By Dr. Will Roberts (Cardiologist)
The picture you most probably have in your mind when you imagine ‘Ethiopia’ is that of an emaciated child sitting in the middle of a desert, with flies hovering around his head. That was the picture I too had of Ethiopia before my visit, but the reality is quite different. In this report I hope to paint a picture of a different Ethiopia, the Ethiopia I found, the Ethiopia I both love and hate.
However much I write in this report, I can only give you a very meagre view of Ethiopia. During the two months I spent in different parts of Ethiopia I would like to think I learnt a lot about the place, though obviously this is still a subjective outsiders opinion. To know Ethiopia you have to live and grow up there, appreciate the history by living it. That said, Ethiopia was not a closed off culture, the people I met were very willing to discuss their thoughts with me, correct my errors and show me around. On several occasions I was invited to peoples’ houses to eat, and I doubt that has anything to me being a particularly worthy guest.
Lets start with the simple tangible things, easy to see and contrasting greatly to what we see in our lives. The country is poor, one of the worlds two poorest countries in fact and this is readily displayed. The buildings are badly maintained, the main roads are single dirt tracks, only major roads in some cities are tarmaced, there are beggars everywhere, there are disfigured and sick people wandering the streets. The majority of people live in mud huts and live off their land; even in cities only the lucky have solid houses with ‘real’ floors. There is massive unemployment; in Addis I was told that 50% of the people there were unemployed. The waitress in my restaurant was the top student at her university, but could find no other job and coveted the one she had. Many people don’t wear shoes, but there is a peculiar obsession with keeping them shiny, despite the filthy, muddy streets. This obsession has spawned a horde of shoeshine boys who attack anyone they think should have their shoes polished. Saying no, or even having your shoes shined by one doesn’t deter the other twenty who still shout ‘Mister? shoes-clean, shoes-polish, mister!’ The shops and markets give a good idea of the poverty of the country, though always seemed flushed with food of some kind or other.
Most amenities and facilities do exist in some form or other, though many may be out of the reach of most Ethiopians. There are places you can get (slow) internet access, there are banks, airlines, tour agents, electronics shops, music shops, post-offices, chemists, sweet shops, clothes shops etc. But these were not shops as we know them, you buy bread or a live chicken from a guy who jumps on your bus, fruit from the man on the corner, bread from a window in someone’s house. Outside Addis, when I came across a shop I could actually go into, I found it strangely comforting with all the various household items piled to the ceiling and a man looking obliquely at me across the counter.
I also found Ethiopia dirty and not such that it could be explained by poverty, this was more a cultural issue. Unwanted things such as bottle tops and used batteries are just thrown into the nearest gutter or just outside the front door. For days I walked past a dead dog in the road on my way to the hospital, gradually decaying and being eaten by flies, I even drove over it once in the bus. Another issue was people going to the toilet, OK so I don’t expect public lavatories with hand dryers and flushing loos, but people pissing and shitting in the streets, that can’t be healthy, and it certainly doesn’t smell nice. I think that must be due to the fact that in the rural areas, when people are farming or herding their animals, they just stop where they are when they need to and offload their waste, but in a city thousands of people doing the same thing is asking for trouble.
The people of Ethiopia are not just one people there are many tribal / racial groups. In the area around where I was staying most people where from the Amhara tribe, the largest in Ethiopia. Ethiopian people are quite a beautiful race, and the wide white grins are uplifting. People say that the Ethiopian people are a friendly and happy people, but that is as much a naïve stereotype as any that would offend in the UK. Certainly, many Ethiopians are happy, but many are unhappy, some are angry. I think that being at ease with happiness and a more willingness to show emotion would be a better way to contrast with the masses in England. Perhaps what strikes most people is that fact that people can be happy in such conditions, can play games, laugh and be human. Unlike, some of the other African countries, Ethiopia is not a violent or dangerous place. I never once felt under threat, in the middle of the mountains or in the Capital City.
I have no room to tell you about the history, the fascinating solid coffin, the fallen stellae, the Aksumite empire, the awful food, the arc of the covenant, the singing fountain, the castles of Gonder, the brothel hotels, the beer commercialism, the scams, the children on the street, the mission hospital, dancing the iskista, the volcanic view in the mountains, the 700ft waterfall, the Blue Nile falls, the monasteries of Lake Tana, the horse we killed.
Gondar and surrounding area
Gondar is a city with population of about 120,000; the surrounding areas are concerned with agriculture. The farming methods are primitive, using manual ploughs, sowing and harvesting. Individual families manage and live on a small area of land. Outside the city there is no electricity, except, intermittently in some health centres. This electricity is sporadic and unreliable. Water is of a poor quality; largely coming from unprotected springs and wells. Sanitation is poor and waste is disposed of on land near the house or into open sewers in villages. But Gondar is a Pepsi town, what wonderful contributions the developed world has given Ethiopia; Michael Bolton and Pepsi.
I was attached to Gondar College of Medical Science (GCMS) for my elective, this is one of Ethiopia’s three medical schools and its associated hospital, known locally as kolej. The hospital has approximately 350 beds and provides both medical care for the population of Gondar and surrounding rural areas and training for doctors, nurses, midwives and other medical staff. There are currently 800 students at GCMS, but this is increasing greatly next year.
The hospital facilities are, as you would expect, radically different from those found in the UK. There is a shortage of EVERY routinely required object; needles, gloves, fluids, all medications, bandages, dressings etc. ‘Traction’ in Ethiopian means tying a bag of rocks to the bone nail and dangling it over the end of the bed - crude but effective. In terms of investigations, the doctors have little more than extremely good clinical skills and the ability to cut a patient open and have a look. X-rays are available, but they are of poor quality, ultrasound is sometimes available, but there is a problem with trained personnel. Blood tests are minimal and the results variable. Don’t even dream about CT, MRI, nuclear medicine, echocardiography and other fancy stuff.
There are no intensive care facilities, so sophisticated operations cannot be performed and trauma patients have a much higher mortality. There is no functional ambulance service, trauma victims and acutely ill patients are brought to the hospital in taxis or minibuses. There is an ambulance, which patrols around the city some evenings picking up the losers of fights and victims of attacks, but it is not a reliable service. Again I will mention that I did not feel that Ethiopia was an unsafe place, and if I had not been working in the hospital I would never have seen Ethiopia’s violent side.
One thing that I disliked greatly about the hospital was the fact that there seemed to be little pride taken in it. Basic maintenance was not carried out and it was quite filthy and I just assumed that the operating theatre had to be sterile. This cannot be excused through poverty or lack of resources, screwing a nail into a wall, changing a bulb, mopping the floor do not require as much money as a vial of insulin. One day whilst waiting for a clinic to start I counted fifteen used needles, several syringes, a used bag of fluid and what I think was a catheter, all in a small patch of ground where patients sat waiting.
I should mention that in Ethiopia medical care is not free, unless you have ‘poverty papers’ you must pay for everything yourself. A site in surgery that always amazed me was the patients walking in with a plastic bag containing sterile gloves, cannulae, bags of fluid, sutures etc, plonking them down at the anaesthetists feet and lying down on the operating table. You must also pay for your bed and you are likely to be looked after by a member of your family who does all your cooking and nursing and washing etc. At Leicester we have the social implications of medicine rammed down our throat at every opportunity. In Gondar, social circumstances are rarely considered, is that because everyone is assumed to live in poverty? Or is it because that is a luxury secondary to the real business of treating patients? During the ward rounds, all relatives and carers are rounded up and dismissed from the building and patients are generally treated in an off hand manner. Perhaps ‘communication skills’ is an area where the highly astute clinicians of Ethiopia could improve.
My original plan for my elective was essentially two small projects. The first was to help the medical students in Gondar write patient information leaflets for some of the commoner chronic illnesses and the second to gather a small amount of information about diabetes as part of an international project.
The first project was suggested by one of the doctors visiting Leicester from Gondar, a year prior to my visit. With this in mind I had accumulated a small library of English language leaflets and CD ROMS packed with diagrams to aid in my quest. My suspicions to the value of this project were confirmed on arrival in Gondar. Despite the efforts being made in urban schools, the literacy rate in Ethiopia is tiny, with less than 25% of the population literate. In the rural areas covered by some of the hospital’s clinics this was suspected to be optimistic. A confounding problem being that the tribal nature of Ethiopian society there are several different languages and dialects even in the area around Gondar. I felt that there was very little point in spending time on this project as it was unlikely to be of any real use and decided to cancel it.
The second project was to find out a small amount of information about diabetes care, and the supply of insulin to patients. Around the world there are many other medical students gathering similar information from as many of the worlds HIPCs (Highly Indebted Poor Countries) as possible. The aim is to provide data to support the work of Professor Yudkin of the International Health and Medical Education Centre at The University College London. Professor Yudkin is in the process of forming an ‘International Insulin Foundation’ with the aims:
1. To improve the access to insulin for Type 1 diabetic patients.
2. To improve efficacy and sustainability of diabetes management in Type 1 diabetic patients.
3. To collect accurate information on diabetes prevalence, incidence and morbidity in these countries.
My part in this was to assess all issues I could surrounding Insulin Availability in Ethiopia, to provide information to support the foundations creation and to help choose the pilot site for the scheme. I have written about my findings in the section below.
Diabetes Care and Insulin Availability
I wanted to assess the availability, cost and consistency of the supply chain for insulin in Gondar, I was also interested in the provision of diabetes care.
Gondar and the neighbouring areas are very lucky in that a Chronic Illness Project is being undertaken here under the umbrella of the Leicester-Gondar Link. This has provided funding for a team of doctors to travel to the rural health centres once a month to run outpatient clinics for epilepsy, diabetes and hypertension. Otherwise the patients would have to travel to Gondar, usually by foot, a journey that would take several days. The work of Dr Shitaye Alemu, a highly motivated doctor, has also led to greatly improved diabetes care.
99% of patients are managed on a twice-daily regime of slow acting insulin. There are problems in implementing any other regimes because of the lack of other types of insulin and mixes and because of the difficulties in training and educating patients both in terms of poor education and resources.
The average monthly income of a family living in a rural area is: 100Birr, which approximates to £10. A doctor earns approximately 400Birr per month (£40).
Insulin is handed out at the rural clinics free of charge, inside the city; it is either given free when available or can be purchased from the pharmacy within the hospital or in the local chemists. The cost in the pharmacy is 48Birr (£5)
The type of insulin available is animal (bovine).
Blood sugar tests are carried out by finger-prick if the patient attends the monthly clinic, these are not charged for. There are no facilities for monitoring long-term control by checking levels of HBA1C.
Patients are given on average one syringe every month or two. They must reuse this syringe 60 times or more. When you consider that these syringes are usually kept in the bags that the patients carry everything, you might expect them to get damaged or dirty to the point where it would cause frequent infections of the injection sites.
This was not reported, but I have no specific data for this. The cold chain does appear to be reasonably intact, though I think it is quite a fragile system. Electricity is intermittent in the city, and non-existent in the rural areas. Some of the rural clinics are equipped with refrigerators and generators. I did note that on several occasions the insulin appeared to be kept in a cupboard in the hospital and left in the vehicle overnight before heading to the health centres. I was assured that this was not the case.
The supply of insulin is quite variable, Dr Shitaye relying on insulin from various sources. Some of the insulin is donated from abroad, via charities or individuals, some is purchased by the hospital with government funding and some is purchased with money from the chronic illness project, supported by THET (Tropical Health and Education Trust) and the Children’s Research Fund in Liverpool.
Once the patients receive the insulin vials they will carry them to their home, a journey that may take a day or more. I estimate that 80% of patients keep their insulin in a tin buried in the ground. 18% do not make any attempt to refrigerate their insulin and the remaining 2% have access to a fridge. This hole is surrounded by sand and during the summer months it is regularly watered to keep it cool. I do not know how cold this actually keeps the Insulin. Ordinarily a patient will receive one vial every month, but over the rainy season when rural clinics are not operating, they will receive 3 months supply. I am aware that the official recommendation is that insulin that is not kept refrigerated will only last 24-48 hours. How long it actually lasts at these temperatures is of great importance. It would appear that the insulin is enduring these conditions as patients are surviving.
If it were not for the Chronic Illness Project, the cost of providing insulin would be prohibitively expensive to make treatment of diabetics an economic impossibility. If we consider that basic sanitation and nutrition needs have still to be met, it would seem an inappropriate priority for the hospital to purchase insulin, which is essentially a high annual cost project. Insulin accounts for a massive proportion of the hospitals drugs budget. If insulin were freely available, work would need to be done to assess the effectiveness of the cold chain and the patient refrigeration to ensure that the insulin was still viable.
A final word
I have so many things I want to say about Ethiopia, I feel they would fill a large book, but probably my most important one I will try to explain below.
The saddest thing for me in Ethiopia was the lack of hope, the feeling of need and worthlessness and paucity of motivation. There is an ill-defined concept called aid-fatigue, when countries are so used to foreign aid that they become dependant on it. The lack of motivation from within Ethiopia that I perceived must be stalling the change that could help the country out of this mire. I cannot point and blame, nor do I know why this situation exists, but it does.
Many people are aware that ploughing in indiscriminate aid to countries such as Ethiopia does little to improve the lot of the people there. I agree entirely but I also think that some attempts at sustainable development are still aiming a level too high, they must go deeper.
Ethiopia must get itself out of this mess, but we must help it a great deal, charity is not the right concept. The people of Ethiopia must feel proud of any improvements it makes, rather than feeling grateful to the rich countries of the world. We should not put up big banners declaring every time we dig a well or build a school. This only serves to make us feel better about ourselves and perhaps less guilty for our privileged position on this planet. We must quietly point them in the right direction, hope they can miss out some of the mistakes we have made in our ‘development’ and most importantly we should not exploit their people or natural resources. We must not tolerate regimes that are corrupt or impinge on human rights.
One thing that frustrates people is that this will be a very slow process, you can’t just create a modern society overnight, it must evolve in stages to reach the levels of technology and standard of living that we enjoy in the UK. Maybe it can be sped up slightly by borrowing knowledge that we have already learned, but it will be hundreds of years before the catch up game is finished. The difference between people living in mud huts, ploughing the land manually and the high technology world we live in is hundreds if not thousands of years. Huge changes in social structure and economic arrangements would be necessary to bring these millions of people to a standard of living that would ease our minds.
My priorities would be:
· Human Rights
However poor a country is, however ill its people are there is never any need to compromise human rights, to kill each other and discriminate. I would encourage this as the main ethic behind any assistance to Ethiopia. Once we have ensured that, what remains is degrees of life; more people unemployed, more people ill, less people reading, people living shorter lives. None of these is to me as awful as what humans continue to do to each other today in terms of killing, wars, torture, discrimination and persecution.
If we want Ethiopia to share in some of the delights of our world, where the degrees are different, it must come through knowledge. We must support Ethiopia in its provision of education at all levels from schools to Universities, to education in terms of improving skills and training in the workforce. Ethiopia will be dependant on foreign aid until it is able to compete globally with other countries and to do this it must have people who are educated and well resourced. There has been progress here; Adult literacy has risen from 28 to 40% for men and from 11 to 26% for women since 1980.
By stability I am talking politics, years of war caused great problems for Ethiopia, and the relative tension that remains in that area to this day greatly discourages foreign investment into the country. Hopefully peace will be retained and this situation will improve. The Ethiopian government is still finding its capitalist feet and is very controlling of any commercial development. When companies feel safe venturing into Ethiopia, they will bring with them jobs and money for many. Hopefully some of this will come from enterprising Ethiopians, rather than being imposed externally. Greedy foreign companies may see dollar signs in the wealth of cheap labour available in Ethiopia, but we must not let these companies exploit the Ethiopians, they must pay them a fair and reasonable wage. Infrastructure too will enable the creation of commerce and business so Ethiopia has it’s own share of the world’s money. Stability in terms of population is also important, fortunately the growth of the population is not rising, but it would certainly be easier to feed all the mouths if there were fewer mouths to feed and the same can be said of jobs, healthcare etc. I think this comes through education as well.
Strange that for a medical student health isn’t in that list, but is it such a huge priority? I realise that these are quite radical comments I am making. In a country where one of the biggest problems is the overpopulation, is making people healthier really useful? It hurts me to think I am suggesting we let people die. And how can I argue that my top priority is human rights and yet suggest not looking after people’s health. Well, the biggest obstacle to people’s health in Ethiopia is poor sanitation and the living conditions so that should be a priority - and it is; infrastructure includes water supply, sewerage, and housing. Another obstacle to peoples health both directly and by the effects on poverty is education, hence another of my priorities. A great problem leading to illness is the shortage of food, or the inability to pay for food. An infrastructure which allows the delivery of food to all parts of the country and distribution to the most needy is more important than sending the equivalent in medicines or medical equipment.
There is a great deal of work going on in Africa, some may be misplaced and it is certainly a drop in the ocean. But progress is being made and it will remain slow progress. I hope that through all this development some of the cultural individuality of Ethiopia remains and Ethiopians regain some pride in themselves and their country.