I don’t plan to only post about medical issues, but I m learning so many interesting things, I hope you all will also be interested to hear more about work and the medical system here. I’ve previously talked about how St. Paul was established to be the hospital for the poorest of the poor, and they continue to serve that population, 70+ years later.
One thing I’ve noticed since the first day are big posters in Amharic and Oromifa, which I couldn’t read. I asked my colleague, Mekdes, about them this week, and they are charts that display the costs of every service and procedure patients can get. There is also a poster that doesn’t have any prices, because some services are free for everyone, including Maternity care, family planning, pediatrics for 5 year olds and under, STI testing and treatment, workplace injuries, and a few other things. However, what was more astonishing is the costs of other procedures. The GYN procedure poster indicates that hysterectomy (second listed) costs 25 bir. That’s less than $1. Ovarian cystectomy is 15 bir. And if someone can’t pay, they simply go to their city council representative and get a slip of paper indicating that, and then they’ll get their care for free. I think the US could learn a lesson both about health care for all and about transparency in medical costs!
Last Friday we had our first All Fellow Didactic, with Mekdes and Ferid here in Addis, and Tesfaye and Lemi in Geneva. It was great to have a discussion altogether, and we now have an active curriculum moving forward. We plan to use these didactic sessions to learn and review, and also to create protocols that can be used at St. Paul (and perhaps more broadly) to standardize family planning care. I feel like I’m starting to identify my roles and where I can be most productive and helpful, and that feels great. After three weeks at work, I’m understanding the Ethiopian-accented English better, and I now have a clue what is being discussed at morning report. The pathology that comes in the door every day and night is astonishing. First, just the volume means we’re bound to see whole bunches of stuff, plus this is a referral center for anything complicated. Last week there was a triplet delivery and about 4 twin deliveries, some with twin-twin transfusion syndrome, and some negative fetal outcomes. I didn’t think it was possible, but there is even more preeclampsia here than at UW! And lots of eclampsia, which we almost never see at UW. One woman last week came in with a ruptured uterus – term pregnancy, 6 prior vaginal deliveries, presented to a clinic and was sent directly to St. Paul. Still, probably about 4 hours from the time she left her home to arrival at St. Paul, hemorrhaging into her abdomen the entire time. The baby was dead, and the woman almost so, due to hemorrhagic shock. She was immediately transfused and had an emergency surgery to remove her uterus. She recovered well, and my colleagues tell me that almost never are they able to save the baby in cases of uterine rupture (especially since patients are often not at a surgery-capable facility when the rupture occurs). In the US, we almost never have a fetal (or maternal) loss due to uterine rupture. This sort of differential mortality simply due to resources and access is really sad. My colleagues here are amazing doctors, providing incredible care with limited resources – I’m already learning a lot, and expect I’ll leave here a better doctor for the experience. I really love my colleagues here – family planning fellows and the rest of the department – and everyone has been amazingly welcoming and really makes me feel like part of the department. Tomorrow I will be going to a different clinic to help with a laparoscopic myomectomy – slightly outside my comfort zone – but I’m interested to see the laparoscopic set up here, and also see this other clinic, where most of the reproductive endocrinology and infertility is managed. I love this broad exposure to how OBGYN is practiced here.
One of the other things with which I’ve been developing a lot of experience is driving. More accurately, I’m an experienced passenger, as neither Eric nor I have an Ethiopian license currently. Side note, we’ve been told this is “no problem” to get, not hard, just get your license authenticated at the Embassy then go to the Ministry of Transportation to get your license. However, this, too, apparently gets put through the “Addis Complicator” – our friend Margot’s term for how simple things become difficult here. Another friend, Tej, recently spent a day going to the Embassy to accomplish the first part of this, and was told that no, before the Embassy can authenticate her driver’s license, she has to go to the Secretary of State in her home state to get it authenticated, then bring it to the Embassy for authentication, then, of course, to the Ethiopian Ministry of Transportation. So, for Eric and me, that would mean spending thousands of dollars to go back to Washington just to go to Olympia to get our licenses notarized. Oy. Possibly we could mail our licenses to someone in Washington who would then be willing to go to Olympia and try to do this, however, it’s difficult to both send and receive mail here – our address is literally Addisalem Luxury Apartment, Sarbet Square, behind Adams Pavilion. The building is on an unnamed alley, no address. I suppose we could add Apartment 201. But don’t try to now send us a care package – it won’t get here! So, now we’re hatching schemes about possibly getting an international driver’s license through AAA (which can be done in about 6 weeks), or possibly trying to get a South African Driver’s license when we’re there in a couple weeks, but then we don’t know if we’d need to get it authenticated at the South African Embassy? Or possibly just not be able to drive while we’re here…which may not be the worst thing in the world.
So, back to driving after my related digression…it’s TERRIBLE. Even my Ethiopian colleagues complain about it. The top speed limit here in the cities is 30 km/hr. That’s approximately 18 mph. And I will add that it’s uncommon to be able to reach that speed. The roads are extremely poorly maintained, with huge potholes everywhere. There are also randomly speed bumps that don’t seem to serve much of a purpose, given the already low speeds. The cars are also relatively crappy. Most cars here are imported used vehicles, so they get here and they’re at least 10-15 years old. All the taxis are blue and white Toyotas from the 80s or 90s, and it’s rare to find one that has working door handles. Occasionally they’re missing major parts of the floor. Seatbelts are a laughable idea – good thing everyone goes so slowly.
My unscientific study leads me to state that about 90% of all the cars here are Toyotas – our driver says this is because it’s easiest to fix them because they’re more likely to have parts. If you see a nice SUV (still usually Toyota), it usually is affiliated with one of the Embassies or it belongs to one of the ex-pats. Otherwise, these cars are all so old and fragile, that even going over a small divot in the road could knock something important off (Shocks? You’re kidding, right?). Not one single car would pass inspection in the US from a pollution standpoint, and the pollution is awful (though last Spring the new government banned big trucks in the city during the day, which has lowered the pollution levels during daylight hours).
Finally, there are the rules of the road (or apparent lack therein). Lanes appear to be completely disregarded, traffic lights are maybe more of a suggestion than a rule (and there are only a few of them in the whole city), there are no stop signs and most big intersections have a roundabout. Surprisingly, this more often than not works relatively well, but occasionally gets cars locked in to the point that literally no-one can move. I spent about 20 minutes in one round about during a heavy rain on the way home from work one day last week. Finally, on the road are cars, trucks, buses, the occasional bicyclist, plus tons of people weaving in and out and crossing everywhere, not to mention the goats, dogs sheep and donkeys. So, not personally driving here may not be the worst thing in the world…
Well, I started with a job update, and ended with a description (rant?) about transportation in Addis. I suppose these are two issues I deal with most frequently in my time here. I hope it’s been somewhat interesting for all!