regular basis.  Even if the final part is not successful we will have around 80 better trained health care staff working in Ethiopia and if they put their new skills into practise that alone will be a year well spent!

 Progamme and all improtant "ground rules" agreed by participants

 Susan and the participants

 Hands on practice with "neonatalie"

 Susan leading a scenario

 Caroline leading a scenario

Participants helping each other

Professional Accountability

I saw a patient with the medical students last week who was 4 months old and only weighed 2.9kg, which is the smallish end of normal even for a newborn infant. The baby was the 10th child and unusually all of her siblings were alive and well. Her mother had breast fed all the other 9 children but for some reason on this occasion she didn't produce any milk. Not producing milk is pretty unusual, but this is also a very experienced mother who has managed to keep 9 other children alive and relatively healthy in Ethiopia, which is no mean feat, so I'm inclined to believe that she knows what she is talking about. As an alternative, she had fed the baby 1/3rd cows milk, 2/3 water boiled together and cooled, 3 times a day since birth. Not surprisingly, the baby had failed to gain any weight and was subsequently admitted to our ward with severe acute malnutrition.

This story is not that unusual here, but the thing that is frustrating is that this mother had taken her child to a private health clinic 4 times since it was born and they had clearly failed to act or give appropriate advice to this woman, with the result that her child has ended up with a life threatening condition. Unfortunately there is very little that can be done about it. There is no professional accountability here at the best of times. The doctors leave for a 2 hour lunch break often regardless of the state of the ward, and although someone is nominally on duty to be called in a emergency they will be at home which could be 30 minutes away.

If a child dies here, no body asks "why did that happen? Could something have been done to prevent this? What can we learn or do better next time?" It is just accepted as part of life.

I always used to get a little irked by endless clinical governance issues at home, but seeing a world without really brings out the importance of working in a enivronment where as a professional you must be accountable for your actions, and have a responsibility to remain up to date with the evidence for the best treatment for your patients.

Safe to say that any clinic or health professional who had not picked up the baby above sooner in the UK would have their practice scrutinised and measures put in place to ensure it didn't happen again, but here we will probably never know the true story and many more child will suffer malnutrition.

More baby hat action!

 This is the little girl from the last picture I posted. All snuggly and warm with her hat. Sadly her brother didn't survive. She's doing well but not out of the woods yet by a long way.

This little one was born the day after my second instalment of hats arrived. About 9 weeks early and born in the street! She was very cold on arrival so we decided to put her in the newly functioning incubator (as you can just about tell from the photo). It worked quite nicely and she didn't get cooked either!

Easter at Amaha's

 Some snaps from Ethiopian Easter at Amaha's house. The first one shows Jenny, Susan and Gary with Amaha standing in the background. This is a traditional but really quite nice Ethiopian House. And yes thats a Christmas tree which seems to stay up all year!

 Amaha's wife in traditional dress makes coffee Ethiopia style.

Susan, Amaha's son, Jenny, Amaha's wife, me and Amaha.

Melkam Fasika

This weekend Ethiopia celebrated Easter. It is the end of 55 days of fasting (ie vegan diet), and is the biggest annual holiday in the country. People spend it with their families, and eat a lot a meat (much of it raw) to celebrate. We were fortunate enough to be invited to one of the local teacher’s homes in Bati, the village at the university gates. We had a lovely meal, although it wasn’t the traditional Doro Wat and injera that we were expecting but an amazing spread of “ferengi food” prepared especially us.  I was only slightly put off by having previously met the goat they had slaughtered that morning. We also had some not quite so lovely Tela which is a local alcoholic drink brewed from Barley and that tastes like muddy ditch water –yuck!

The rains continue here. Intermittently, but still there never the less. On the whole it is very welcome, as everything is beginning to look green and lush again and it’s a good bit less dusty which is a relief. On Saturday, Susan and I went for a walk down to the eucalyptus woods at the bottom of campus. It had been raining earlier in the day and the smell from the trees was just amazing. I couldn’t decide if I was back in Australia or perhaps in a herbal essences shampoo ad!

I took ownership of the next consignment of baby hats today – this time courtesy of my cousin Sophie and the lovely ladies of Briston and Melton Constable WI. Thank you! They are really appreciated. I’ll take them in tomorrow and get a few more photos of them in use!

Work wise, things are slowly improving. We have managed to get our one non-functioning incubator working, which is great news, but the problem is none of the staff know how to use it. It’s not that high tech, but it requires close observation, and that is not part of the psyche here. Even the most critical patients are doing well if they get more than one set of vital signs recorded in a 24 hour period unless I’m there nagging. I can’t be there 24 hours a day though and I’m a little bit worried that if I put a baby in the incubator it might get cooked. Not literally, but it might overheat and I can’t be sure that any one will check its temperature or turn the incubator down, even if I leave explicit instructions.  I guess there is only one way to find out though..... hhhmmm might get that incubator out tomorrow.

Baronesses, Big thunder, Bowel trouble and Baby Hats

Back in Harar this week and trying to get back into the swing of things at work. My last week with Calum here was spoiled by a nasty bout of gastroenteritis, which pretty much stopped me from seeing anything of Hawassa, in southern Ethiopia, other than my immediate surroundings. The immediate surrounding were however lovely, and were quite nice enough to keep us occupied for a few days. We treated ourselves to a stay at the Lewi resort which is a lovely but expensive hotel on the shores of the lake. It has free boat rides, mini golf, table tennis, badminton and a lovely pool for its guests to take advantage of. There are beautiful gardens and trees full of very cheeky monkeys who spend most of their time spying on other people’s lunches from their aerial vantage points, and then mounting co ordinated raids on the unsuspecting diners below stealing what they can. Very amusing to watch – and we managed to keep all our food, only sharing a left over saucer of tomato sauce, which one young monkey came right onto our table and stuck his face into, ending up looking much like a toddler who had just fed himself a bowl of spaghetti hoops! Very comical.

Since being back in Harar, we have been visited by Baroness Blackstone, who has come with VSO on a two week parliamentarian scheme to see development work in action. She is also chair of the board at Great Ormond Street, and was very interested to see the paediatric ward at Hiwot Fana.

Every night we are having big displays of thunder and spectacular lightening forking across the sky and the small rains continue, although interestingly we seem to get the lightening most, often the thunder, and uncommonly the rain. The total opposite of Scotland where you get loads of rubbishy drizzle and occasionally a clap of thunder,  but rarely a good full on thunder and lightening display. I really like a good storm, it’s quite exciting and we get an amazing view from the full length windows in the living room. Being on the top floor of a 4 story apartment block has some perks!

Finally I have received my first instalment of baby hats from Calum’s Mum- thank you! They are beautiful. I was able to put 3 of them to use as soon as I got to work as we had a set of twins born 10 weeks early and weighing about 2.2lbs each who were so cold the thermometer could read their temperature (pics to follow) and a bigger full term baby, who’s temperature came up from 34.1 to 35.6 with an hour skin to skin and a hat on. She was still a bit cool but I’m confident that as long as she stays with her Mum things will continue in the right direction. The hats are massively appreciated -all of the mothers want one for their baby but at the moment I’m rationing to those that are cold or very small until we get a few more – so thank you, and do keep them coming!

An interesting few days

This week I have been in Addis Ababa, at the Ethiopian paediatric society meeting. It was really interesting, not particularly because of the content of the meeting (although the content was good), but because of the opportunity to network a little with other paediatricians in Ethiopia. The Ethiopian Paediatric society are doing really good work, developing national management guidelines, encouraging continuing professional development and accountability, and providing training for staff to help improve conditions in the country’s paediatric wards. They also made us as VSO paediatricians very welcome, and invited us out for dinner on both evenings, which  gave us really good opportunities to discuss some of the things we are trying to achieve in our placements, and work out just how we fit into the multitude of NGOs working in Ethiopia. I met representatives from the Ministry of Health, the world health organisation and other NGOs such as ICAP. We also managed to get ourselves invited to a meeting about improving neonatal health which is one of the main goals of many of the paediatric placements here. It’s is a bit frustrating that we hadn’t been invited before this, especially since it is a major reason for our being here, but we did get there eventually. Two of the doctors I work with in Hiwot Fana Hospital were also there, although I didn’t know they were coming. They were really enthusiastic about making some changes in our neonatal unit and I hope that we will now be able to work together as a team to improve things.

The other change in the last few days is that the small rains have come with a vengeance. The Ethiopian climate has two wet seasons: The small rains in Feb & March and the big rains in July, August and September. The rains are late, but very refreshing. Now instead of 25 – 30 ^oC and sunshine, we have cooler weather, a build up of cloud through the morning and early afternoon and then torrential rain and spectacular thunder and lightening in the late afternoon and evening. It’s the first rain Calum has seen since arriving in mid December! The arrival of the rains means we are likely to be in with a busy month or so at work and the incidence of malaria and water borne infections will rise significantly...

A tough day

Well another week has passed and time continues to accelerate here. Monday was a tough day in the neonatal unit, even by Ethiopia standards. Three babies died, and I am fairly certain that at home they would all have survived. The reasons for this high death toll are multiple. There is the obvious lack of intensive care facilities and skilled staff, but there are also major issues with the infrastructure and systems that underlie how things are done. The first baby was admitted on Sunday night, but had really difficult venous access and no one was able to site an intravenous line.  He was therefore given an intramuscular antibiotic injection and left overnight without feeding or fluids so that by the next day he was dehydrated, with low blood sugar, and very sick. I was able to site an umbilical line the next day but it was really far too late. There is no system or protocol for the staff to get help in these situations. IV access is almost exclusively done by the nursing staff here, and in general it is only the paediatric specialists who can do umbilical lines, and there is no paediatric specialist on call. It’s not clear who was called for help and whether the on call doctor was even consulted, and it never will become clear because there is no procedure to be followed following the death of a patient to review the cause of death, and see if there are any lessons to be learned.

Equally one of the other babies really needed a blood transfusion, but there was no blood.  Blood transfusion is a risky business here at the best of times as the blood is often not matched to type, let alone cross-matched for antibodies that may cause an adverse reaction. One unit is shared between many patients, and it is kept far longer than it ever would be at home. Amazingly I haven’t yet seen any bad reactions to blood transfusion, which surprises me given the high level of care and documentation taken over the decision to transfuse blood at home. Sometimes we try and persuade family members to give blood that can be given to their relative, but that costs them money for the equipment, and in this case would very likely have taken too long and probably been futile.

I find this really frustrating. Things are the way they are for a whole multitude of very complex, interlocking reasons and that makes it very hard to know where to start. I am always conscious that I don’t have all the answers, just a different way of doing things that may or may not be better than what is in place in the context of what’s available.

Happy Holidays 3 Lovely lalibela

After our amazing few days in the Simiens, we returned to Gonder, happy but tired, and very, very dirty. Possibly the dirtiest I have ever been, in fact. Our clothes were actually black (even the underwear!)  because of the fine dust blowing around the mountains which gets into everything. We stayed in the Goha hotel for a few days relaxation and luxury, but unfortunately the Ethiopian food had finally caught up with Calum ( I’m amazed it didn’t get him sooner actually) so he got well acquainted with the toilet, while I sipped Gin and Tonics on the terrace!

In Gonder, I visited the royal enclosure and Fasilada’s baths. Gonder was previously the capital of Ethiopia and a the rulers lived here in the 17^th and 18^th century. The royal enclosure has been preserved by UNESCO and is in remarkably good condition.

From Gonder we flew to Lalibela, which is only a couple of hundred kilometre east, but very difficult to get to by road. Lalibela is the spiritual home of Ethiopian Orthodox Chrisitians. It was built by King Lalibela in the 12^th century. The story goes that Lalibela was poisoned by his sister and in a coma for 3 days. While in a coma he was spoken to by god, who ordered him to build a second Jerusalem in Ethiopia, and so construction of the rock hewn churches commenced. There are 11 in total, all carved out of the rock and surrounded by a myriad of passage ways and tunnels that allow easy access from one church to the next.

At the time we visited, the orthodox Christians were fasting prior to Easter. This means eating only vegan food and for the strictest not eating anything before 3pm in the afternoon. The churches were full of people praying, and it was touching to see the depth of their faith. The whole atmosphere here is really hard to describe unless you’ve experienced it, but for me there was a deep sense of spirituality in the people which I found fascinating.

Another highlight of our trip to Lalibela was a visit to Ben Abeba restaurant. This restaurant is newly opened, and is housed in a unique building on the hill with spectacular views. It is run by an Ethiopian man and a Scottish woman who initially came to Ethiopia as a volunteer. The food is lovely, the views spectacular, the prices very reasonable and the welcome exceptionally friendly. Oh and they are so proud of the cleanliness of their kitchen that they give tours (definitely a first in this country).

So that concludes our amazing trip up North. Unfortunately we didn’t have time for Aksum, the oldest Ethiopian capital, and supposedly home of the Ark of the Covenant, but this just means the chance for a return visit. I was impressed by the friendliness and the diversity of the country and although Ethiopia has a way to go to reach standards of tourism expected in the West, or even India and SE Asia I would definitely recommend it to anyone with a sense of adventure....

 Royal Enclosure Gonder

 Ben Abeba restaurant Lalibela

 Rock hewn churches

 Faith

 Priest

St georges