Shiro!

Shiro tegabino is my favorite food here. It's pretty simple - a sauce-like mixture of water and spices and you eat it with injera. It's bubbling in a little pot when they bring it out to you at restaurants which makes it even more exciting.

Really, the only thing I haven't liked so far was kitfo, a mixture of raw meat that we had on Easter. It tasted okay but I couldn't wrap my head around the idea of eating something that raw.

Injera (the pancake-like white thing in the picture) has definitely grown on me - it's really sour, may be an acquired taste at first, but I've started to have these intense cravings for it lately, even though we are eating it all the time! It's made out of teff which is this really tiny grain that is one of Ethiopia's main crops.

Good thing Denver has a lot of Ethiopian restaurants...

Mother and Children Rehab Center

Third stop of the day.. The Mother and Children Rehab Center, also in Addis. This center houses nearly 80 children who would otherwise be on the streets. It was created by a woman named Jutta (unsure of proper spelling) who is from Germany and she provides schooling, art, dance, music, and other types of training for women and children. Her philosophy is that she can't help everyone, but those who she can support will live well. While we were there the children performed dances and songs for us. It was so beautiful that it brought a lot of us to tears- yup, most of us lost it when the kids starting singing "Lean on Me" in English!!

By the end of the day we were all pretty overwhelmed. I felt like my life is so insignificant compared to what these "heroes" are doing! These people have given up their entire lives to creating better lives for children and adults in need. Absolutely amazing.

Mother Theresa Mission

Our second stop was at the Mother Theresa Mission, where we met with Rick Hodes, an American doctor who has recently been gaining media attention in the US for his 20+ years work in Ethiopia. Most recently, he was on Good Morning America: (http://www.huffingtonpost.com/2010/04/13/rick-hodes-american-docto_n_535533.html) and an HBO Documentary entitled "Making the Crooked Straight" (www.makingthecrookedstraight.org). 

The organization is worldwide and it's mission is to treat "the poorest of the poor." Dr. Hodes specializes in patients with heart conditions, spinal tuberculosis, and cancer.  He takes it upon himself to seek pharmacological interventions and surgeries for the patients that need them- he finds the best surgeons around the world to perform these life-saving operations. Dr. Hodes has adopted a number of the children himself in order to get them health insurance for the operations. He is a hero in so many ways and it was a privelige to meet him and his patients and to see the facility.

 

The Fistula Hospital

One day, three heroes...
Yesterday we visited three different facilities and I'm overwhelmed (in a good way) by the dynamic leaders that I met at each.

First stop was the Addis Ababa Fistula Hospital. (For more information on fistulas, check out my earlier blog post on "Maternal Mortality." Also, PBS.org has a free documentary on this facility called "A Walk to Beautiful." - see my link)

 Dr. Williams led us on a tour of the facility and it was fascinating to finally see this place that I've been reading about for the last year. It was a very beautiful, clean facility. Each woman there was given a hand-woven blanket (like the ones in the picture) on her arrival and it was clear that quality of care is a high priority here. It's much more than just a hospital - programs are running for midwifery training, rural outreach, job training/employment, etc. We spent some time in the PT treatment room and I hope that we will have a clinical site there next year as it could be a great opportunity for collaboration.

Originally the hospital was founded by the Hamlins, who did a lot of ground-breaking work with surgical techniques in this area. Catherine Hamlin wrote a book "Hospital By The River" (amazon.com) which gives a very interesting overview of her life's work, the hospital and maternal medical complications in Ethiopia. She is now 80 years old and still performs surgeries once per week! We were lucky to run into her while we were there and I was so excited to meet one of my "heroes." We also got to meet Hans Dietz from Australia who is a leader in the field and happened to be doing some ultrasound research there that day. He showed us some imaging and I learned quite a bit from him in just a short time.

Currently, 75% of fistula cases are completely cured at this facility. That's pretty amazing. I was astounded by the spirit of these women after what each one has been through- most had been ostracized from their communities and left to die before they found the Fistula hospital, yet here in recovery they were all smiling, laughing together. Clearly the hospital also plays a role in their psychological recovery and renewed sense of community.

Easter at the Orphanage

Three us walked to a nearby Catholic church Sunday morning in hopes of catching an Easter service. There are three Catholic churches in all of Addis and it was difficult to get information about the services. Unfortunately we missed the mass but went inside St. Mary's to have a look anyways. St. Mary's also runs a school and orphanage on the property and we ended up wandering to the backyard where the children were playing. There are several orphanages in Addis but I believe that this is the only Catholic-based organization here. We got a little tour of the area - it's a very clean facility and the children all looked happy and well-fed. We found about ten babies in one of the rooms and I am thinking of bringing them all home with me now :). Ethiopians are very beautiful people in general- distinct facial features and very nice skin - and the children are all so adorable. A side note- pretty much everyone at our hotel outside of our group has been there for adoption. Definitely something to consider down the road!

So we ended up spending most of the day on this impromptu visit to orphanage- holding babies, playing sports with the older children, singing songs, having my hair braided by little girls.... They were such greats kids and I'm impressed by how much English is spoken at such a young age. It was a memorable experience, very hard to leave at the end, and a nice way to spend the Easter holiday.

In the evening myself and Keri met with some of the PT's from our hospital. We had dinner at a place called Teuj Bet - or "honey-wine house". It was a giant tukul with low chairs and tables and teuj was served in these glass carafes. Teuj is a drink usually only prepared for holidays and it's pretty strong... not my favorite Ethiopian beverage thus far, but I was glad we got to try it!

After dinner we finally got the 'real taxi' experience (our group has used the same land rover drivers thus far) which was not as crazy as I imagined - everyone had their own seat for this ride. However, when we got out of the taxi, some guy was running by and bumped into me head on, almost knocking me over. People around us started screaming and I jumped out of the way as 5 men in white clothing (holding these huge spears) ran by chased him over a fence. Apparently, he was being chased for some kind of theft. Yikes!

Just when you start to forget you're in Africa...

A patient case

It's so difficult not to get attached to the patients here. During my two weeks at the hospital, I became particularly close to one of my patients. Here is her story...

At the age of 19 and 8 months pregnant, Susina (not her real name) at the small frame of 5 foot 6 and maybe 115 pounds began having terrible headaches and neck stiffness.
By the time she got to the hospital, she'd had an intracerebral hemorrhage secondary to a pre-ecclampsia-related condition called "HELLP" (Hemolytic anemia Elevated Liver enzymes and Low Platelet count).
Her blood pressure was severely elevated and as a result of the infarct she became cortically blind and had left sided hemiparesis. Her baby was delivered immediately and fortunately is now a healthy 3-month-old.

However, Susina is now suffering from the physically disabling complications.
The first day I saw her in the clinic, she was carried in by family members and all of her treatment was performed in supine by her PT- mostly PNFs and other manual resistive exercises. Her PT and family were afraid for her to walk because "she is blind and maybe she fall down." While she had 3+/5 quadriceps strength in her left leg, her ankle dorsiflexion was 1/5. I coaxed them into some gait training using an arm crutch and she was able to walk - with left foot drag and knee hyperextension - but she was walking! At first she was very nervous about walking without vision but over the last week we have significantly improved her confidence and gait pattern.

We also performed some vision training using bright objects and mirrors. I had difficulty finding research on this with limited internet access so I just made exercises up! Cortical blindness is unique in that the optic nerve and other ocular structures have no damage. Thus it is solely cortex structures that inhibit what the patient perceives. It was pretty incredible but she was able to gain some vision in only two weeks time. Patients with this condition can have some spontaneous recovery so it is difficult to say whether what we did was related to the change, but she was able to recognize how many fingers were held up on her last visit.

Other treatment aside from gait training included quadruped exercises with a stability ball to improve hip extension strength, seated stability ball exercises with upper extremity movements and reach/grasp training. We also practiced sit to stand and over one week's time she went from max assist with sit to stand and gait to contact-guard assist with the arm crutch!

Susina was excited with her walking and vision progress but still depressed about her overall condition. Particularly, her family babied her a lot and did not want her to hold her infant son for fear that she would "drop him or poke his eyes out." Such interesting cultural perspective! I asked if I could meet her son and one day she brought him in for her PT session and we were also able to do some holding/positioning training with the infant!

The hospital has an orthotist and I prescribed her an AFO. She owed the hospital over 14,000 birr (about 1300 dollars) and she said that she would not purchase it because of financial reasons. Myself and some classmates/professors decided to pitch in and purchase her AFO, proper shoes, and an arm crutch. In the US a custom AFO alone may be around $1000 USD, but here it was 300 birr, or a little under 30 dollars! I was able to accompany the family to the fitting sessions with the orthotist which was really interesting to see.

In the end, Susina was able to ambulate with stand-by assist over flat ground, outdoor conditions (uneven ground) and stairs, with occasional verbal cues for visual assistance. It was so exciting to be a part of her PT and it seemed that we were able to impact her quality of life. Susina had an incredible amount of courage and perseverance. I know her road from here will not be easy- without vision she is especially limited in the Ethiopian trades and even daily cooking,childcare and house duties. I'll never forget her story.

Ethiopia Reads

Last night Jeremy and the nursing students arrived! Today we met with Gebregeorgis Yohannes, founder of non-profit organization "Ethiopia Reads." (www.ethiopiareads.org). This is an incredible organization that supplies school and independent libraries around the country from donor support. Yohannes is a very intelligent, energetic and inspirational individual who grew up here in Ethiopia and has a very interesting life story. (Perhaps for another blog posting...) Prior to this organization, virtually no books existed for children to read in their native language, Amharic. Now, thanks to Yohannes, there are hundreds of books available for various age groups in various languages (Amharic, Oromia, English, French, German, etc.) This organization has created 43 school-based libraries around Ethiopia with a start-up cost of $10,000 USD per library. There are no maintenance costs as the libraries are maintained by school staff. Unfortunately the organization has been strongly affected by the US economy and the disaster relief work in Haiti. The largest branch here in Addis was recently shut down in January. To learn how you can help, check out the website and talk to me.

The MERKATO!

The commercial part of Addis Ababa has two central areas- Merkato and Piassa. Piassa has a more Italian feel with European-style buildings, cobblestone streets, and fashionable clothing, shoes and jewelry. Both areas are bargain-friendly, as are most shopping spots in the city. Most of our shopping has taken place in shops near the Black Lion Hospital.
Yesterday I was carrying a bag with my Asics running shoes in it and many of the vendors swarmed around them offering to buy my (gross,dirty used)shoes for 500 birr (about 45 dollars!) I neglected to take the offers as I suspect I will need a pair of shoes for the next few weeks!
We went to a few stores in the Piassa area this week in search of orthotic-appropriate shoes for one of my patients. Today we ventured out for some shopping at the Merkato in the center of the city. The Merkato area has historically been known for its higher level of crime, pickpockets and prostitution. Currently, the biggest threat seems to be pickpocketing and we were very cautious- I would not recommend bringing a purse or backpack. There were many armed men walking the streets and standing around but fortunately we saw no signs of violence.
However, the entire experience was sensory overload and mass chaos- people navigating potholes and manure shoulder to shoulder, donkeys with loads running up the street, cars and trucks and taxis zooming in and out of the crowd, people carrying live chickens and goats/crates/other food on their heads, children following us begging, words in Amharic coming out of loudspeakers, vendors waving their handicrafts in our path. A massive afternoon rainstorm added to the colorful scene and one of our drivers, Fantu, led us for about 20 minutes through the crowd until we reached an area that sold handmade baskets and musical instruments. Taxis here are the blue and white buses that are generally overloaded with 20+ people and one person literally hangs out of the window shouting out the destination to people on the street. It’s difficult to discretely go anywhere in public here… We are now used to the stares and have seen few other “ferenjis” (foreigners) here – aside from some hospital staff and other Americans at our hotel. Apparently most tourists don’t spend much time in the capital city and instead head to the other tourist areas in Ethiopia. I always love to try blending in to countries but unfortunately for me I am a) WHITE and b) with a group of 10 other white people. Needless to say, we get a lot of unwanted attention!

I hate goodbyes!

Today was our last day in clinic due to the holiday starting tommorrow. It was sad- I really do hate goodbyes! All of my patients wanted my contact information- questionable whether for VISA opportunities or really just to keep in touch. It was also difficult to say goodbye to the staff at the hospital. They have all been so welcoming and hospitable. Over the course of the two weeks it’s been a great growth into collaboration across cultures. The first few days were difficult- we learned that we were the first American PT students to ever come to the hospital. But, as we got to know eachother it turned into a fantastic learning experience for both sides. We took turns doing inservices in the afternoons- the Ethiopian PT’s taught us about unhealed fracture management that is so common here and we did inservices on low back pain and spinal manipulations. There was a clear difference between our schooling background and theirs and we noticed many discrepancies in information. We had many great discussions about evidence-based practice and the future of PT in Ethiopia. Currently, the only PT school is in the town of Gonder, but it looks like in the next year there will be a PT school at Addis Ababa University- ran out of Black Lion Hospital. Even more exciting- there are some passionate individuals who are aiming to make it a DPT program! My professors had many meetings while we were here in order to build on partnerships and we are hopeful that this country will make great strides in the advancement of the field in upcoming months. Regis University, a PT school in Switzerland and the Ethiopians will be working together to get this program going. There are many obstacles unique to this country – the government, financial resources, technological resources, educational resources, etc. – but we are hopeful that the future will be bright when it comes to PT. As the Ethiopians always say, “We will hope.”

Easter Traditions

Easter is this weekend! Holidays in general seem to be a much bigger deal here and Easter is no exception. The entire week the city streets have been an even busier flourish of activity than normal. Tents are set up on the sidewalks selling items for holiday preparation. No plastic eggs and chocolate here- just food products for the big meal! Live goats and chickens are everywhere- strapped to the top of cars, carried by hand, clustered for sale next to the road.
The entire city is shut down from Thurs. night-Sun. night. The Orthodox Christian celebrations involve an 8 hour church worship on Good Friday, and 3 hours of church on Sunday. Saturday night at midnight marks the end of the fasting period and the celebrations begin. We’ve been told that every family that can afford it buys a live chicken. The traditional Easter meal is chicken “wot”- chicken in a sauce with injera. It’s very spicy! Each family will also make teuj- a strong honey wine. Others may also slaughter a goat for Easter meals. We have been invited by the PT’s at Black Lion to join them in a dancing celebration on Saturday night! More updates on this holiday to come…
Happy Easter!

More Airport Fun...

Our return flight from Gonder-Addis was on one of those small prop planes. Once we’d all boarded, the captain came into the aisle and said,
“We have problem. Plane broken. Both batteries will no start. Everyone must get off plane. We try to fix. We hope for the best.”
We proceeded to spend 7 hours in the tiny Gonder airport (there were no other planes there, so they had to fly the part in). A little bit of food, cards, and hackey sack helped pass the time. Met some very interesting people. One guy named Andrew was returning to Portland,Oregon after his non-profit organization (www.ethiopiaproject.com) put on a series of running races in Ethiopia. Very cool! After a long day we finally made it back in one piece.
But the whole day embraced to me what I love about this culture. If that had happened in the US, people would have been pretty upset and wanted vouchers or some kind of compensation- and surely there would have been a lot of complaining. The Ethiopian culture is so laid back, “no worries”! I love it! America has a lot to learn…

Weekend in Gonder

Gonder is located in a beautiful valley on the edge of the Simien mountains. The outskirts of town are dotted with cattle, farmers, tukuls (straw-thatched circular huts), and dirt roads with people carrying loads on their heads and shuttling herds of goats or a few donkeys along. The town is much smaller than Addis but with similar scenery- small homes made of cement or mud blocks covered with tin roofs, people selling agriculture and other goods along the roadside, and erratic drivers swerving around the mix. Seatbelts are uncommon and driving rules are pretty much non-existant but with the road conditions fast speeds are not possible which offers some comfort. As we entered the city for the first time we came upon a funeral procession. It was eerily quiet aside from Muslim prayer chantings. Several men carried a coffin at the front and at least 100 people all dressed in black walked behind.
We were staying at a hotel in the heart of Gonder with a nice rooftop café. Our first task was “business”- we headed to the PT school where we met with faculty and students and toured the facilities at Gonder University. The facilities were quite the contrast from Regis and all of the people we met were very friendly. The site has an outpatient clinic and an inpatient ward so students regularly were able to practice in these areas during their 2nd and 3rd years.
Later in the day we hit up the “ferenji” tourist spots in the area. Gonder is so rich with interesting history. If I had more time I would go into details- but for now I will refer you to the Gonder Wikipedia page which probably has a more accurate representation. We toured the castles, bath area, and Haile Sellassie church with a local guide. I’m not the biggest fan about history details but I was very intrigued the entire time! And the views were beautiful.
Our second day we drove toward the Simien mountains for a hike. We stopped about an hour outside of town and began our hike with one guide... after about ten minutes we had about 10 children from nearby villages joining us! Their English was pretty good and they got a kick out of our attempts at Amharic. We stopped to watch packs of baboons, birds, and breathtaking views. It was one of my most memorable experiences so far. I spoke with one of the locals for a long time as we walked. He was 26 years old and worked as a teff farmer (the grain used to make injera- one of the most common agricultural products here). At the end of the hike he told me that he was looking for his wife – would I be interested?! (Don’t worry- no lemons were thrown; I politefully said no!)
On our way back to Gonder we stopped at Falasha village, a Jewish community that houses a women’s agricultural training organization. We watched women make pottery, weave baskets, and had our first official coffee ceremony. The coffee here is fantastic. It is much less acidic than what I am used to. They roast the beans right in front of you and serve it in small cups.
We finished off the afternoon by stopping at the local Dashen Brewery and then went out on the town to practice some shoulder dancing!

Airport Adventure!

This weekend we had a 3 day trip to the town of Gonder which is north of Addis near Lake Tana. The whole experience was quite the adventure, I will do my best to provide a short concise summary…
We arrived at the Addis Airport at 5am for a 6:30 flight which was our first mistake. It was the only flight to Gonder from Addis that day. Just to get into the building to check into the flight you had to go through one slow-operating security checkpoint that had a large mob outside of it. As we neared 6am and the funnel had moved a few feet, people began to yell at eachother and ram their luggage carts into their neighbors. People would cut in line near the door which created more chaos. Luckily our group literally grabbed eachother and elbowed the cutters out until we all made it through the door at about 6:20am. The check-in process was a lot quicker and they held the plane for us. We ran through the airport to the next security checkpoint. I was almost through when the guy in front of me was caught with a huge knife in his carry-on. He proceeded to argue for a good ten minutes about bringing his knife while the line was stalled behind him. Finally I got through but my professor (ahem..Tim!) forgot to remove his scissors from his toiletry bag so that was another ten minute delay. By that point the rest of our group was already on the plane. We were sent to a door which led you down two flights of stairs and out to the tarmac. There were 6 planes scattered around the tarmac and I panicked and started running toward the nearest one. Apparently that plane was headed to Lalibella.. not Gonder. Eventually I was shuttled to the correct plane and we somehow all made it to our destination!

Hospital Acute Care

This reflection is by no means intended to incriminate the hospital system in Ethiopia, but I wanted to paint a true picture of my experiences here. Today I got to experience the acute care area of the hospital- specifically the medical ward. It was an extremely overwhelming experience. It was particularly eye-opening to see the conditions the patients are living in as well as the conditions that plague them- many of the hospitalizations could have been prevented had vaccinations, screening processes or other medical care been provided earlier.
For a cost of 2.5 birr/day (less than 20 cents), patients are placed in the general rooms that may have 12 patients per room. Patients may also opt to stay in a less crowded room (2-4 patients per room) for a slightly higher fee. Imagine this: as previously mentioned, the halls are fairly dark due to frequent power outages. The patients that I treated were in rooms with 12 patient beds in a space the equivalent of maybe two patient rooms put together at Spring Valley Medical Center in Las Vegas (my last clinical experience). There were 1-2 nurses for the 12 patients and there did not seem to be much interdisciplinary (ie-PT/nurse/MD) communication, aside from the rounds that occur once per week. One toilet/shower was available per floor unit and patients had no privacy/dividers, and were lucky if their soiled sheets were changed in the duration of their stay because everything is hand washed. It was common to see pots on the floor catching the water dripping down from the ceiling, and there was an overpowering scent of sweat, urine, feces and bleach mixed together in the air. Patient family members and friends were gathered around the patients beds and pots of lentils and injera crowded the windowsills.
My first patient was previously a world class distance runner who had a rusty nail break through his shoe a few months ago. He proceeded to get tetanus and was so atrophied and weak by the time we saw him that sitting up was an immense effort. He was in the ICU for 5 weeks and on a ventilator for several weeks, during which time he was literally bedridden and immobile. His therapy had up to that point consisted mostly of passive range of motion and efforts to improve his elbow joint contractures. PT here has proven to be fairly conservative in general which has been a challenge. After some coaxing, everyone agreed to let him try walking with me. We walked about ten feet before he succumbed to extreme fatigue but the smile on his face was priceless when we left. It was so frustrating to hear his story knowing that in the US he would have received immediate treatment upon initially injury and never would have gotten to such a near-death state requiring such a lengthy recovery.

We saw a number of other patients. The patients stories are heartbreaking to say the least. One of the PT’s, Nigatu, has told me that the only way he can do his job is by not truly “hearing” the stories. It is easier to put up a wall and not get attached to patients he has said. I’ve had a really hard time with this factor. Other conditions I treated have included cancers, spinal fractures, bacterial meningitis/hydrocephaly, and Brown-Sequard Syndrome. Fractures are so very common and I think it is definitely tied to widespread nutritional deficits here.
My classmates have also worked with very interesting cases- for example, one patient had an affair with another man and her husband beat her and buried her alive. Miraculously, some nearby children heard her screams and came to her rescue. Another story- a 12 year old boy was beaten so severely by his teacher that he needed skin grafts, developed contractures and is now months later just attempting to stand up again. While outpatient care has been very culturally educating, the inpatient side of things here even more greatly outlines the vast cultural differences between the US and Ethiopia. It’s incredibly humbling yet frustrating.

The Shoulder Dance!

We've been fortunate to experience some of the traditional Ethiopian dancing while we have been in Addis Ababa. Ethiopians have a great deal of pride in general and there are different dances for different ethnic areas. For example, the Amhara people of this region have different types of dances than the Oromo people of the East or the Tigray people of the north. We went out to dinner the other night and enjoyed a number of performances. The dancing is generally very fast-paced and we could not help but wonder what types of orthopedic complaints these dances are going to have! Ha.. kind of like how we see people on the streets ambulating incorrectly with an assistive device and we want to stop the car and do some gait training! Must be a PT thing.

Anyhow, in Ethiopian culture there is a dance we call the "shoulder dance" (cannot think of the Amharic word for it at the moment). Traditionally the dance has been performed during the time of the Epiphany holiday (Orthodox Christian church). Before the celebrations begin, the man purchases a lemon from a street vendor. During the dancing celebrations, groups funnel a man and women together until they are "shoulder dancing" in close proximity. (Usually they have never met eachother). At the end of the dance, the man may choose to throw the woman his lemon. If she catches it, they will be married. This is still practiced in many parts of the country.

Quite the contrast from American dating. I see two problems with this. What if I am really hungry and want the lemon, but not the man? Or, what if I want the man but am clumsy and don't catch the lemon?

Black Lion Hospital

Myself and 4 other classmates were assigned to work in the physiotherapy department at Black Lion hospital here in Addis Ababa. Black Lion is the largest hospital in the country (720 beds!) and the physiotherapy department alone staffs 23 PT's. The PT's rotate on a 2 month schedule between casting/plaster, electrotherapeutic modalities, inpatient care ("the ward"), pediatrics, and an outpatient clinic. The hospital is by far the most crowded facility I've ever been to. People are literally everywhere- hospital beds haphazardly angled throughout the hallways and terraces, no private rooms (there may be ten patients in one room!) family members surrounding and medical staff literally running between people. Power outages are common here and so most of the time everything is pretty dark. I went to order some plaster materials from the pharmacy today and it was push-and-shove just to get to the counter to order my supplies.

The PT's here receive their bachelor's equivalent with 3 years of PT school. There is a clear resistance between the physio staff and the doctors here- most doctors do not support PT nor know what we are really capable of - it is much more pronounced than in the US. However, with the high incidence of diseases like HIV/AIDS, Tuberculosis and Malaria, it's also understandable that much of the focus has to be on saving lives rather than improving the quality of life. Disability is so high here and it's unfortunate that PT here does not have more support. 

So far I've been working in the outpatient clinic entirely. Today was Day #3 in the clinic. The main challenges thus far have been the language barrier with both the patients and local PT's- but this is getting better. (My Amharic is improving and I am used to getting laughed at as a "ferenji" - foreigner!) It's also difficult to know where our boundaries are as visiting students. We don't want to "step on toes" so to speak- and our school background appears to be more thorough than what the PT's here were exposed to. We do not want to "correct" anybody but at the same time it is hard to stand back and watch techniques when we believe that there may be a more evidence-based option. There is a brand new electrotherapautic modalities room and the Ethiopians are very proud of it. However, from my schooling I believe in a more hands-on approach and there is not a lot of evidence behind the ultrasound, diathermy and infra-red machines used here as opposed to more recent PT techniques.

On the contrary, there is also a lot that we are learning from the PT's here and our cultural knowledge and experiences have been very interesting.  The patients are very friendly and welcoming. I have become quite attached to many of them! We are now used to the prison guards with shotguns that pace around the clinic when we are treating prisoners!

The patient case load is different from the US, even in the outpatient side of things. With poor road conditions, pedestrians everywhere, and lack of seat belts in cars, combined with poor nutrition, many orthopedic injuries revolve around bone fractures. Most of my patients suffer from what they term "fall-down injury"- many broken tibias and femurs that were displaced fractures that did not have surgical options secondary to lack of resources. So many of the patients are 3 and 4 months post-fracture with huge leg length discrepancies and edema/weight bearing problems. We also see a number of patients with low back pain, hand injuries, and neurological injuries.

I have a very interesting neurological case I will share later. Until then- Letinachen! (Cheers)

First Impressions!

Many power outages have prevented me from using the internet but hopefully I can connect several more times as I have much to write about!

After about 24 hours of traveling we finally arrived in Ethiopia and spent a good 2 hours trying to get the luggage and get through customs with all of the medical equipment donations. We spent our first day at Addis Ababa University where we went to an Ethiopian cultural museum - very interesting. Afterward, we had lunch at a restaurant on the hill that overlooks the city.  This is an amazing place. I don't even know where to start. The city itself is green but also very dusty and polluted- lots of diesel fumes and construction. Roofs are made with patches of tin coverings welded together and vendors, coffee shops and fruit stands line the streets. Addis Ababa has a population of over 3 million crammed into an area much smaller than the size of Denver or even Anchorage. There are literally people everywhere. It's an interesting mix as the Muslim and Orthodox Christians are the two predominant religious influences. People in traditional Muslim coverings walk next to women in stilettos and skinny jeans. Islam prayer calls wake us up at 4am and portraits of Jesus line the streets for sale. "Taxis" similar to VW vans are crammed with 20 people (people hanging out the windows) next to a single well-dressed man talking on a cell phone in his Mercedes. Men here walk hand in hand as a form of good friendship. I have yet to see an obese individual and have only noted one person with grey hair (a sad reflection of the low life expectancy). With all of the contrasts, I'm amazed at how peaceful it seems. I feel very safe here and even though I've never felt so white in my life, people stare out of harmless curiousity. There are many more people with disabilities on the streets and it seems there is a greater respect for disability in general here.

I have so much to share related to our clinical experience that began yesterday but will have to save those thoughts for next post! (huge line forming for the internet...)

What is Project Mercy?

T-minus 1.5 days to departure! Before we leave I wanted to take the opportunity to share information about a fantastic organization...


Project Mercy is a non-profit International Emergency Relief and Community Development Ministry based out of Yetebon, Ethiopia.
Marta Gabre-Tsadick established Project Mercy in 1977 and the organization has served many countries in Africa beyond Ethiopia. We'll have the opportunity to work with this organization at the end of our trip and it sounds like we'll be able to help with manual labor tasks like painting the hospital walls and laying down cement in addition to health education sessions with the kids.


Vision (www.projectmercy.org)

By providing self-help programs, Project Mercy seeks to reduce the needs for crisis-driven, emergency aid. Through our holistic development plan, Project Mercy strives to make the Yetebon people self-sufficient. We seek to eliminate famines through creating a reliable food supply. We teach valuable trades to give people a means of generating income. Through access quality health care, we treat illnesses and educate the population about healthy lifestyles. By constructing schools, we give children the tools to create a better, more educated life for themselves and their community. Our vision is to create a thriving, independent community that empowers this generation and generations to come.


Specifically Project Mercy has programs in place including

-Feeding centers

-Medical care including antenatal and postnatal care, immunizations and HIV/AIDS testing and counseling

-Health education (housing, communicable diseases, sanitation, malaria prevention, personal hygeine, women's health, etc.)

-Medhane-Alum School for children

-Adult literacy program

-Orphan care

-Agriculture

-Skill enhancement


We'll spend about ten days in the mountain village of Yetebon working with this organization.
Can't wait to get there!

Maternal Mortality and.... the Titanic?

Our upcoming Ethiopia clinical experience includes touring of the Fistula Hospital in Addis Ababa, and we also hope to set up a future clinical site there.
You are probably wondering, What is a fistula?
Below are excerpts from an essay I wrote last semester...

Many are familiar with the historical event that took place on April 15th, 1912, when a ship called the Titanic hit an iceberg and sank to the depths of the Atlantic Ocean. In 1997, the movie based on the historical event became the most expensive film ever produced at the time, with 20th Century Fox spending approximately 200 million dollars on its creation.1 Now, imagine a Titanic ship full of about 1,600 women sinking down into the ocean – every single day of the year. According to Nancy Durrell McKenna, founder of Safe Hands for Mothers, death is a reality for 500,000-600,000 women per year secondary to pregnancy-related causes. Ninety-nine percent of these deaths occur in developing countries, including Ethiopia.2 Put another way, every minute, 110 women experience a pregnancy-related complication – and one woman dies.2


Maternal mortality is clearly a worldwide issue that deserves much attention. If a woman does not die in childbirth, she is likely to suffer from a number of complications. The sad reality is that these women will likely face maternal mortality personally or with a relative or friend, and those who survive often suffer long-term consequences in the form of an obstetric fistula.

Of all of the statistics monitored by the World Health Organization (WHO), maternal mortality is the one that has the greatest discrepancy between developed and underdeveloped countries.3 Currently maternal mortality in developed nations is at record low, with improvements in antisepsis, trained personnel/facilities, and blood transfusions attributed to the changes.3 Direct causes of maternal mortality include hemorrhage, infections, hypertensive disorders including eclampsia, unsafe abortions, and prolonged labor. Indirect cited causes include anemia, tuberculosis, malaria, viral hepatitis, and malnutrition. High rates of HIV/AIDS and female genital mutilation are additional factors that may also contribute to maternal mortality, particularly in Ethiopia. Ultimately, a lack of access to adequate nutrition and medical care – beginning as a child but particularly during pregnancy and delivery – accounts for the astounding maternal mortality rates still present today in these developing nations.


A number of facts and statistics help paint the picture of the reality that so many women face. Women ages 15-49 are more likely to die due to complications from pregnancy and childbirth than they are from HIV/AIDS or malaria in developing countries. Uncontrolled bleeding and sepsis account for the majority of these deaths. While I mentioned that one woman dies per minute due to these complications, this number is accompanied by 70-80 more that simultaneously suffer debilitating injuries in the two minutes it takes to brush one’s teeth in the morning. In addition, a woman in Sub-Saharan Africa has a one in 16 chance of dying during pregnancy and childbirth, which is significantly higher than the one in 75 chance that is the average of all underdeveloped countries.2

Numerous socioeconomic and cultural factors contribute to maternal mortality and pregnancy related complications. As mentioned, factors like malnutrition beginning in childhood contribute to these statistics. It has been estimated by the WHO that if women were adequately nourished from a young age and received appropriate pre/postnatal and delivery care, infant mortality would be reduced by at least ¾.4 Undoubtedly, some of the predisposition in underdeveloped nations is also cultural, as women tend to marry and have children earlier when the female body, particularly the pelvis, is less prepared for childbirth.5 Socioeconomic status also likely contributes, as within Ethiopia, wealthier women have on average 3.2 children compared to the 6.6 average among the poorest women.

Physical access, resources and education also carry great implications for outcome. Fewer than 1 in 100 deliveries involve a doctor, nurse or midwife in the poorest regions of Ethiopia.4 Often, these births occur in areas that lack sanitation and clean water. Ethiopia as a whole is not much better off, as only 5% of pregnancies between 2000-2007 involved institutionalized delivery care.6 Most women in Sub-Saharan Africa also lack reliable family planning methods, and only 18% of married women in this region use modern contraception.4


Worldwide, about 100,000 women suffer from obstetric fistulas per year, and approximately 2 million cases are currently untreated.7 Compare this to the United States, where in 2007 not one fistula case existed. The obstetric fistula used to be present in the US and Europe in the 19th century, but have disappeared with improved obstetric care and the use of the c-section during obstructed labor.


An obstetric fistula describes the presence of an opening between the female vaginal and anal orifices or between the vagina and urinary bladder. This condition results from unrelieved obstructed labor, and without surgery the fetus either dies or is finally passed from the mother with accompanied tearing of the tissue.8 Often this condition leads to permanent urinary and/or bowel incontinence- in other words, the woman will constantly leak urine and feces from the damage sustained. Most of these women are then ostracized from their communities, divorced from their husbands, and find themselves living in even greater levels of poverty than before.8


In the PBS documentary “A Walk To Beautiful,” one is able to glimpse a small idea of what these girls and women go through. A specialized fistula hospital in Ethiopia provides free care to women, with hospital costs of about 450 dollars per person, which includes the surgical procedures, recovery, new clothing and even a bus ticket back to their village. However, while the hospital services are free to patients, many of the women lack the resources for the cost of traveling to the capital city to receive the care. Sadly, even more are unaware that their condition can be helped.

Follow this link to watch the excellent PBS Documentary for free!
http://www.pbs.org/wgbh/nova/beautiful/
Read this book on how the Fistula Hospital in Ethiopia came about - very good read: The Hospital by the River - A story of hope by Dr. Catherine Hamlin (available on Amazon.com)
And stay tuned for my next blog on how I think we as PT's can help the maternal mortality/obstetric fistula problem!



References
1. Titanic film information. http://en.wikipedia.org/wiki/Titanic_(1997_film). Accessed September 22,
2009.
2. Safe Hands for Women website.
http://www.safehands.org/index.php?option=com_content&task=view&id=12&Itemid=30.
Accessed September 22, 2009.
3. Maternal Mortality. http://dcc2.bumc.bu.edu/IH887/presentations98/mmpaper.html. Accessed
September 22, 2009.
4. PBS Film: A Walk to Beautiful. http://www.pbs.org/wgbh/nova/beautiful/women.html. Accessed
September 22, 2009.
5. Norman AM, Breen M, Richter HE. Prevention of obstetric urogenital fistulae: some thoughts on a
daunting task. Int Urogynecol J. 2007;18:485-491.
6.UNICEF website: Ethiopia statistics. http://www.unicef.org/infobycountry/ethiopia_statistics.html#59.
Accessed September 22, 2009.
7. The Fistula Foundation. http://www.fistulafoundation.org. Accessed September 22, 2009.
8. Wall LL, Arrowsmith SD, Briggs ND et al. Urinary incontinence in the developing world: the
obstetric fistula. Presented at the second international consultation on incontinence.
[Unpublished] 2001. Paris, France, July 1-3, 2001;40:893-935.

What does healthcare look like in Ethiopia?

From what we've studied, the healthcare insufficiencies are vast and overwhelming in this country. Outside of the capital city, healthcare facilities are few and far in between, and more than 85% of the country's population reside in rural areas. Factors including widespread poverty and lack of access to education, sanitation, clean drinking water and healthcare facilities contribute to the high disease rates. Ethiopia's healthcare system is among the least developed in Sub-Saharan Africa and the government has chosen to focus on strengthening primary care. Healthcare delivery is strongly impacted by the lack of skilled manpower combined with insufficient funding/number of facilities.

A few statistics: (http://cnhde.ei.columbia.edu/healthsystem/)

In many areas, 80% of Ethiopia's healthcare problems are due to preventable communicable/nutritional diseases.
The life expectancy is 54 years (and will decrease to age 46 if the present HIV rates are maintained).
There is 1 physician per 35,493 people (In the U.S. it's 1 per 392).
Maternal mortality rate is 871/100,000 (In the U.S. it's 11 per 100,000).
Malaria is the primary problem with 8-10 million cases reported annually.

Evidently there are numerous challenges and as healthcare providers we will be facing a number of diseases and conditions that have long been eradicated from the U.S.

What do Ethiopians Eat?

(Naturally, my first question is related to food). I've had Ethiopian food once (in Denver) but wanted to know more about what to expect. I've already purchased a sufficient stock of Tums, Pepto, etc. to bring along.

It will be interesting to see how I handle a change from my typical mac 'n cheese, burritos and top ramen diet...

Coffee is a huge crop in Ethiopia and the coffee ceremonies will be really fun to experience (maybe I will cut my Splenda and creamer habits for good!) I highly recommend a documentary called "Black Gold" on coffee crops and fair trade in Ethiopia- see the website under my links.

According to wikipedia... (http://en.wikipedia.org/wiki/Ethiopian_cuisine)

Ethiopian cuisine characteristically consists of spicy vegetable and meat dishes, usually in the form of wat (or wot), a thick stew, served atop injera, a large sourdough flatbread, which is about 50 centimeters (20 inches) in diameter and made out of fermented teff flour. Ethiopians eat with their right hands, using pieces of injera to pick up bites of entrées and side dishes. No utensils are used.

Traditional Ethiopian cuisine employs no pork of any kind, as most Ethiopians are either Ethiopian Orthodox Christians, Muslims or Jews, and are thus prohibited from eating pork. Furthermore, the Ethiopian Orthodox Church prescribes a number of fasting (tsom Ge'ez) periods, including Wednesdays, Fridays, and the entire Lenten season, so Ethiopian cuisine contains many dishes that are vegetarian (Amharic: ye-tsom, Tigrinya: nay-tsom). This has also led Ethiopian cooks to develop a rich array of cooking oil sources: besides sesame and safflower, Ethiopian cuisine also uses nug (also spelled noog, known also as niger seed).^[1] Ethiopian restaurants are a popular choice for vegetarians living in Western countries.

FOODS
Wat- stew with any variation of onions, spices, meat, legumes/lentils, other vegetables, potatoes
Tibs- sauteed meat and/or or vegetables; in history was cooked for special occasion to show particular respect for someone
Kitfo- raw/rare marinated ground beef (spicy)
Fitfit- breakfast dish made of shredded injera (Fatira and Chechebsa are pancake-like breakfast items)

BEVERAGES

Tej is a potent honey wine, similar to mead, that is frequently served in bars (in particular, in a tej bet; Ge'ez ṭej bēt, "tej house"). katikal and araki are inexpensive local spirits that are very strong.

Tella is a home-brewed beer served in bars, which are also called "buna bets" (coffee houses).

Coffee (buna) originates from Ethiopia, and is a central part of Ethiopian beverages. Equally important is the ceremony which accompanies the serving of the coffee, which is sometimes served from a jebena, a clay coffee pot in which the coffee is boiled. In most homes a dedicated coffee area is surrounded by fresh grass, with special furniture for the coffee maker. A complete ceremony has three rounds of coffee and is accompanied by the burning of frankincense.

Goorsha

A goorsha is an act of friendship. As stated above, a person uses their right hand to strip off a piece of injera, roll it in the wat or kitfo, then put the rolled injera in their mouth. During a meal with friends, a person may strip off a piece of injera, roll it in the sauce, and then put the rolled injera into a friend's mouth. This is called a goorsha, and the larger the goorsha, the stronger the friendship.^[4]

My first post!

So, I've never tried this blogging thing, but I thought it would be a fun way to connect with family and friends while I'm overseas.

On March 19th, 2010, I'll be headed with a group of 8 other PT students, 2 nursing students, and 4 faculty members to Africa. We'll spend one month there in all- about 3 weeks in the capital of Ethiopia - Addis Ababa - and the last week working with non-profit organization Project Mercy in the mountain village of Yetebon. I hope to capture every element of the culture and our experiences while we're over there in this blog!

So far, I don't think it's really hit yet that in 18 days, 9 hours and 39 minutes we'll be boarding a plane to head across the world! Trip preparations are in full swing. Last month I finished the immunization process...

Typhoid vaccine
Yellow fever vaccine
Meningitis vaccine
Hep A/B vaccines
Anti-malaria pills (purchased- Doxycline)
Polio vaccine
Routine immunizations (MMR, DPT, etc.)

About $450 dollars later... yikes, but beats bringing back a tropical disease!

I want to thank those who helped with our fundraising for the trip.
To those who sent checks - I'll be putting together a photos/video presentation upon our return and will be sure to send my gracious donors a copy! Thanks a million!