Malnutrition babies overflowing by Jessie

The hospital is overflowing with malnutrition babies. Some puffy and edematous, with their eyes swollen closed; some wasted and emaciated, with their ribs poking through and the skin hanging loose off their bones; some both emaciated and edematous, the worst combination. Some have naso-gastric tubes taped to their faces because they refuse to eat. Some have IV’s for IV antibiotics because they also have pneumonia or fevers. They overflow the little four-bed malnutrition room and fill most of the main hospital ward. Bed after bed of miserable babies and desperate parents.

The smell of urine and rancid butter, the thick stench of so many sick and dirty and vomiting babies, eventually became overwhelming. We moved all the families outside one morning and made the parents bathe their children. They lined up in the sunshine along one cement wall of the hospital where the grass was green and soft. It was quite a sight, a whole ragged line of naked crying malnutrition babies under blue skies in the bright warm sun. The nurses made a bucket-brigade to haul water outside. Solomon cut up bars of soap into little chunks for each family. Their dirty clothes – often stained with urine and diarrhea because the children do not have diapers, or soaked with old vomit because there is no change of clothes if the child throws up on himself – were hauled to the laundry room. We gave each child a fresh set of clothes from the donated clothing pile. Not necessarily appropriate clothes. Boys in dresses, kids swimming in t-shirts too big for them, unmatched shirts and shorts, light summer clothing that will not withstand the nighttime chill of rainy season. But at least they were clean. The ragged line-up of freshly washed babies was transformed into an even stranger sight – a bunch of miserable, malnourished Ethiopian babies wearing cast-off American Baby Gap clothing.

One malnutrition baby died last week. The mother had no husband and no family, and because of cultural taboos, she was not allowed to touch her dead child. There were other people from her hometown at the clinic, but they refused to carry her child for her, because they were not her relatives. The clinic paid a stranger 10 birr to bury her baby here in Chiri, and then gave the weeping mother bus fare for the ride home. Another malnutrition baby died last night. I can guess which one will die next, the skinny girl with the cough that won’t go away. She is so small that her tongue looks like a kitten’s when she coughs. She’s losing weight despite treatment and antibiotics. I don’t know what else to do. My heart becomes more desperate and sad each time I enter the hospital, even though I try to smile and speak words of encouragement. I should focus on the ones who get better. But the death of a child is like a splash of black paint into a bucket of white; it taints the whole thing grey, and it’s nearly impossible to add enough white paint to erase the dark shadow.

By now I must seem jaded or cynical to the other American volunteers here. I asked one of them if they feel anything when a hospital patient dies. No, she answered honestly. You are the doctors, I don’t see the patients every day, she explained. The patients who die are abstract to her. Sad stories, but nothing personal. It strikes me how intimate and emotional our job here really is. How different it is than being a program director or an outreach coordinator. How maybe, after holding a child in my hands and trying everything I know to keep it alive, after comforting grieving parents as they wail and beat their chests, maybe I have earned the right to be jaded and cynical about our work here. This is unlike me. I want to be optimistic and hopeful. But I also want to run away, to hide from the baby with the kitten tongue who will die next, to escape the malnourished children and the smell of the inpatient ward and the pleading eyes of mothers and fathers who don’t quite believe me when I tell them everything will be okay.

Emergency thoracentisis by Jessie

Tamiru weighed 76 kilograms when he first entered our TB program. That doesn’t sound like much by American standards, but our Ethiopian TB patients rarely top 40 or 50kg. He looked tall and well-nourished, and really, not that sick, except for his dry cough and the swelling in his legs. He was diagnosed with pleural and pericardial disseminated TB in Jimma and sent back here, nearer to his home, for anti-tuberculosis treatment. Despite his gentle giant stature and apparent health, Tamiru quickly became very sick.

He developed intractable bloody vomiting just a few days after starting his TB treatment. There’s a lot of things in Ethiopia that make people vomit, and it was possible that his “bloody” vomit was normal vomit stained brick red by the rifampicin in his TB medicine, but to be on the safe side we admitted him to the hospital. The vomiting improved a little but he developed a fever, and blood film showed that he had malaria and possibly typhoid fever also. Then his liver swelled and became painful and his mild cough turned into painful shortness of breath. His right lung was surrounded by fluid. Then his eyes turned neon yellow – jaundice. His condition was getting worse and worse. His face became gaunt and sallow. Per the WHO TB protocols that are used in Ethiopia, jaundice and liver enlargement while on TB medicine is cause to stop the TB meds and refer the patient to a higher hospital, since TB medicines are potentially toxic to the liver. We explained to Tamiru that he needed to go to Bonga Hospital for evaluation. He agreed. We were planning to make a trip to Bonga in two days time, and since his condition was serious but stable, we arranged to transport him in our Land Cruiser at that time.

He almost didn’t make it.

The nurse came to the Big House the night before Tamiru’s planned transfer, asking us to turn on the generator so Tamiru could be placed on oxygen. He was in respiratory distress. Edwin and I were alarmed – he had been coughing and short of breath that day, but not in enough distress to require supplemental oxygen. We went to evaluate the patient. He was gasping for air and unable to speak complete sentences because of his breathlessness. Unlike his previous slow decline, this was a sudden and dramatic turn for the worse. We knew there was a pleural effusion around his lung. Draining fluid from the pleura is dangerous though, because it requires sticking a needle into the lining of the lung without sticking the needle into the lung itself. It is a difference of only millimeters. Poking a needle into the lung would cause pneumothorax, lung collapse, and in this situation, probably death. Unfortunately, Tamiru was pretty near death already. The pleural effusion was crushing his lung. Edwin decided to do an emergency thoracentisis.

Tamiru’s relatives carried his now gaunt frame to the treatment room. We had Tamiru sit on the side of the exam bed, leaning his chest forward onto the bedside table to expose his back. I carefully cleaned Tamiru’s right ribcage with iodine and placed a sterile drape over his back. Edwin climbed onto the exam bed behind Tamiru, donned sterile gloves, and carefully inserted a simple IV cathter into the patient’s back. Not quite the right equipment, not the most sterile technique, but it was the best we could do. Edwin’s hands were steady. If the patient moved, or if Edwin inserted the needle to deeply, the lung would collapse completely. Edwin’s syringe filled with red-yellow fluid. He was in the right place! Using a 50ml syringe, Edwin drained 1500ml of fluid from Tamiru’s pleural space. “How are you,” we asked Tamiru intermittenly to make sure he was ok. “Toruno,” he replied in Amharic. “Excellent.” He didn’t look “toruno” to me, but his respiratory distress quickly improved as the fluid was removed. Tamiru was able to walk back to the hospital instead of being carried. He was by no means out of the woods, but at least he was alive.

Edwin was talkative and lighthearted after the procedure, but the nonchalance could not hide his overwhelming relief. As we cleaned up, Edwin’s steady hands trembled.

Retained placenta by Jessie

They said she had come in because of retained placenta after childbirth at home. She lay on the delivery table, umbilical cord clamped and dangling, bleeding a small but constant trickle, like a faucet that leaks even after the tap has been turned off. But that isn’t what drew my attention. It was the desperate way she was breathing – her chest heaving, nostrils flaring, sucking fast and shallow breaths – it was her restless movement on the delivery table, writhing as though she was trying to escape an ill-defined pain – but most of all it was her eyes, wide and glassy eyes shot through with fear like a trapped animal, bright, unfocused. Her body trembled. I tried to find her pulse but it was fast and weak, barely a faint hummingbird flutter in her wrist. Her blood pressure was too low to measure. Cardiovascular collapse. Her abdomen was tender and rigid and distended like an overinflated beachball. I knew in an instant that she was dying.

The nurses tried to resuscitate her with IV fluids but had only been able to place one tiny IV in her inner elbow. Even wide open, the IV dripped maddeningly slowly. Edwin managed to place an IV in her neck, but her restless movements immediately dislodged it. I made a mental list of possible causes – uterine rupture, DIC with spontaneous intraabdominal bleeding, less likely placenta accreta or amniotic fluid embolism or simple hypovolemia from bleeding. It did not seem that a retained placenta alone could cause her critical state. The hardest part to explain was her bloated abdomen, hard as a rock, exquisitely tender to touch. I couldn’t find the contracted knot of her uterus that usually is palpable at the level of the belly button after delivery – I couldn’t feel her uterus at all. The moaning mother turned her head to the side and heaved. I grabbed a trash can but her convulsive vomiting overshot the bucket entirely, spewing foul brown vomit with feces across the room.

She has to go the hospital, I announced. Now. One nurse was still trying to place a second IV and another nurse was unsuccessfully trying to extract the patient’s retained placenta. They seemed surprised – the patient had just arrived, they had just started working, and retained placentas are common enough, not a reason for emergency referral. But they did not argue. I don’t know if it was the patient’s state or my own unusual agitation that convinced them. In my heart I feared that the OB surgeons at Bonga Hospital would not be able to help her anyway. As the Land Cruiser pulled away from the clinic, I did not feel rage or even strong grief at her plight. Just helplessness and quiet sadness.

That night, I dreamed over and over again about her death and I woke up in the darkness crying. The next morning we got the report – her placenta had been removed manually in Bonga Hospital and she was fine. I was stunned and confused and embarrassed. It was just a simple retained placenta after all? My clinical judgment was so off base? I misdiagnosed her symptoms and referred her to a surgeon when really I should have just taken out the stuck placenta and everything would have been fine. I had been so wrong. I tried to put aside my pride and focus on the fact that she was ok. But, there was new doubt and caution in my heart.

Days later, we got a more complete report. “Complicated manual extraction of intra-peritoneal placenta.” That was it! Placentas should never be “intra-peritoneal,” which means outside of the uterus and in the general abdominal cavity. A thousand questions sprang to mind. How did they get their hands into the abdominal cavity? Did they operate? How did the placenta end up in the abdominal cavity to begin with? Uterine rupture? It must have been uterine rupture… But my intellectual confusion was mixed with sheer relief. I wasn’t crazy. I didn’t overreact. An “intra-peritoneal placenta,” regardless of how it got there or how it was removed, could have caused her symptoms of abdominal distention and shock. And it would have eventually caused death. Of course she has other problems now – anemia and a draining vesiculo-uterine fistula. But fortunately the patchy Ethiopian health system worked in her favor, and she is alive.

Waiting for the other shoe to drop by Jessie

Living here, I am always waiting for the other shoe to drop. A sense of unfocused dread and fearful anticipation strikes at the most unexpected moments. Every knock on the door – is it a guard, calling me to the hospital because a child is about to die? Footsteps on the path outside – are they coming near our house, are they climbing the cement steps to our door? I stop whatever I am doing, perched, alert, waiting for the sound to come closer or to fade away, waiting to see what catastrophe is waiting outside. I hear the sound of wailing at night – is it the monkeys howling, dogs fighting, or is it maybe drunks fighting in town, or a fire, one of the straw houses burning down with all the people inside trying to rescue their belongings, will the bloodied and burned patients come to our health center? I wake up from a dead sleep – did I hear a noise? Was it a knock at the door? Is that wind or is it an ululating death wail down at the hospital? A bleeding mother. A dead baby. An unconscious and seizing patient. Tetanus, meningitis, appedicitis, obstructed abdomen, third degree burns, open gushing gaping wounds. No IV access, poking, searching, external jugular, Edwin can you get a line in. No surgeon. No blood transfusion. No lab. No money. No transport. No second opinion. Fight or flight kicks in. A constriction around my stomach. Heart pounds harder, hands tingle, muscles tighten, vision becomes sharp and narrow. Here we go again. I should have known better than to let my guard down for even a minute.

But. Half the time it isn’t really a knock on the door, it’s just a big bird landing on our tin roof. The footsteps outside are Emily returning to her house. The nurse just needs me to unlock the pharmacy and get out some more IV medicine. The howling in the dark is an unknown, unseen animal, and my sudden fearful waking is just that, just fear. My muscles relax and my senses soften. I feel the pounding of my heart and feel silly, getting all worked up like that for nothing.

But even then, I know. I know that sooner or later it won’t be nothing. Maybe next time the other shoe will drop. And despite the implication that the shoe can only drop once, it will drop again and again and again. One disaster does not grant immunity from another. Each day that passes without a catastophe is a relief and a triumph, because every day is water under the bridge that cannot return, it is sealed and done. Every day, I am one day closer to home. I only have to worry about tomorrow.

Where oh where has my hydro gone? by Jessie

We are lucky now to have electricity every other day. The rains are failing, and apparently the lake that fills up to run the hydroelectric plant has run dry. Abba Petros, the local priest and passer-on of news, says that a few years ago when the hydroelectric project started, one of the lead engineers predicted that the water would seep out through the soil faster than the lake could refill. In the meantime, we run the generator a few times a day to keep the fridges cool so the vaccines don’t spoil. Emily puts ice packs in the fridge overnight to keep things cold until the morning. If a patient needs oxygen, we leave the generator on for four hours at a time and then let it rest for an hour, rechecking the patient and the generator each time. We are often more worried for the generator than for the patient, since the radiator has taken to leaking and the machine overheats quickly. The breaker switch has been flipping for no apparent reason. I wish I knew more about generators. Or electricity. Or both.

The lack of electricity is affecting the country in unexpected ways. The price of concrete has quadrupled because the factory that makes cement can’t run without electricity. Diesel is a hot commodity because people have to fill their generators. Some businesses admit defeat and close down every other day when the hydro is gone. One of the nurses at the clinic admits that she is relieved when the electricity goes off, because then the little shops by her house stop blaring their music into the street at all hours of the night. The town becomes dark and peaceful. The phone system has also stopped working, which may or may not be related to the power shortages, but it seems awfully coincidental to be considered just bad luck. No hydro means no computer, no lights, no radio, no hot water, no email, no fax, and perhaps, no phone either. On the up-side, it also means candlelight dinners and night skies crowded with bright stars, and it forces us to actually read books instead of watching DVD movies on our computer. I guess you can get used to anything.

The Breastplate of St. Patrick of Ireland

I rise today
Through a mighty strength, the invocation of the Trinity,
Through belief in the Threeness,
Through confession of the Oneness
Of the Creator of Creation.

I rise today
Through the strength of Christ’s birth with his baptism
Through the strength of his crucifixion with his burial
Through the strength of his resurrection with his ascension
Through the strength of his descent for the judgment of Doom.

I rise today
Through the strength of the love of Cherubim
In obedience of angels
In the service of archangels
In hope of resurrection to meet with reward
In prayers of patriarchs
In predictions of prophets
In preaching of apostles
In faith of confessors
In innocence of holy virgins
In deeds of righteous men.

I rise today
Through the strength of heaven
Light of sun
Radiance of moon
Splendor of fire
Speed of lightning
Swiftness of wind
Depth of sea
Stability of earth
Firmness of rock.

I rise today
Through God’s strength to pilot me
God’s might to uphold me
God’s wisdom to guide me
God’s eye to look before me
God’s ear to hear me
God’s word to speak for me
God’s hand to guard me
God’s way to lie before me
God’s shield to protect me
God’s host to save me
From snares of devils
From temptations of vices
From everyone who shall wish me ill
Afar and anear
Alone and in multitude.

Christ to shield me today
Against poison, against burning
Against drowning, against wounding
So that there may come to me abundance of reward.
Christ with me, Christ before me, Christ behind me,Christ in me, Christ beneath me, Christ above me,
Christ on my right, Christ on my left,
Christ when I lie down, Christ when I sit down, Christ when I arise,
Christ in the heart of everyone who thinks of me,
Christ in the mouth of everyone who speaks of me,
Christ in every eye that sees me,
Christ in every ear that hears me.

I rise today
Through a mighty strength, the invocation of the Trinity,
Through belief in the Threeness,
Through confession of the Oneness
Of the Creator of Creation.

Today I really love the patients by Jessie

Of course if you asked me any day, I would say that I love the patients. But. It is love in principle, in a spiritual sense, in theory. Some days there may be a lot of qualifiers attached. “Loving” patients does not imply that I enjoy them or like them at that moment – the same way, I imagine, that parents “love” their children even when the parent is exhausted and the child is throwing a temper tantrum. Love, perhaps, in action – if not necessarily in emotion.

Today, however I enjoyed the patients. I liked them. I liked smiling at them just to see them smile back. I liked saying “welcome, how are you?” in my mangled Amharic just for the joy of hearing them giggle at my attempt. I liked giving diagnoses just to watch the fear drain out of the patient’s eyes as their pain was given a name and a solution. I liked the contrast of white teeth against black skin as the patients smiled. I liked the chubby baby arms and legs pumping the air with unexplainable enthusiasm. I liked the familiar and comfortable feeling of an exam room, sitting across from a patient with a pen behind my ear and stethoscope around my neck and a blank blue patient card at my fingertips. Chief complaint, HPI, exam, assessment, plan. I loved seeing an illness and knowing what to do. It felt as natural as breathing. I really loved the patients.

Not that I loved the patients because they were all really nice. More that I loved them for letting me help, for filling up the empty space in me that I didn’t even know was empty - like not knowing you are tense until you stop and stretch, and it feels so good, the release and the relief of unnoticed stress. I realized after the day was over and the clinic was empty that only seeing patients makes me feel that way. Fills that emptiness, releases that stiffness. And I love the patients for that – for engaging my intellect and my emotions and my spirituality all at the same time – for allowing me into their lives for even the briefest moment – for giving me a purpose.

In the hospital (IV fluid and IV antibiotics) by Jessie

The inpatient ward of our health center is meant for simple things. A child with pneumonia who needs IV antibiotics and oxygen for a day; a dehydrated patient with vomiting and diarrhea who needs some IV fluids, a mother who hemorrhaged after delivery and needs to be monitored overnight for further bleeding. What is actually admitted to our hospital, however, is far more varied, more critical, more surgical, and more chronic than was intended.

This week began with a woman admitted with bloody diarrhea. She was nine months pregnant when she got sick. After four days of illness, she delivered a stillborn baby. She arrived at our hospital five days later, unconscious, with profuse diarrhea and a raw rash across her face. IV fluid and IV antibiotics against dysentery and intra-abdominal infections improved her status somewhat throughout the week, but she still has a tender abdomen and some vomiting, with persistent cough and dizziness. She remains deathly pale and too weak to sit up by herself. There is no fever. When we approach her bed, she asks weakly and fearfully, “how am I doing?” I try to laugh and smile to encourage her, but really, I’m stumped. A blood transfusion may help. So would a CT scan of her abdomen and a chest x-ray and blood cultures. But what we have is IV fluid and IV antibiotics, so that’s what she gets.

She was followed by a similar case – a woman who delivered a stillborn baby at home and then developed a high fever. She was semi-conscious and burning with fever when she arrived. Her uterus was tender. The lab is closed because our only lab technician is gone for a training, so we could only guess at the cause of her fever. She received IV antibiotics against typhoid fever and against post-partum endometritis. Within a day, her fever was gone and her abdomen was less tender. Within two days, she was able to go home. A pregnant mother admitted with hemorrhage after a spontaneous abortion in her fourth month also improved quickly and was discharged home (Edwin removed the fetal parts and treated her uterine hemorrhage – I’m not sure his internal medicine training prepared him for everything he would have to do here!).

One bed has been occupied all week by a baby with Vitamin D deficiency and pneumonia who had been coughing for a month prior to admission. His cough is so violent that he vomits after coughing. The first IV antibiotic failed to improve his respiratory distress; changing to a second IV antibiotic and adding an oral medication failed to cure him also. We tried treating intestinal parasites to see if that may help decrease his vomiting. It didn’t. He continued to cough and vomit. Babies with Vitamin D deficiency are notoriously hard to cure – their constricted ribs and weak immune systems predispose to respiratory infections. Today we discharged him with oral medicines and a follow-up in one week, when our lab is open, to do blood tests. If he is still coughing, we will start him on tuberculosis therapy. Regardless, his prognosis is poor.

The bed beside the Vitamin D deficient baby was occupied by another baby with cough and vomiting, but no vitamin deficiency. The first antibiotic also failed for this child, but fortunately, the second antibiotic worked. Or possibly – the pneumonia was never bacterial at all, it was viral, and it happened to improve at the same time that the second antibiotic was started. Regardless, the baby was discharged home improved. Her bed was immediately filled by another child with severe pneumonia, this one semi-conscious with lungs full of crackles. He was dehydrated because he was too lethargic to drink. Within 12 hours of IV antibiotics, he was playful and drinking normally. He also was discharged home.

The bed beside him was occupied by a chubby 2-month old baby who also seemed to have severe pneumonia – a low grade fever plus a respiratory rate of 112 (try breathing 112 times per minute, it’s pretty hard!) with vomiting and diarrhea and constant crying. CONSTANT crying. We eventually had to move the baby to the isolation room because none of the other patients could get any rest. At first the baby did not respond to IV antibiotics, and I was afraid that the fast breathing and fever and diarrhea were actually due to a surgical intra-abdominal problem, but on the second day improved and the baby quieted down. I wanted him to stay longer because he was so little and had been so sick upon presentation, but all the hospital beds were full. He was actually sharing his hospital bed with another patient who was waiting for someone to be discharged. So the baby was sent home early, with a hundred cautions and reasons to return immediately, and early follow-up in the clinic. His bed was immediately filled by another child with severe pneumonia who had been treated as an outpatient but got worse anyway. The new pneumonia patient was older but equally irritable and crying constantly. He also improved with IV medicine, but is still in the hospital because he failed outpatient treatment and early discharge could easily lead to relapse.

The far corner of the isolation room is occupied by a emaciated chronic alcoholic – the town drunk – who lived by himself, and had been bedridden for 2 weeks before presentation. His neighbors finally brought him in when he stopped eating all together. He was comatose and his wasted limbs were rigid. He was hypothermic and his lungs rattled with cough. Of course, a CT scan of his head and liver function tests and blood cultures would have been nice. But of our quick differential diagnosis list – hepatic encephalopathy, stroke, aspiration pneumonia, and alcohol withdrawal – aspiration pneumonia was the only one we could treat. He was started on (you guessed it) IV antibiotics and IV fluid. Amazingly, he did wake up enough to ask for a cigarette, although he is still quite confused. He has developed a fever and remains hypotensive.

A young, healthy appearing man was admitted the same night as the town drunk. He had been treated for typhoid fever and malaria at another clinic, but still had persistent vomiting and weakness. A preliminary HIV test was positive; we recommended confirmatory HIV testing but he refused because it would cause him “too much stress” if he was found to have HIV. After he left, his bed was filled by a young woman who “fell on a knife” and had an infected puncture wound through her forearm. She is deaf and cannot speak, but she smiles a lot, and the infection seems to be improving. An elderly man admitted with “pyomyositis,” a deep infection of the muscle that I’d never heard of before coming to Ethiopia, also seems to be improving. His thigh is still tender but is less swollen. Needle aspiration of the area did not reveal pockets of pus, so he did not require incision of the muscle to drain the infection. He will limp home tomorrow on oral antibiotics.

Also discharged from the hospital this week was an 8-year old boy with swelling of his entire body and heavy protein in his urine – signs of nephrotic syndrome. Usually grounds for a kidney biopsy, but no one was too keen on sticking a needle into his kidney or trying to analyze the glomeruli under the microscope afterwards, so he was treated empirically with high dose steroids and diuretics. He was so puffy that even his scrotum looked like a balloon, but slowly, the edema decreased. He lost more than 14 lbs as the edema disappeared. In a different bed, another 8-year old boy presented with a swollen abdomen and swollen feet. Unlike the first boy, this child had signs of liver failure. We drained liters of yellow ascites fluid out of his distended abdomen, and then referred him for treatment of possible liver or peritoneal tuberculosis.

We also admitted two children with severe dehydration due to vomiting and diarrhea, both of whom improved with injections of anti-vomiting medicine and ORS (oral rehydration solution). The older child was still vomiting when she left, but she had regained consciousness and was urinating plenty – and we needed her bed. The hospital was full. The family stayed in town overnight and will bring the child back today for a checkup.

The hospital is alternately exhausting and fascinating and frustrating. So many people need so much more than we can provide. So few people have the resources to seek care at a higher level, and the referral hospitals themselves often do not have any more resources than we do. So many patients don’t get better. But – so many do. And being limited in resources stretches us mentally, to think of differential diagnoses without the aid of lab tests and to find alternative treatments. We are limited but not helpless. Who knew that IV fluid and IV antibiotics could do so much?

Garbage by Jessie

There are three plastic trash buckets under the wooden countertop in our kitchen. A red one, for burnable trash, that is emptied into the incinerator every Friday. A blue one with a lid, for food waste that will either be thrown down a compost pit or fed to the chickens. The last one, a green bucket, is for everything else - the plastic wrappers and aluminum foil and broken glass. The “everything else” bucket is emptied into The Pit, a deep hole originally dug as a possible well that did not yield water. Medical waste like used needles and dirty gloves are dumped in The Pit, along with our household trash. During rainy season, The Pit fills with groundwater and the trash inside swells toward to top; now at the end of the dry season the bottom is barely visible. We avoid throwing big things into The Pit, if possible, knowing that it will inevitably fill up and need to be replaced with a new one.

Most trash that would end up in The Pit is recycled. Not put into blue bins with yellow arrow triangles on them – recycled as in reused. The TB patients in the morning take their pills with water in “cups” that are actually empty medicine containers – multivitamins, albendazole, ferrous sulfate, phenobarbitone, amoxicillin. We wash the tin cans and the jelly jars and potato chip canisters and water bottles reuse them as cups for patients or toys for kids. We use flimsy plastic bags from market as barf-bags for patients on car trips to Jimma (most rural Ethiopians aren’t accustomed to car travel!), and if no one throws up, we use the little bags to hold the fruit that we buy from roadside vendors. Staff members fight over the big Nido powdered milk cans with snap on plastic lids. One perk to being the cleaner or cook at our Big House is having first pick of the nice glass jars and cardboard boxes. Any substantial plastic bags are saved and used to carry food from market, since the food is sold by the kilo and bags are not usually provided. I realized the worth of our used tin cans when I saw similar used cans being sold for profit in the marketplace.

Most of our non-burnable, non-compostable trash is from the clinic. There are two trash baskets in every clinic room, one for burnable things like tongue depressors and used gauze and another for non-burnables like disposable syringes and latex gloves. The disposable cardboard “safety boxes” for sharps like needles and razors are first burned in a barrel to dispose of the bulky cardboard box and to melt down any little plastic pieces, and then the charred remains are dumped in The Pit. I am amazed by the amount of trash that our little clinic creates, until I remember hospitals and clinics in the US, where everything that touches a patient is disposable. Most of our household non-burnable, non-compostable trash is not local – it comes from Addis. Ramon noodle packages, candy-bar wrappers, the foil lining from inside boxes of cornflakes. Even more comes from the United States. What else can we do with the reams of bubble wrap that have accumulated over the years? Old CD’s and DVD’s scratched beyond repair, shiny puzzles with missing (or rat-chewed) pieces, broken flashlights, electronics fried by the 220 volt outlets.

There is no litter in rural Ethiopia. I am accustomed to roadsides strewn with plastic bags and wrappers in Central America, or even open fields in the US peppered with plastic pop bottles and greasy fast-food bags. But here, if anything is wrapped, it is wrapped in banana leaves. Most people don’t have latrines so they don’t have toilet paper either – a leaf is used if any cleaning up is needed. And if anyone finds a used magazine or newspaper, they use its pages to paper their mud walls. People are way too poor to buy stuff so there are no fancy wrappers or excessive packaging. People in general do not have cell phones or computers or refrigerators that break and become obsolete and need to be trashed somewhere. There simply isn’t that much garbage in rural Ethiopia. Not yet, anyway.