Daily Life in Chiri by Jessie

I wake up with the sunrise at 6:30am. Leopard print curtains cover the bottom of the windows in our house to keep people from looking in, but the tops of the windows let in the moonlight at night and the dawn in the morning. I struggle to find my way out of the mosquito net, seemingly a simple task but actually challenging when you are half-blind and half asleep! I leave the house in my pajamas and walk to the Big House. At first I felt self-conscious making the short walk outside in my pj’s, but after I saw the tattered or mismatched clothing that is worn here, I remembered that clothing has a purpose. To cover us up. As long as I am covered up here, anything goes, even peppermint-striped flannel. First things first in the Big House – I turn on the hot water heater so I can take a hot shower. It needs to heat up for at least half an hour, so in the meantime, I open the doors to let in the morning sun and make some coffee. We make coffee by putting a funnel in a thermos, putting a cone-shaped filter full of coffee grounds in the funnel, and then pouring boiling water into the funnel. Amaz, the cook, roasts and grinds fresh coffee for us every week. I eat bananas from the market in home-made yogurt, or I toast Amaz’s homemade bread in a pan on the stove and eat it with honey. Sometimes I try to check my email, with variable success.

After showering and going back to our house to get dressed, I head over to the clinic. Edwin is usually there already, in the pharmacy, distributing TB meds with the help of a translator. I open the clinic manager’s office and get ready for the day. At 8:30am, the front gate opens and the guard lets in the first 20 patients of the day. As they register, one of the staff stands at the guard house with a megaphone and gives a “health talk” about subjects like breastfeeding, HIV, or environmental sanitation. In the meantime, we round in the hospital. The “team” (when it is full, which it has not been for a single day since we arrived) consists of four junior nurses and two senior nurses, the pharmacist, the lab technician, the inpatient nurse, Edwin, and me. The hospital has 12 beds divided between two rooms. We do traditional bedside rounds, walking from bed to bed and examining each patient together, then discussing the plan for the day. Edwin and I try to teach. It sounds organized but it’s not. There is no chart, no daily notes. No one takes vitals on a regular basis. Patients keep their medicines on the table between the beds or tucked under their mattress, and administer their own pills. The nurses give IV medicine. After rounds in the hospital, we go to the four-bed malnutrition unit and examine those patients as well. Ideally, the whole process lasts half an hour.

At 9am, we begin seeing clinic patients. Patients line up on wooden benches outside the clinic rooms, and file in one by one. Fever. Abdominal pain. Cough. Aching muscles and joints. Edwin and I take turns seeing clinic patients every other day. There is only one translator, so we can’t both see patients at the same time. Also, there is not enough space – the exam rooms are doubled up with providers already. The nurses here are like nurse practitioners in the US – they act independently in the clinic, presumably under the supervision of a physician or a “health officer” (between nurse and M.D.). There is also a dentist chair in one nurse’s exam room, where he pulls teeth. Among the exam rooms are the “treatment room” and the “injection room,” where daily wound dressings are done and children are vaccinated. Anyone who needs stitches or needs a bug rinsed out of their ear goes to the treatment room.

While one of us sees clinic patients, the other does administrative tasks – government reports, requests for supplies and medicines, resolving staff conflicts. We also use the time to research questions that came up during hospital rounds and to make lectures for the weekly education session on Thursday morning. Lunch is at 12:30, but everyone stops working at noon and the clinic is deserted by 12:05, regardless of how many patients are still waiting to be seen. There is little point in trying to continue to see patients, since the lab tech and the pharmacist are both gone so no tests or medicines can be ordered. Edwin and I meet up with Karen, Carole, and now Emily (she’s new!) in the Big House for lunch. Amaz cooks her version of American food, much to the relief of most of the Americans here. I’m secretly disappointed. I’d love to eat more Ethiopian food. A lot of business gets discussed over lunch, debriefing the morning. Edwin and I consult each other about patients. Back to work at 1:30, although the patients trickle back in slowly, and we don’t really start seeing patients again until almost 2pm. The clinic closes at 4pm, and the on-call nurse (junior nurse), back-up on-call nurse (senior nurse), Edwin and I do afternoon rounds in the hospital. Usually about 100 patients are seen at the clinic each day. On busy days, we have to turn patients away at the end of the day.

After afternoon rounds, sometimes Edwin and I keep working. Out of habit, mostly. Sometimes I’ll do yoga or jump-rope. Sometimes we take the time to catch up with each other, discuss our day. Often, the children from the orphanage are playing on the clinic campus – volleyball, soccer, ping pong, or just running around – and we’ll join them for a while. We usually have supper at about 6 o’clock, as the sun is beginning to set. We don’t have a shared meal with the other volunteers, but it seems we are all usually in the big house at about the same time. We scrounge up whatever is around – pasta, sandwiches, leftovers. By the time we finish, it is dark outside. Edwin and I usually study or read other books for a while in our house. There’s a ton of DVD’s of TV shows, so these days we might watch an episode of Boston Legal on the computer (SO much better without the commercials!).

Often times this routine is interrupted by emergencies – obstructed labor, bleeding in pregnancy, a very sick patient who is admitted to the hospital. Last week we made four emergency trips to the hospital (Edwin is getting to know the drive very well!). Our evening reading will be interrupted by the tap-tap-tap on our door of the guard calling us down to the hospital to help the on-call nurse, or worse, the evening’s stillness is broken by death wails coming from the hospital or the front gate.

My night-time is a rewind of my morning. The major difference is that I spray my legs with bug-spray before I get into bed, in a desperate attempt to avoid the itchy red bites that appear on my legs during the night (and that for some unjust reason, Edwin never gets). Then I mess with the mosquito net again until I’m exasperated and give up, leaving it for Edwin to mess with instead. I lay in bed, thinking about patients. Making a mental list of things to look up tomorrow, things to get done. Watching distant lightning through the tops of the windows. Listening to the night-sounds of unhappy cows and gentle, insistent crickets. Hoping the guard doesn’t come knocking. Wondering if I’m really doing any good here. Looking forward to breakfast. Feeling my breath rise and fall. And, despite my busy mind, quickly falling asleep.

Kurku by Jessie

Kurku is the newest orphan at the orphanage down the hill. She doesn’t speak either Kafinoono or Amharic, certainly not English, so it is hard for anyone to communicate with her verbally. I specify verbally – because Kurku communicates in many other ways. At first she sat shyly on the bench while the other children danced. All she needed was an invitation to join the crowd in the center of the room though, and she danced with abandon. Her own dancing sometimes, sometimes mimicking the other children as they jiggled their shoulders loosely in time to the music, sometimes simply grabbing my hands and hopping from foot to foot. Beaming. She communicates with that smile. I have never seen her without a smile on her face. As soon as she sees us, she rushes forward, smiling, then stops just short of us and extends her hand politely to shake hello, still smiling, then submits to the handshake-turned-hug, smiling bigger still. I must not actually hug very many nine-year-olds because I’m caught off guard by the slimness of her shoulders and the lightness of her frame. I remind myself to hug her gently. She lingers by our side, and I can see how badly she wants to hold my hand or just stand beside me with my hand resting on her shoulder. Compulsive affection, at once both shy and bold. There is nothing calculating or demanding about her attention. It just seems like she is visibly aching to be loved.

Kurku is not really an orphan. She is from a distant area, a different tribe, a blacker shade of black than the other children. Her father tried to drown her because she has epilepsy, a clear sign that she is possessed by evil spirits. The family of one of our employees found them at the river and saved Kurku and brought her to the orphanage. I wonder about her father. I wonder if it hurt him to try to drown her, or if he had closed off the part of his heart that had once loved his daughter. I wonder about her. About Kurku. I wonder if she understood what her father was trying to do her. I wonder if she was loved at home or if she was shunned. I wonder how she can be so fearless and affectionate here, how she can cling to us, when the last person who was supposed to take care of her tried to kill her. I wonder why she doesn’t seem confused or hesitant. Of course, all the children at the orphanage have sad stories of loss or they wouldn’t be here. But there is something about Kurku that makes me ache, about her jet black skin and her constant smile, her eagerness, her gentleness, her slight frame folding into my arms, the preciousness of knowing that she was plucked from death’s arms and that she’s safe now in a place where epilepsy is a treatable disease and not a death sentence. I wonder if she will ever understand how tenuous her position was, how she came within a hair’s breadth of being lost forever. I hope she never knows.

The History of Coffee* by Edwin

*As told in Lonely Planet’s Guide to Ethiopia and on the wall of the Ethiopian version of Starbucks

As the legend goes, there was a herder who noticed that his goats were more lively and energetic after eating a certain wild plant. Excited by his new discovery, he went to the nearest monastery and told them about this new plant and its properties. The monks chastised him and said that his discovery was sinful, so they burned all of the plants that he brought. After inhaling the smoke of the burning plants, the monks had a change of heart. They decided that anything that would allow them to stay up later to do their prayers was good.

Supposedly this all occurred in the Kafa region of Ethiopia, sometime between the 5th and 10th century. Kafa is in the western highlands, where Jessie and I are living. However, the local term for coffee is pronounced “boona.” People take pride in their boona. If you’re lucky you’ll be invited over to someone’s home for a boona ceremony, where they will roast, grind, and serve up some fresh coffee. The times that we’ve gone somewhere for boona, the cup is filled, literally, half way up with sugar! But from what I’m told, it is a special treat when you get salt or butter in your boona.

Lost Two, Saved One by Edwin

After I got back from my hour-long drive to nowhere, Jessie said to me, “Well now you have something to write about.” I thought to myself: well not everything I do is a blog entry; and was there anything extraordinary about this afternoon’s events? Probably not – it’s just a bunch of stuff that happened…that happens, over and over. Only this time, I was there as an active observer.

That afternoon, I was in the pharmacy looking for someone to interpret for me so I could tell my TB patient that he was finishing up his treatment course. One of the nurses, Desalegn, appeared and I grabbed him to pass on the information. He looked somewhat lost and anxious. Kindly, he translated for me, then told me there was a pregnant mother, at term, who arrived unconscious and bleeding

When I walked into the OB room, the patient was lying in the delivery bed, awake and looking around – good! IV fluids were going in both arms – good! The nurses updated me, saying that she had been bleeding since early this morning, and now had what looked like tissue sitting at the opening of the birth canal. After a few minutes of explanation using their hands as crude models, Jessie et al. explained to me that the woman likely had placenta previa, and needed a C-section – bad.

After conferring with our medical staff, we loaded the woman and some family members into the back of the Land Cruiser. We had two of them hold the IV bags so that we could continue fluid resuscitation on our way to Bonga Hospital – our referral hospital. I drove and Desalegn, who is trained as a midwife, came along to provide assistance.

Bonga is about 30 kilometers away on a hilly, bumpy, dirt road. An experienced driver gets there in 30 minutes. At the time, I wondered, “how long will it take an inexperienced driver with a bleeding, pregnant woman in the back to get there?” That’s a question that will never be answered, because we never made it to Bonga. About 30 minutes after we left, we stopped because the woman had started to deliver the baby. Seeing that the baby was breech and not budging we decided to keep on going, this time with Desalegn in the back. Five minutes later, we stopped again. This time the baby came out, then the placenta.

It was a relatively quiet delivery. No screaming mother. Just Desalegn and I talking, trying to get the baby out. No words of encouragement for the mother-to-be. Just Desalegn and I looking, making sure there was no bleeding. No crying baby.

There was no heavy bleeding afterwards, but the baby was not alive. For the first time since I became involved in the case, I took a look at the patient, not to assess her level of consciousness, but just to look at her. She was just a girl, young, late-teens. She had an expression on her face of, “well, what’s next,” – not fear or sadness. She said that this was her second still birth and wasn’t going to become pregnant again.

Driving back to Chiri along the bumpy road, now going a little faster and with a little less caution than before, Desalegn and I were silent. The passengers, on the other hand, sang. I couldn’t understand any of the words, but the songs weren’t mournful. They had an uplifting feeling to them. Every now and then, I heard a “Jesus” or an “Amen” in the lyrics. From my rearview mirror, I couldn’t see if anyone was crying or teary-eyed, which is what I would expect. Who knows what the young girl felt. However, the songs sounded encouraging. I felt it was no longer me driving them back, instead it was their songs carrying us home.

Later that night, Jessie and I celebrated our anniversary with dinner and some dessert. We retired back to our house ready to rest after an exhausting day, when a guard showed up at our door. In his limited English, he told me someone was very sick and I had to come. I followed the guard back to the hospital and he pointed toward the corner bed, where a middle-aged man was crying loudly. As I walked past the bed with the young girl, still recuperating from her miscarriage, I wondered, “wasn’t this the bed with the old woman with the swollen knee? Didn’t we discharge her?” My mind raced, trying to prepare myself for what the guard anxiously called me for. The crying man stepped aside and I saw a blanket covering a small body, too small to be that old woman. Still unsure what was under the blanket, and a little scared, I pulled it back to find a girl, about seven years old, pulseless, lifeless.

“What the hell,” I thought. Who is this? Where am I? To say the least, I was frustrated. It turns out she was referred to us a few hours earlier, from a smaller clinic. She needed x-rays; she needed surgery; she needed a health care system that can respond to emergencies. Unfortunately, this girl had too many strikes against her and didn’t survive. Wanting to let my frustrations out on somebody, I kept quiet, knowing that nothing I said at this point would make this situation better. Jessie, acting with a little more empathy, comforted Desalegn, who was now on-call, because she knew that he was just as affected by the day’s events as we were. He let out an exasperated sigh, smiled, and said, “Lost two, saved one.” Doing the math, you wouldn’t think that this was an optimistic statement. It wasn’t a “glass half-full” versus “glass half-empty” situation. It was more like the glass tipped over, cracked, and a middle-aged man is still crying over the spilt milk…but we still have the glass. So, I kept quiet, trying to let my frustration pass.

My Least Favorite Diagnosis by Jessie

In the States, my least favorite diagnosis was “dizziness.” All clinicians have one, I think, a least favorite. The one that just makes you cringe as soon as you pick up the chart and see the chief complaint noted at the top. Some people hate back pain, some hate viral upper respiratory syndromes, for some it is headaches. It is usually a symptom that could have a wide variety of causes that are difficult to tease out. Often the least favorites are least favorite because they are chronic, with no good cure and few effective treatments. For me, dizziness is awful because it is such a vague complaint - everyone means something different when they say they’re dizzy, and most people find it difficult to pin down the exact symptoms and situations. This leads to an exhaustive list of questions than invariable yields conflicting answers about dizziness with head movement, position changes, laying in bed, etc. The patient starts to look at me with exasperation and impatience, and I start to look at the patient the same way. Worst of all, some of the possible causes of dizziness are very serious, so I have to be sure to avoid overlooking brain tumors and arrhythmias and multiple sclerosis and mini-strokes and severe anemia. But most of the time, especially for young people, there is no serious cause. Usually no cause at all. Which leaves me trying to treat a distressing symptom with no cause and therefore no good treatment, while holding in my mind that it’s probably nothing but possibly something, hoping that my Dix-Hallpike maneuver will be positive so that at least I have an official benign diagnosis to offer the patient.

I now have a new least favorite diagnosis. I may actually hate it even more than dizziness. Lower extremity swelling! Under any circumstance, the differential diagnosis is wide. Heart failure, kidney dysfunction, liver failure, venous disease, blood clots, tumors, cellulitis. Fortunately, there are diagnostic tools that can differentiate pretty well between the various causes and can quickly pick out the dangerous ones. Simple blood and urine tests check on the kidneys, an echo cardiogram can evaluate the heart, a Doppler ultrasound can rule out a dangerous deep vein thrombosis. The difficulty in the United States is usually controlling the swelling, if anything. Not the case here in Ethiopia.

Two problems – those diagnostic tools that differentiate the causes? Not available here. Not even remotely. Patients have to travel four hours and spend a year’s salary to get an ultrasound. So we examine the patient closely. Any jugular venous distention that may indicate heart failure? Other stigmata of liver disease? Positive Homan’s sign? Of course physical exam is supposed to be the basis of diagnosis, and western doctors are notorious for defaulting to lab tests instead of actually touching the patient. In this case, however, physical exam is not sensitive or specific for any of the potential causes.

The second problem is that there is a whole new differential diagnosis in Ethiopia, and a much higher prevalence of the problem. Filariasis – infection of the lymphatic channels with parasites that cause scarring and block lymphatic flow – is endemic in eastern Africa. So is onchocerciasis, a similar disease that can block the lymph channels. These are the major causes of “elephantiasis.” Filariasis is diagnosed by detecting the micro-filariae in the bloodstream between 10pm and 2am, when they make their diurnal excusion out of the tissues and into the blood. Now I admit we are better resourced than many clinics since we do have a lab and a lab tech, but I don’t know how he would feel about coming in at midnight to do filariasis tests. Then there is podoconiosis. Podoconiosis only occurs in people who don’t have shoes. The silica in the mud works its way through the skin of their feet and clogs up the lymphatic drainage. Spending your life barefoot also causes a lot of other infectious problems that are rarely seen in the US.

The kicker is kwashiorkor. Kwashiorkor is protein deficiency starvation that causes edema. When there is no protein in the blood to hold fluid in the bloodstream, all the fluid seeps out into the tissues. It is a cruel irony that these malnourished patients appear swollen and chubby, when really their body is cannibalizing its own protein stores to stay alive. Of course, most of the Ethiopian differential diagnosis list cannot be confirmed in our lab. We are left to treat a few things and see what responds, and hope it is just starvation and not organ failure.

Filariasis with lymphatic scarring, hepatocellular carcinoma from endemic hepatitis B, deep vein thrombosis – nothing can be done for these problems anyway. Maybe I should feel relieved that having an exact diagnosis doesn’t really matter, since most of the diagnoses have no effective treatment in this setting. But now in the hospital, we have a young woman who came in with undetectable blood pressure and a fast heart rate. Her presenting complaint was diarrhea. On physical exam, her legs were swollen. IV fluid administered gently did normalize her blood pressure but it also made her entire body puff up. Her legs became twice as swollen. Kidney, liver, heart, kwashiorkor? I can guess. But I’ll never know. And even if I did know, chances are I couldn’t do anything about it. I hate lower extremity edema.

Eden by Jessie

Behind our house lie tangles of green wilderness that extend all the way to the horizon. The bright green backyard scoops down into the deeper green valley, where clouds often settle in the morning and in the late afternoon. The deep green valley makes a distant ascent into dusty green hillsides that rise into dusty blue-green tree-covered mountains in the distance, and then the mountains themselves fade into the hazy blue sky where clouds are waiting to rain. The hazy blue belly of the clouds sometimes glides over the valley and swallows our hilltop in fog and rain, a rain so fine that I can feel it and hear it on the leaves but I can barely see it. Tonight the cloud-belly is building higher and higher into impossible white cottonball cloudtops that stand silhouetted with golden edges in the sunset. The whole valley is full of breeze, as though an invisible hand were petting the back of a huge green beast with tangled fur.

Right off our porch are bushes filled with flowers. Closest to the steps are orange lilies with their flowers facing off into the distance. Their long, lanky stems lean into the sunset. They remind me of trumpets serenading the sun. Once the sun is set, the trumpeting lilies close their blooms into tight orange buds until morning. To the right of the lilies is a small spiky bush that seems to be sprouting small marigolds, and off to the left, a huge loose bush dotted with tiny red and yellow flowers. Wild pink roses with olive leaves flank the flower bushes. Close to ground grow tight purple balls of velvet violets. The whole wild garden is guarded by flying beetles that seem big enough to knock me over if they were to fly into the side of my head, but they are consummately uninterested in people. They buzz so loudly that it almost drowns out all the other sounds. They alternately circle the flowers and circle lazy figure eights around each other.

Insects in the distance sing a song so constant and so loud that without trying I’ve begun to tune it out. It sounds like an orchestra of violins all playing the same note with a fast and choppy motion. When I stop to listen, I’m surprised to find that it sounds like a louder version of the fine buzz that I can hear in my ears when the world is silent. Above the background noise of the insects are the voices of the children at the orphanage down the hill. Shrieking, laughing, pure as bells, talking loudly in a language that I don’t understand but that at the same time I understand totally. The sound of carefree happiness. The monkeys begin to chatter too, with such rhythm and emphasis that it’s easy for me to believe that are speaking a perfectly formed language that I just don’t understand.

I sit in the middle of all this glory, the hazy mountains and towering clouds, the bright tangles of flowering bushes, the laughing children, I think to myself – surely this is Eden. Surely God reached deep into his pockets and pulled out the most mysterious, most beautiful, most fertile, most pure gifts and planted them all here in Ethiopia. Throbbing, pulsing life. How could there be poverty here?

Don’t look a gift holiday in the mouth by Jessie

Edwin and I woke up to the sound of rain this morning. Not pattering, gentle rain. Torrential rain. It is a soothing sound when you’re lying in bed, but it doesn’t make getting up and going to work seem very appealing. At least it would promise a light day in the clinic – patients do not like walking in the pouring rain any more than I do! But after breakfast, Edwin discovered that the on-call nurse was already handing out the morning TB meds. The only time the on-call nurse does that is on weekends … and holidays. Surprise! The clinic is closed today! It’s Ramadan.

We knew that the clinic’s Muslim employees had been fasting for a month. Not Catholic “no meat on Fridays” fasting. Really fasting. Nothing could pass their lips between sun-up and sundown. Some would not even swallow their own spit. I offered a cough drop to a Muslim employee with laryngitis – she took it, but said she had to wait until after sunset to use it. When a Muslim says nothing passes her lips, she means it. Not even medicine. I thought back to my day in the clinic and wondered how many Muslims I had accidentally given medicines that are administered 3 or 4 times daily. I think that in countries where the majority is Muslim, the pace of society slows down during the Ramadan fast. Not here – the Muslim staff still went on three-hour hikes to vaccinate people in the far-flung villages, still worked full days, without taking as much as a sip of water, without making excuses.

The end of the Ramadan fast was a little unclear to us. It was marked on all the Ethiopian calendars as Thurs, Oct 2. However, it is apparently a “rolling” holiday that can only be announced the day before, depending on the moon. But the cycles of the moon are pretty clearly marked on my calendar too; not a mystery, just a 28-day cycle. Yet if we asked 3 different people which day we should plan on closing the clinic, we would get 3 different answers. So today is my Ethiopian equivalent of a “snow day” – an unexpected day off in the middle of the week. Of course, it would have been nice to know that this morning as I prepared to go out in the thunderstorm. But you know the saying, “don’t look a gift horse in the mouth?” I’m not about to look a gift holiday in the mouth either!