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

oops

Hhhmmm not sure what happened to the giant photos in the last post. calum will tell you I'm a luddite with a terrible relationship with my computer. I blame that then. Still you get the picture - kind of....

HappyHolidays 2 - The Mighty Simien Mountains

After leaving Bahir Dar we headed north by road to Gondar. The drive is spectacular, and it was a really great chance to see just how different the north of Ethiopia is to our base here in Harar. This is the region of the Amhara people ( in Harar we have a mix or Oromo, Haraghi, and Somalis) and they really are quite different. Lighter in skin tone, the women wear their hair short and often uncovered which would be unusual in eastern Ethiopia. They tend to wear the traditional white dresses with embroidered borders and  matching scarfs. The majority seem to make their living from farming, but it is not chat growing territory. Instead they grow cereals and vegetables, and you will often see people out ploughing the fields with an old plough and oxen.

Gondar serves as the start point for most tours to the Simien Mountains although they are in fact a 3 hour drive north along a dirt road. The Chinese are currently putting in an asphalt road to make access easier. (The Chinese involvement in Africa is a blog topic all on its own...)

We had arranged our tour through a guy called Nega, who many other volunteers had recommended. To visit the mountains you need a chef, guide, scout/guard, mule men and camp hands and he co-ordinated all of this for us.

We trekked for 4 days and spent 3 nights camping in the national park which is listed as a UNESCO world heritage site due to being an area of outstanding natural beauty. It is also home to several endemic species including the Gelada baboons, Walia ibex and Ethiopian wolf. The trekking is absolutely spectacular and for the most part not too hard going, although it is mostly at an altitude of 3000-4000m above sea level. We noticed the altitude despite having been acclimatised to 2000m for the last 6 months so I can imagine that it might be really tough if you had just come from Europe. You also really need a head for heights to do this. Much of the first two days we followed a cliff top path along the escarpment and at times were less than a meter from up to 1000m vertical drops. Spectacular but also pretty scary especially when the altitude is already making you feel a little dizzy!

The camping here is pretty easy going. Each day our tent was packed up for us, packed onto mules and carried the shortest route to the next camp, where it was unpacked and set up again in time for our arrival. Three delicious meals a day were provided – with lovely things such as porridge, scrambled eggs or pancakes for breakfast, and a three course evening meal. We even had a bottle of wine on the last night. We had mattresses to sleep on and two sleeping bags each because once the sun went down it was really,really cold!

We saw loads of baboons which are amazing to watch and really not afraid of people at all. We also saw several Walia Ibex, which are apparently a relative of the goat family, but the males have the most enormous horns which look really spectacular. Photos to follow.....

A Good Week

Life in Harar has been pretty good since we got back from our holidays. I feel like I’ve had a really productive week which is great, as so often it takes forever to get anything done here and it can be really frustrating. So what have I achieved....? Pretty simple stuff really but it still feels good. The internet has been reliable enough to get in email contact with all the other volunteers and start planning a set of guidelines that can be used in neonatal units across the country, my neonatal admissions book, which is a record of all the admissions to the neonatal unit, their diagnoses and outcomes was received with great enthusiasm by my colleagues, and we had a visit from the director of VSO Ireland and a gaelic football player called Pat Spillane, who are about to do a VSO recruitment drive in Ireland and wanted to come and meet some volunteers and hear about their experiences. They seemed genuinely interested and impressed with what we are trying to do and it’s always so lovely to get a nice bit of positive feedback.

One of the things I’ve been mulling over a bit recently is what I can do to try and keep the babies warm. It seems ridiculous that this should be a problem in tropical Africa, where the average daily temperature is somewhere in the high 20’s, but it is. The problem is that all babies, and particularly those that are born prematurely or with low birth weight have real difficulty in maintaining their body temperature. The mechanisms which keep them warm are immature and they have less fat stores to burn to produce heat so they become hypothermic very easily. There is lots of evidence that in most cases getting cold is detrimental to both immediate chances of survival and long term developmental outcomes, so hypothermia is a real problem. The thing that frustrates me about it that the solutions are not particularly high tech. Yes a lovely heated humidified incubator would be great but these things often break or require maintenance and the support services are simply not in place to make that kind of equipment sustainable. We do actually have an incubator but as soon as you turn it on it just alarms and says it requires a qualified technician to service it, so it doesn’t get used much. The simple things we need to do are keep the babies dry, keep them skin to skin with their mother, and keep a hat on their head but this is easier said than done. There are no nappies of of any variety here, and babies are wrapped in whatever light cotton shawl the mother has spare when she arrives in hospital. They pass urine, the shawl gets wet, they get cold. The hospital doesn’t have nappies, or blankets or hats – we just use what the parents bring which is often not a lot. We have one radiant heater on the floor in the neonatal unit and we cram as many cots next to it as we can. So what is the solution? I have a few things in mind. I have been finding out about some simple incubators suitable for resource poor settings, that aren’t heated but protect infants from drafts. I am hoping that my neonatal unit admission book will help me prove what a common problem this is and we will be able persuade the powers that be to get some of these made locally. Secondly I will keep insisting infants are placed skin to skin as much as possible. Finally, I wondered if anyone reading this knows anyone who knits? And if so, whether they would like to produce some hats for my neonatal unit? We need as many as possible, in a variety of sizes with a circumference of between 28cm and about 38cm.... so can anyone help? If you think you might be able to, please comment on the post and I will email you. Oh and any suggestions for the nappy problem would be greatly received  Jo x

A few more Bahir dar Photos

 Sunset

Hippos

Bahir Dar Photos

 Hornbill at the ghion hotel

 Marabou storks

 Lake Tana

 Caromine Bee-eaters

Sunset silhouettes