Death and Destruction, a Dilemma, and a Disheartening Experience

Every morning, the doctors gather in the administration building. Those who have been working during the night will give a report to the hospital administrator and the rest of us (I have not figured out who everyone is, but most are doctors.) I have found that these morning reports are more like M&M conferences in the US—(I was telling this to Ryan at lunch and he said, “The chocolate with a candy coating?”
Me-“Very funny. No, M&M stands for morbidity and mortality. It’s wheresomeone presents a clinical case where the patient either died or hadsignificant morbidity (something went wrong) during their time in thehospital.”
Ryan- “Oh, so like death and destruction!”
Me- “Well…mortality is death and morbidity could be a destruction.” Smile.“Death and destruction, touché.”)
—Last week, they reported that a mother had died in childbirth in the town. I was shocked. She had post-partum hemorrhage, but she had already died by the time they brought her to the hospital. I knew that the maternal mortality rate was awful in Ethiopia and developing nations in general, but I had assumed it was because of lack of access to care. But here was a woman who lived in the town with a tertiary care center with the capability to do a c-section, and she still died. Also, this week, the morning report was cancelled once because all the doctors were treating casualties from an automobile accident. Today, they talked about a man who came from one of the monasteries on the lake with a volvulus (where the colon is twisted on itself and it obstructs the bowel). During a procedure to untwist it using a sigmoidoscope (fancy word fora device that snakes into the colon like a short version of acolonoscopy instrument), the man began bleeding. They needed to take him to the OR for a surgery to see if they had perforated the colon with the sigmoidoscope and to untwist the colon manually. The man refused and left the hospital.
-“Why did you not look through the sigmoidoscope to see if you had perforated the bowel?” one doctor asked.
-“There is no light on the instrument. It is very difficult.”
-“Why did you let him leave? If he left for religious reasons, that is okay, but it is unacceptable if he left due to financial reasons. He IS going to die. There is some kind of emergency fund for these cases.”
-“I don’t know. I wish we had a sigmoidoscope with a light. They have them in Addis.”

It was an interesting conversation. Most of the morning, I pondered the reasons for sub-optimal health care. The doctors here seem quite competent- they teach most of the same things I have been taught. However, the resources put into healthcare are abysmal. The doctors perforated the bowel last night because they lacked proper medical equipment. They use toilet paper to clean off a woman’s stomach after an ultrasound. Since the sewer system has backed up into some of the OR’s, they are doing surgeries with less space. They ran out of beds today in the hallway, so they put down a plastic mat for some of the patients. Come on! They are already in the hallway with a bed number written in magic marker on the wall above them, and now they don’teven get a simple mattress?? The doctors deal with a huge percentage of wound infections, not only because of lack of sterility (one confessed that there had been a cockroach running over the “sterile field” during surgery), but also because there is dust from the road not being paved outside and the windows being open to the surgical area. They use IV tubing for a tourniquet to insert IV’s. Some of the beds are propped up with rocks if the wheels have fallen off. Half of the surgical patients are in beds outside. At least they are covered by a roof, but they are still outside with new wounds from surgery.They use a space heater to keep the newborn babies warm after birth. Roughly 2/3rds of the sinks don’t work to wash your hands in- nothing like having alcohol dispensers outside of each patient room like in the US. The ceilings are high, but they are lit with only a row of single florescent bulbs, and half of them don’t work. If an emergency were to occur, it would be very difficult to get a patient onto a stretcher and maneuver past all of the patients in the hall, outside zig-zagging through multiple open courtyards and multiple hallways to finally get to the OR. There is one blood pressure cuff for the whole gynecology ward. If the patient needs medication, a prescription is written and their family has to buy it at the local drug store. It is not readily available for the doctors to administer if they need to do something quickly. It seems that healthcare here is subsistence healthcare (analogous to subsistence farming)- doing what they can to survive, to making do with what they have. It seems that there is no time for foresight into what improvements could be made. I have been told that the doctors are not paid a good salary- they can make more money even in other countries in Africa like neighboring Sudan orKenya. You can’t really blame 58/60 graduating doctors for leaving Ethiopia when they are not provided the tools nor the money to provide the care they know is best. Ethiopia does have great medical education and trains very smart doctors… exports great doctors. Retaining them is a different story.

I am facing a dilemma. Does a person work with the government to improve existing structures and institutions, or does a person forget about that and build a completely separate (and sometimes unsustainable) mission hospital? Does a person focus on one specific issue or work on the bigger picture? Mission hospitals are usually better funded (by donations to charity) and more efficiently-run. The fistula hospital is a mission hospital. Tenwek is a famous mission hospital in Kenya which does excellent work. But there is something to be said for working with the government to raise the level of care given to a great percentage of the population. It takes a great deal more patience and persistence, but I think a lot of good can come of it. Where as the Fistula Hospital treats one condition with excellence, they cannot address broader issues in healthcare. It is a shame we cannot provide the kind of care the fistula patients receive for the rest of the population. It seems it would be better to get a fistula during childbirth so that you could receive top-quality care than to only suffer a 3rd degree tear or have a rectocele (bulging of the rectum into the vagina) and have to stay at the government hospital. I know that one person cannot tackle all the problems, but I am glad that there are people and organizations like the Clinton Foundation and the Spanish one (name escapes me) which Ryan is working with to help solve some of the overall problems.

Ryan has gained the confidence of Jose, the doctor from Spain we mentioned earlier. Ryan taught some of the hospital staff a little bit about working with their database. They seemed to really benefit from that, and Jose started asking for advice/recommendations regarding the sewer system and anti-virus software for the computers and x-ray machine help. I’m really very proud of what Ryan is being asked to do for the hospital, and I am excited for the wonderful contacts we have met to make this possible. Thank you to all who have been praying for that specific prayer request. It seems that this has been answered in a mighty way!

I had a bit of a disheartening experience on the way out of the hospital today. God was protecting me. I was seeing a newly-admitted patient with one of the other students (an older, wise male student)and we finished a little later than usual. Since we were both walking the same way, we decided to continue our conversation on the walk. We took off our white coats and strode out of the hospital gate. We were deep in conversation when, out of one of the restaurants, walked one of the doctors whom I have worked with the most (and who has been the best teacher thus far). Something was wrong. He was dressed in plain clothes, and he had not been in the hospital that day. Had he not been someone I knew well, I would have been across the street to walk on the other side in a heartbeat. But I thought maybe he was coming towards us to greet us- although his gait was definitely unbalanced. I reached over to shake his hand, but soon, the other student stepped in-between us. The doctor began saying things, slurring his words, and nearly falling onto the student to get to me. His words were inappropriate. The student started walking faster, stoically looking forward. I followed his lead, and soon the doctor could not keep up. We did not look back, and we walked along for awhile- our friendly conversation forgotten. The student looked stern, angry almost. Finally, I stated the obvious, “So he was drunk.” Immediately the student said, still looking straight ahead, “I am so sorry. He should not have said that to you.” I pitied him. Surely, this must be the most embarrassing thing- to have a “respectable” teacher become despicable in front of a foreign visiting student. There is nothing quite like feeling you or your country will be judged by actions of people which are out of your control. “Is he depressed?” I asked,trying to make some excuse for his behavior, if only to ease the student’s discomfort. “Most likely.” I considered my observations of the conditions at the hospital. He broke into my thoughts, “There is no reason an educated person of elevated status should act in such an undignified way. We must always keep our dignity. Once that is lost, it is lost forever.” We walked in silence the rest of the way. When we parted, I said, “Well, I am glad you were with me. God was protecting me.” He nodded in agreement and turned to go his own way. I guess thisis my way of asking for a prayer of wisdom for me as I, no doubt, will deal with this very awkward situation, having lost the trust and respect I once had for a talented doctor. I think he needs help. He needs Jesus. He probably also needs AA (alcoholics anonymous), if only they had that in Ethiopia. Pray for us.