And Then There were Two (a Rough Week in Chiri) by Jessie

When we first arrived, there were seven government-appointed nurses at our health center: four junior nurses that rotated overnight and weekend call, two senior nurses who took backup call from home and came in if the junior nurse needed help, and a higher level Health Officer who also took backup call. It seemed like Edwin and I were hardly necessary from a manpower standpoint. We struggled to define our roles here.

The Health Officer was fired soon after we arrived. Then nurses began to disappear on vacations and family emergencies, and as provider numbers dwindled, Edwin and I started to see more patients in the clinic. Soon we were no longer extra providers that helped the nurses and saw some patients on our own for fun. We had to work hard to see all the patients that showed up at the front gate every day. Edwin and I continued to share administrative responsibilities – managing the clinic, stocking the pharmacy and the hospital storeroom, overseeing the clinical staff, running the TB and malnutrition programs, plus trying to get the new hotly-contested HIV/ART program up and running. The clinic was bulging at the seams, but it was efficient. Everyone was busy.

But this week, nurses started disappearing for good. Yared and Tariku, the senior nurses who were gone on seemingly indefinite personal leave, quit without notice. Solomon, our notoriously unstable but ambitious midwife (and the only nurse who knew how to pull teeth) put in for a transfer so he could be closer to his family. He wasn’t actually transferred, but he did stop coming to work. One loyal nurse finally got accepted to nursing school to finish his education. He was gone within a day. The government did assign another nurse to our clinic, but before starting to work, he had to return to far-flung northern Ethiopia to get his stuff. He was supposed to be here on Wednesday. He never came; not that it would help, because he is fresh out of school so he needs to be trained before he can see patients or take call on his own. And worse, all of this personnel-shifting happened within the space of one week. Worse still, it was one week at the beginning of the dry season, when patient numbers begin to swell.

So then there were two. Two Ethiopian junior nurses, alternating overnight and weekend calls. One is already about to crack. And two American doctors, trying to manage a clinic over which we truly have no power, trapped on the clinic grounds indefinitely because there is no one else to back-up the exhausted junior nurses who are constantly on call. Almost every day this week, we turned away furious patients who walked for hours to get here.

I thought the challenge here would be medical. Little diagnostic capability, unfamiliar diseases, few medicines, no attending physician to tell me if I was doing things right or not. And those things were challenges at first. But after a while, I accepted the limitations and discovered that there is still a lot that we can do. Medically, I can adapt. And medically, the work is more and more satisfying every day. But trying to be a personnel manager in a foreign culture – trying to accomplish the most necessary or even the smallest tasks within a messy and corrupt governmental bureaucracy – trying to support the nurses and pacify the patients that are about to riot outside the front gate – trying to manage an NGO-run clinic when decreasing contributions mean we have to cut our budget 50% - it is these management issues that will drive us crazy. Not the medicine.

The Ants Go Marching ... by Jessie

… And not one by one. One thousand by one thousand, maybe. It began with innocent puddles of ants on the walkways as the rainy season started to dry up. Then innocent puddles coalesced into rather alarming solid black ribbons of ants streaming in perfect organization across the walkways. We learned quickly that these ants were not as harmless as they seemed. They’re carnivorous. In the past, they ate entire chickens down at the orphanage. Maybe they can’t eat a whole person, but they do bite pretty hard, so we steer clear of the swaths of ants. My morning walk to the Big House became punctuated by dainty pajama-clad leaps over the wide black ribbons of ants on the path. We bided our time, waiting for the sizzling dry season sun to arrive and force the ants underground again.

Until one day, Emily came to the Big House pale-faced and announced there were ants in her room. And not just a few. The cement floor was carpeted with ants. It was impossible to see the paint on the walls in some areas because the layer of black ants was so dense. A soft-ball sized mass of ants clung to the light switch. I suddenly understood why she was so upset! But it seemed like a first – a rarity, not something that had ever happened before. So out came the ant spray. Emily slept in the Big House that night and swept the layers and layers of dead ants out of her room the next day. We thought it was over.

Until they got into the kitchen in the Big House. Ants, swarming all over the sink, all over the dishes, pouring in through a crack in the wall. Soon the guards were up at the Big House asking for ant spray, because their guard-house was invaded too. Man vs. Ants. It was war! The ant spray made its foray into the great outdoors, shamelessly poisoning Mother Nature I’m sure, but more importantly, dousing the ribbons and piles of ants outside that would surely find their way into our home eventually. No more jumping over the ants. No more peaceful co-coexistence.

Maybe it is my imagination, but there seem to be fewer ants around these days. Maybe it’s the sun. Maybe it’s the ant spray. Maybe it’s the evil eye that I gave every ant that crossed my path. Regardless, I think I’ll still keep a bottle of bug spray by my bed for now.

Electricity in Ethiopia (“Hydro”) by Jessie

Electricity came to Chiri a couple of years ago. The power lines followed the road from Addis to Jimma, from Jimma to Bonga, and then from Bonga to Chiri. As the lines were being strung, they first hung slack and loose down by the ground. People hung their clothes on them like laundry lines. Then the wires were pulled tight, and electricity came to the country-side. Sort of.

The entire electrical infrastructure of Ethiopia is based on hydroelectric power that is distributed to the country through un-insulated above-ground wires. Three problems.

The “hydro” part of hydroelectric seems like it should be no problem, since the rainy season dumps tons of water onto Ethiopia for six months out of the year. The other six months, however, are dry season. Sometimes power goes out for weeks at a time during dry season due to lack of water to fuel the hydroelectric plants. The second problem is the un-insulated wires that carry the electricity across the country. Anything that touches the wires breaks the electric circuit, and everything downstream loses its power. And Ethiopia is a big country. There is ample chance for an unmaintained power line to go down in a rural area. Especially because of the third problem – jealousy. The power lines may pass through villages without providing them with power, or people may be unable to afford the service. So, jealous folks purposefully cut down trees so they land on the wires and take out the electricity. People steal the posts. And since most of these problems occur in rural areas, it takes forever for the power plant in the city to figure out where the problem is, especially because they don’t have a truck to drive around and look for the cause of the power outage, and because they themselves are not affected by the outage so their motivation is pretty slim. There is the added problem of unpaid bills – if someone near you doesn’t pay their bill, everyone’s electricity gets cut off.

There is a fourth problem that may or may not be true. Volunteers who come from the States say they have read that Ethiopia is selling its electricity to neighboring Kenya and Sudan due to excess supply. When power becomes scarce, Kenya and Sudan get the electricity. Ethiopia goes dark. Addis Ababa, the capital, suffered from rolling blackouts. It is almost impossible to buy a generator in Ethiopia now, because any businesses in the cities that rely on electricity snapped them all up. Also, there are wild swings in the electric current that quickly kill computers and keep our voltage regulator box humming and clicking all day long.

I wonder if it hurt the Ethiopian engineers who designed this system to do it so half-heartedly. I assume they are much smarter about electricity than I am. They must have known the problems that un-insulated lines pose. They must have realized that sometimes even in wet season, the rains fail. They must have seen that there were no safegaurds in the system. I imagine them arguing that unreliable electricity most of the time is better than no electricity at all. I imagine them evaluating the cost of upgrading the system and realizing they would never have that money at their disposal. They are in the same boat as the guys who build the terrible dirt roads, saying that a dirt road that is washed out for half the year is better than no road, saying a paved road is out of the question.

So, every time we turn on our oxygen concentrator in the hospital, I hold my breath. If the hydro goes off, the barely breathing patient will lose her oxygen. Our generator can keep the power-hungry oxygen concentrator running for a while, but not for long periods of time. Just let the antibiotics kick in first, I pray. Just give us a day or two to figure out why the patient is so hypoxic, I pray. Just don’t let the hydro go out on a weekend, I pray. Let the problem be at the plant so it will get fixed quickly, I pray. We keep candles and flashlights at our bedside, just in case. I should be praying in gratitude for even unreliable electricity! But I have to wonder how much harder it would have been to make a reliable system. The “threshold effect.” Some things aren’t worth doing half way.

Heart Failure by Jessie

Our encounter with Tigiste began two weeks ago, but I think her problem began before that. At least I hope so.

Tigiste arrived from Angala at 9pm on a weekend night. Angala is an eight-hour walk away, a “settler” area where the government has relocated poor people to unoccupied land for farming. She was unconscious, dehydrated, hypotensive, and breathing fast. Poking, poking, poking, finally Edwin and Desalegn secured an IV line in her flat veins. Her husband said she had been vomiting for the past few days, and had a seizure. Her physical exam told a different story – both lungs were filled with crackles and mysterious gurgles. Her heart was racing so fast it was hard to hear the individual beats. Her oxygen saturation was 70%. She had a fever. After further questioning, her husband said oh yes, she’s also been coughing for the past week. Ceftriaxone, IV fluids, acetaminophen, supplemental oxygen. She seemed to have a bad pneumonia that was causing sepsis. The next morning Tigiste was awake and smiling, even though she was still breathing fast and still needed the oxygen. I thanked God for ceftriaxone. It seemed like she had arrived just in time.

But then Tigiste stopped getting better. Her fever continued, a high drenching fever that left her soaked in sweat and trembling like a leaf. Her lungs were still full of crackles, and she still needed extra oxygen. I stopped thanking God for ceftriaxone and started wondering if we were treating the wrong thing. Then came the heart murmur. Worsening every day, WOOSH woosh, WOOSH woosh. The veins in her neck started to stand out and her liver became enlarged and tender with congestion from heart failure. Her blood pressure remained very low. Tests for TB were negative. With frustration, I realized there were no other tests we could do. No blood cultures, no echocardiography, no chest CT, no central venous pressure measurements, no sputum culture. Antibiotics were added and changed. Her heart failure was treated with digoxin, the only heart failure medicine we had that would not lower her already barely detectable blood pressure. She still didn’t get better. We gave IV fluids for low pressure until her hands started to become puffy. Her heart went into an irregular rhythm. Her breath came in gasps. Tigiste was dying.

Did she have the heart murmur when she came? I tried to remember that night, her exam. Why wasn’t her fever going down with IV antibiotics? Lung abscess, emphysema, tuberculosis, endocarditis? Every day I wiped the beads of sweat from her face as we helped her sit up in bed to examine her. She started to smell stale and musty from sweating in her only pair of clothes. But still, every day, she met my eyes and smiled.

It seemed that Tigiste’s only hope was transfer to a bigger hospital. But she and her husband were obviously very poor, so he had to go back to his hometown to get a “free letter” to receive free treatment. If they got the letter, they would come back for referral. Otherwise, he would take her back to Angala to die. The only thing worse for her than dying at home would be dying here at the hospital, because transporting a rigid dead body that far away would be nearly impossible. But Tigiste and her husband didn’t make it back to Angala – she was too weak, and he was too poor to pay for a ride. They reappeared a few days later, after spending nights sleeping on the streets of Chiri. They had no free letter. We admitted her back into the hospital. Weaker, thinner. Lungs clearer now because of dehydration and decreased pulmonary edema, but blood pressure very low. She was shivering with fever. She smiled shyly at me with big black eyes, like a child returning home.

So I prayed. I pray sometimes for patients, for health, for strength, for endurance, for relief of suffering. But in Tigiste’s case, for the first time, I prayed specifically that she would be cured. It always seems a little dangerous to pray for a specific outcome for a patient, as though somehow I know better than God what is good for someone. And what does it mean about my God and my prayer if the patient still dies? But still, I prayed for her to get better. It seemed like there should be a cure for her illness. It was a fever. An infection. Infections are treatable. There must be a treatment, I thought; there must be a cure. I felt helpless and angry and frightened and determined all at once. We started TB medicine along with her antibiotics to treat possible TB pericarditis. We added steroids to dampen the possible inflammatory response caused by starting the treatment.

And the next day, her fever broke. Hope surged in my heart.

The day following, however, she was hypothermic. My hope cracked. I almost preferred the fever to such a low temperature. She did not meet my eyes. Her gaze was fixed blankly on the ceiling; her teeth were clamped down on her lip and her mouth was stretched thin in a sort of grotesque smile. Her sheets were soaked with urine.

She died last night. I took the sheet away from her dead body and was relieved to see that the spark and the smile that I loved in her were gone, that her dead body was clearly just a dead body that was no longer inhabited by the woman I knew. She didn’t look peaceful or asleep. She just looked dead. I know that death is not the enemy, that my ultimate goal is not simply preventing death. But I can’t avoid feeling a sense of failure – whose failure I don’t know – mine, God’s, Ethiopia’s. So I said good-bye to Tigiste; I told her dead body that I tried everything I could think of, I told her that I’m sorry. But I wish I could see her smile at me just one more time, so I know that she’s forgiven me.

Kwash kids by Jessie

(kwashiorkor – protein calorie malnutrition)

“Kwash kids” are the most miserable and the most gratifying subset of children at the hospital. Their parents usually bring them in to the clinic for “swelling,” or “rash,” or “poor appetite.” What you see is a miserable puffy child, feet so tense with edema that they look like little balloons with toes, faces so swollen with edema that the puffy eyelids cannot open. The edema is from protein deficiency. The ones who are worse off also have a rash that the textbooks lightly call “flaky-paint dermatitis.” In reality, the skin of the legs and arms peels off in mottled purple sheets, and the skin of the swollen feet cannot stretch any further so it peels open in weeping ulcers. Zinc deficiency adds a red, peeling rash around the mouth and around the neck, like the sunburn you get while wearing a v-neck t-shirt. Their thick, tightly-coiled black hair first loses its luster and then becomes brittle and orange-brown like dried grass. It falls away from their scalp when you touch it. There is often superimposed illness – coughs and fungal infections and draining lymph nodes.

The cruel irony is that the kids are so sick that they refuse to eat, which worsens the malnutrition. They are irritable but too weak to really fight back. They often forcefully resist eating, though. Mothers force-feed the children by pouring formula into the child’s mouth and then plugging the child’s nose, forcing the child to swallow. The tough cases get a tubes put down their noses into their stomachs, and they are fed through the NG tube. Their hands are bandaged up with swaths of gauze like little boxing gloves so that they can’t pull the tube out (which they still manage to do about once a day). They glower and scowl and bat at the NG tubes taped to their faces with their little gauze mitten hands. It’s hard to say if it’s comic or pitiful. Regardless, it’s hopeful.

Because they get better.

The beginning is often a struggle – constantly re-inserting NG tubes, bloody noses, distended tender abdomens, painful skin infections, vomiting, diarrhea. But then one day the child can open her eyes – the edema has drained out of her face. Then from the top down, the edema decreases, leaving wrinkled raisin skin behind. The children transform slowly back to their original physical selves – some still have happy round cheeks even after the edema goes away, some have suddenly thin faces but their big beautiful eyes are revealed. They start to take the formula willingly, then greedily. They smile and hide in their mother’s skirts, or reach out shyly and politely to shake hands with the nurses as we do our morning rounds. We tease them, they laugh, we laugh.

The less fortunate ones wither into nothing once the edema has drained out of them. They are left only with skin and bones, and faces that look frighteningly like the gaunt face of an old man. Their “saggy pants” backsides hang like empty sacks where round buttocks should be, but there is no fat or muscle to fill out the loose skin. But these children with combined marasmus-kwashiorkor (marasmus – pure starvation, total calorie deficiency) get better too. Their cheeks fill in, both their faces and their backsides!, and they once again look like little children instead of little old men. It’s hard to believe that the gleeful, playful children who leave the hospital were once miserable Kwash kids.

There is a lot of medicine and science behind treating malnutrition – specially formulated milk that prevents fatal re-feeding syndrome and hypernatremic heart failure, treatment of infection that flares as the immune system reconstitutes, avoiding hypoglycemia and hypothermia, supplementing vitamin A to avoid eye disease. But really, malnutrition treatment feels more like a miracle than like medicine. Children are reborn – they get a second chance – still facing all the same challenges, but now starting out with an advantage. A little bit of reserve. And a lot of hope.