Pneumonia by Jessie

The top two causes of childhood death here in Ethiopia are diarrhea and pneumonia. When children die of “diarrhea,” I’m not sure what the true cause is – if it is pure dehydration, overwhelming infection that spreads to the bloodstream, or just weakness and malnutrition that leave the child vulnerable to every little thing that comes along. Death from pneumonia is easier to see - panting, labored breathing that gradually slows to somnolence and then to death. In the past, two or three children died from severe pneumonia each month in our little hospital. The death rate has decreased over recent years. Better access to health care, more immunization in the community, the purchase of an oxygen concentrator to provide supplemental oxygen? Regardless of the cause of the decreased mortality, children with severe pneumonia are now among my favorite patients – because they get better.

I went down to the hospital one afternoon and discovered an eight-year-old boy sitting in his father’s lap, receiving a nebulizer treatment. Vapor hissed out the sides of the face mask and the nebulizer machine hummed noisily. The boy didn’t seem to notice. He sat slumped, semi-conscious, his eyes glazed with fear. I could see the outline of the individual muscles of his abdomen and neck as he strained to suck air into his lungs. His chest pumped fast and shallow. His skin burned with fever. The nurse quickly placed an IV and the patient got all the right medicine, but in my heart, I thought it was already too late. I reminded myself that this is the reality of medicine in Africa: otherwise healthy children sometimes die of treatable diseases.

When I returned that night, the whole family was bent over his bed. I couldn’t see the patient. I almost turned away, not wanting to see his final agonal breaths, not wanting to intrude on the family. But suddenly the wall of relatives parted and the boy stood up beside the bed to use the bedpan. His mother continued to try to untangle his IV tube and oxygen tube so he could squat down. Everyone, including the patient, turned to look at me impatiently, as if to say, “do you mind?” By the next morning, he didn’t need supplemental oxygen anymore. He was discharged home a day later. At that moment I loved kids with pneumonia, kids with a definable illness who just needed IV antibiotics and oxygen, sick kids that would die without intervention but that we could successfully cure.

Unfortunately, that isn’t always the story. Some kids do not have typical bacterial pneumonia that responds almost instantly to antibiotics – they are malnourished, scrawny babies with vitamin D deficiency. Their pneumonia is just another insult on top of a history of recurrent pneumonia or chronic cough. There is no miraculous recovery, only a drawn out and futile parade of different IV antibiotics and steroids and inhaled treatments. Their journey often ends with treatment for presumed tuberculosis, which usually fails also. The babies linger in the hospital, coughing so hard they vomit up their formula and become even more malnourished, refusing a definitive cure. Chronic vitamin D deficiency causes their tiny ribcages to become pinched and restricted and their soft spines to curve outward; it also causes their immune system to weaken so they never get better. It seems like these unlucky babies always end up in bed number 6 – I’m about ready to take that bed outside and burn it out of frustration!

But for every one of these chronically sick babies, there are two or three kids with simple pneumonia who come in severely sick and leave relatively healthy. I smile as they leave the hospital, knowing that you can’t win all the battles, but it sure feels good to win a few.

Food in Ethiopia by Jessie

The staple of Ethiopian food is “injera,” a spongy flat pancake-like bread that is used to scoop up the other food (mmm, finger food!). A meal is not complete in Ethiopia without injera. The injera is usually served with “wot,” a sort of stew. “Messer wot” is lentil stew, “doro wot” is chicken stew (usually served also with a boiled egg in it, the irony of which I didn’t catch at first – chicken and egg!), “kai wot” is beef stew, vegetable wot is… vegetables. Usually potatoes and carrots. “Tibs” isn’t really stew, it’s pan-cooked chunks of sheep or goat meat. Gomen, a spinach-like leafy vegetable, is also served with injera sometimes. Shirro (a spicy chick-pea paste) and vegetable wot are staples on Wednesday and Friday, which are “fasting days” for the Ethiopian Orthodox church – no meat, no eggs, no dairy. Strange to make a country of skinny, marginally-nourished people fast twice a week, but people take it really seriously. The staff who had just hiked three hours in the sun to do outreach vaccinations wouldn’t eat the nuts out of the trail mix I offered them, because the nuts had touched the M&M’s which had chocolate in them, hence, possible dairy contact.

Most Ethiopians, however, eat “fasting food” all week long because they cannot afford meat. Meat and meat products like cheese are reserved for holidays. When we asked the kids at the orphanage what Ethiopians do to celebrate Christmas, they replied happily, “eat meat!” Despite the lack of meat in the diet, protein deficiency is rare – except in the poorest of the poor. So, it’s easy (almost necessary) to be a vegetarian in Ethiopia; it’s hard to be vegetarian at the restaurants here, though. Restaurants seem to serve only meat dishes, which I presume reflects the fact that average Ethiopians can’t afford to eat at restaurants.

Injera is made of a grain called “tef,” which is almost exclusively grown in Ethiopia. Unfortunately, since food prices have risen around the world, poorer Ethiopians can no longer afford tef. They rely on the root of the false banana plant (“enset”) to make a fibery-starchy bread called “kocho.” They can subsist on kocho alone for long periods at a time, from one unsuccessful growing season to the next (hopefully more successful) season. Kocho can be buried underground for more than a year and then dug up when food is scarce. Unfortunately, kocho lacks zinc and vitamin A and protein, so kids who rely on kocho often become protein-deficient (kwashiorkor).

Strangely, fruit does not seem to be a large part of the diet here, despite the fact that it grows very well in this climate. Papaya, pineapple, avocado, passion fruit, and tomatoes are available when the weather is right. Bananas and cabbage are available almost all year round. A type of local cheese is available in the market – curd-like sour cheese with a strong taste like feta. I like it, but most of the other Americans don’t care for it too much. We buy “faranji cheese” (cheddar, etc) at the supermarket in Addis Ababa when we make a trip out there (a hard ten hours away).

The food is generally spiced with “berberi,” a spice mix containing many of the same ingredients as curry, but with its own distinct flavor. Unlike the food in India – which was so spicy I couldn’t even look at it – the food here is hot enough to be savory but not to burn my tongue!

The only food I avoid like the plague is “kitfo,” or raw beef. Very popular. Very bad idea, as far as I’m concerned. For the most part, however, the cook who makes us lunch every day prepares mostly American food, and when we cook for ourselves in the evenings/weekends, it’s leftovers or sandwiches. We eat Ethiopian food mostly when we travel (American food is rarely available at restaurants) or when we ask Amaz the cook to make it for us. It makes me a little sad, because the Ethiopian food is delicious, but at the same time, I’ve discovered that injera has the distinctive property of expanding in my stomach like a dry sponge soaking up water, which is okay once in a while – but not three meals a day.

Tis a gift to be simple by Jessie

I don’t pay rent.
I don’t have bills.
I don’t get junk mail.
I don’t have an answering machine blinking with messages at the end of the day.
I don’t have productivity quotas.
I don’t work 30-hour shifts.
I don’t have to cook.
I don’t have to do laundry.
I don’t wear make-up.
I don’t have to worry about what to wear.
I don’t have stacks of charts waiting for me every morning.
I don’t have sirens and car alarms blaring through my window.
I don’t have to put gas in the car or remember to have the oil changed.
I don’t have to worry about malpractice insurance, car insurance, life insurance, disability insurance, or renter’s insurance (although we do have “evacuation insurance”).
I don’t have a pager.
I don’t have to memorize which medicines are covered by different health insurance companies.
I don’t have to fight traffic (unless livestock count).
I don’t have to hunt for parking either.
I don’t have to keep up with pop culture.
I don’t worry that a patient will sue me.
I don’t worry about the housing market or mortgages (yet).
I never have to shovel snow or cut grass.

All I have to do is get up in the morning and go to work. And I don’t even have to be there until 8 or 8:30, and it’s just 20 feet away. Really, our life here is pretty simple, and I’m discovering that simple is pretty nice.

Burn (rage and resignation) by Jessie

Just looking at her face gave me an idea of how severely she was burned. Her black braids were pulled painfully tight across the swollen skin of the scalp; brown skin peeled away from her right cheek and forehead to reveal inflamed pink and red tissue underneath; her eyes were swollen shut; blisters rose from the cracked skin of her lips. She tried to wet her dry lips with her tongue and winced. Her breath came in small gasps.

The rest of her body was worse. The skin rubbed off with slightest touch. I was surprised at first, and then worried, that she did not feel pain as we washed the naked pink burns on her back and arms. She moaned and listed to one side. Her two brothers grabbed her burned arms to keep her from falling. That, I thought, is love – to touch such an ugly burn without flinching, to see only the person you love falling over and not to see the skin pulling away under your hands. Gently we washed her whole body with soap and water and smeared the burns with petroleum jelly, cutting away the dead skin as we went, and then wrapping her whole body in layers of gauze. With 3 people, it took an hour and a half to finish cleaning and dressing her burns. She collapsed with exhaustion. The burns covered 90% of her body.

She had run into her burning house to retrieve her belongings. Her clothing had started on fire. Her family lost everything. How could they now pay for her medical treatment?

It was impossible to place an IV through the hard swollen tissue of her forearms, so we tried without success to place an IV through an unburned area of her neck. Nothing she touched seemed clean enough – the wooden bench where she sat in the treatment room, the wall she leaned on, the stool where she rested the burned soles of her feet. Whenever she moved in bed, our carefully wrapped gauze pulled away and rubbed her bare burns on the scratchy wool blanket. I thought of the burn unit at HCMC – the sterile white rooms, the sterile gowns and gloves worn by staff and visitors alike, the careful surgical debridement under anesthesia, the high-tech biofilm burn dressings. That was what she needed. But she was poor, and she was Ethiopian, so what she got was us. Wool blankets and petroleum jelly in a ward full of contagious pneumonia patients.

After a few days, her family gathered a “free letter” and enough money to transfer her to the university hospital. She had done ok so far – she was eating, drinking, and urinating normally. The swelling had gone down enough that I could see the whites of her eyes. But her burns smelled. There was fluid under them in some areas, probably pus, and other areas were hard and thick like white leather – third degree burns. “You must give anesthesia and excise the burns,” the staff told me with all seriousness as they pushed on the hardened areas of her back and torso. I felt helpless. And angry. If I had devastating burns like hers, I would be emergently evacuated and airlifted to a European hospital. Rage bubbled in my stomach. What really is the difference between the patient and me?

So we bundled our patient into the back of the Land Cruiser, naked except for gauze dressings, and sent her to Jimma University hospital. It is blind faith that the hospital in Jimma will be any better. At least here we treated her for free. The treatment room staff washed her wounds every day with as much love as Jesus himself washing the feet of his disciples. But my rage is tempered by a simple, quiet resignation – a sense that you do as much as you can, and if it isn’t enough – then disease takes its natural course. I felt this familiar resignation as I watched the Land Cruiser pull away. We had done everything we could; if anything, she was lucky to have arrived at our clinic where she could receive free transport to the university hospital. A sense of resignation and an acceptance of limitation is almost necessary to practice medicine in a place where resources are so few. But, in my heart, I know that resignation has never changed the world for the better.

Faranji by Jessie

“Faranji” is technically the Ethiopian word for “foreigner.” In practical application, however, it means HEY LOOK A WHITE PERSON! Anytime “faranji” foray into public terrain, they are greeted by children who rush out of the houses (or mysteriously materialize from nearby shrubs and hillsides) shouting “faranji hellohellohellohello!” The exuberant children rush forward shrieking and waving both arms, and often continue shouting until the faranji in question is far past them. The kids don’t seem to understand that shouting “hello” at someone’s backside as they walk away isn’t really an appropriate use of the word. They also don’t seem to understand that you are supposed to STOP saying hello after the other person says hello back. Sometimes the bolder children will rush all the way up to the faranji and extend a handshake in greeting, partly because that is the traditional polite greeting in Ethiopia, but mostly out of cheeky delight at touching the white person. The shy children call out but then run away shrieking when the faranji replies.

Every now and then, a particularly exuberant child will use all of his English vocabulary at once - “hellohowareyouIamfinewhatisyournamethankyougoodbye!” It is common for faranji to collect a crowd of five or ten tag-along children while walking through town, little shadows trailing behind, giggling and whispering in Kafinoono.

The children in Chiri are, for the most part, adorable and harmless. Their smiles are pure and joyful; their eyes are bright and happy. They really look like delight incarnated, despite their dusty faces and tattered clothing (and despite the fact that the little ones don’t wear pants). It becomes tiresome to deal with their loud and aggressive greetings though. Sometimes it is enough to discourage me from leaving the clinic campus. It takes a lot of energy to fend them off. It makes me wish for the anonymity of Chicago’s streets, where you could strip naked or drop dead and people would not even look up from their newspapers.

The adults in Chiri are gentler than the kids – some stare, but few shout. Bustling “chai-bets” (coffeehouses) tend to go quiet when the faranji enters. At first I felt so obvious that it hurt. It seemed that my very presence must be a slap in the face, an offense. “Here is the rich white woman, descended from her palace to gawk at the poor Africans.” I feel so blatantly and offensively wealthy – my clean American clothes without any holes, my soft white hands and fresh-scrubbed face, my digital watch, my nice glasses, the shoes on my feet (or worse, all the extra shoes in my house). I huff and puff climbing the hills that they don’t even seem to notice and I feel shame at how weak I am compared to the locals, because everything I need is handed to me. My body feels voluptuous and soft compared to the hard, wiry muscles of even the oldest women and the littlest boys. I would understand if people here asked me for money – even the poorest American traveler is unfathomably rich to the average Ethiopian. But for the most part, here in Chiri no one begs. The shame I feel is my own creation. If I raise my face and greet an adult on the street with “digo” (hello in Kafinoono), I am inevitably greeted warmly in return with a sudden, bright smile and a polite “digo, salaam.” For some reason the simple acknowledgement brings me relief and happiness. People here don’t seem half as offended by me as I am by myself!

Chiri is an oasis, however. The larger cities are almost unbearable. The gleeful “hellohellohello” of children is replaced by a more accusing sounding “youyouyouyouyou,” or worse, “youyouyouyouMONEY.” It becomes impossible to escape the constant attention. Standing still for too long invites beggars to accost you. Thankfully there is no resentment against Americans or white people in Ethiopia, but I still start to feel like a target. Children fight each other for the chance to be your “guide” through the market or to tourist attractions. If we go to the market or to a soccer game or any public event, we are soon surrounded by a ring of silent onlookers. They stand just looking at us, as though we are about to do something entertaining. I feel like a zoo animal. I’m never sure what to do – greet everyone, pretend I don’t notice the crowd, or vacate the premises as fast as possible (I usually choose the latter). Some other Americans are much less concerned by the extra attention than I am. Dave rides his bike through town, and Emily takes her puppy for walks. If a faranji alone attracts attention, imagine a faranji on a bike or a faranji carrying a puppy! An Australian volunteer nearby frequently went for long runs – with a gaggle of kids behind him, of course. I can’t bring myself to be quite so unaffected and bold in the face of such constant attention. But I figure that this is the closest I will ever come to celebrity status, so I might as well smile and wave. Apparently, part of being “faranji” is developing thick skin.

The Things That I’ve Missed by Edwin

When I was in Ecuador as an undergraduate for about eight months, I was obsessed with all the things that I would miss by being away from home. I was desperate to know what new music I would be missing or what new movies I would miss. This obsession started after being in Bolivia for a month during high school. For months I could feel that I was out of the loop. Comedians’ pop culture references were suddenly obscure to me – and that was only after a month of being away. When I got back from Ecuador, I was disappointed to learn that I hadn’t missed practically anything. On the radio, with the exception of Eminem repeatedly saying what his name was and Brittany Spears apologizing for something that she had done previously, everything was practically the same.

This time around I’ve been less obsessed with the things that I’ll miss. With the internet and e-mail, it will be like I never left. Thanks to Worldspace radio, I still get my news from NPR and “Wait, Wait, Don’t Tell me” (mostly the latter). My in-laws even send us Time Magazines to keep us up to date. So no worries – I still know what’s up. Obama will be president. The economy sucks. The Emmy’s were lame. I even knew that the world was going to end thanks to the BBC’s cheeky reporters discussing that supercollider in Switzerland.

But I miss the details…

I’ve heard so much about Tina Fey’s Sarah Palin impersonation; it kills me that I haven’t seen any of it. And even if I did, would I understand it since I never saw the Katie Couric’s interview or the other events she parodies? Time magazine offers water-cooler commentary on things that I don’t understand. What were the CNN hologram interviews about? Is the US really obsessed with Miley Cyrus, or is that just Time Magazine? And, what is this “Beverly Hills Chihuahua” that you speak of America?

And back to Miley Cyrus…Time Magazine covers so much Miley Cyrus, I can hardly stand it. Here I am trying to actively read about current events and what I get is three accounts of how she spent her sixteenth birthday (all in different issues). Just today I read about her in an article about Obama’s family and in an article about the new Guns ‘n’ Roses album.

So what’s my point again? Oh yeah – that I’ll miss the things that I missed, even if they are meaningless and shallow. Jessie may write about a lot of sad things and it may sound like we are going through a lot of personal growth…(now I can’t speak for Jessie on this) but I’m a pretty shallow person. I want to watch a lot of TV and listen to a lot of awful pop music. Where is my Sportscenter? No more BBC updates of the English Premier League, please! I want celebrity scandals. I wanna see Super Bowl commercials. I want to know what P. Diddy thinks about the current economic crisis.

We see a lot of sick people in our clinic. There are a lot of sad cases that we have to encounter. The level of poverty here is consistently lower than anywhere else I have been. But that is just one side of the story. When you are not looking, people are often smiling and laughing. My theory is that after people have accumulated some of the basic necessities (food, shelter, safety, togetherness), they look for things for enjoyment. Here, it may be gatherings, church, music, possibly gossip. Now, imagine the happiness I could introduce with “pop culture”…

Well, okay, maybe it’s not for everyone. Maybe I’ll stick to medicine as my way of helping people. And, maybe my true growing experience this year will be being away from the things that I’ve missed.