Sunday, August 15, 2010

Return to Mekele

We began our journey to Mekele from Addis about 2 weeks ago. Our means of transportation was by Selam bus, the more accessible and affordable means of transportation for many Ethiopians. The journey was almost 17 hours, with one stop overnight in a town called Alamata. Most of the journey consisted of us going in a criss-cross direction around steep roads built onto the mountain face. As the road approached each summit of a mountain, we received unprecedented views of the valleys, the step-farms built onto the mountainside, and the unique thatch huts of farmers below. Although it was tiring, the amazing landscapes we passed and the opportunity to catch glimpses of the beautiful simplicity of Ethiopian life pass by our windows made the journey fulfilling.

Finally, around 6:00 in the evening, we arrived at our temporary stop for the night, a town known as Alamata. I’m sure that on a really detailed map, one could spot it, but to Braveen and I, the location perfectly seemed like the middle of nowhere. Our bus had stopped at one of the hotels in the town and we went to check out our rooms. Braveen and I decided to get a single, as our stop would be brief and we would have to get back on the bus around 3:30 in the morning. From the top of the hotel, we could see that one side of the countryside was really scenic and beautiful, while the other was packaged with small dirty roads and slum like buildings. There was a tall mosque directly across our field of view. During our dinner out by the courtside of the hotel, heavy rain was pouring. It was mixed with the occasional flash of lightning that ominously brightened up the dark cloudy skies. We also noticed that the night lamps in front of each room of our hotel were flickering in and out. Electricity had gone out. However, we had full electricity back on by the time dinner was done. Our room for the night consisted of a single bed and a single wash basin. The toilet and showers were built dorm style and were located at the end of each hall. We spent the majority of night killing cockroaches that were crawling along Braveen’s side of the bed and ensuring that there weren’t other crawlers prowling across the floors. I tried to get a few hours of sleep, before we began the next leg of the journey. I woke up around 2:30 and quickly brushed my teeth. We were soon back on the bus leaving Alamata around 3:30, while it was still dark.

We arrived in Mekele earlier than I thought, around 8:00 in the morning. It felt good to be back among familiar surroundings. After we had taken a nice, warm shower and had eaten our breakfast, we set to find HayIlom and the Mekele city health office to begin the next phase of our service journey. After a few minutes of confusion and being lost, partly due to me not remembering the exact locations of the streets, we finally arrived at the Mekele city health office. HayIlom was glad to see us and was very happy to see me return with Braveen to Mekele. HayIlom gave us a brief overview of how the Mekele government health centers were organized, information that I hadn’t learned in detail previously during the deworming campaign. We learned that the Mekele city health office had different wings that focused on health promotion and disease prevention, HIV/AIDS, curative and rehabilitation, and regulatory and licensing. There were 8 government health centers that were managed by the Mekele city health office. At these health centers, most of the health services were provided by extension package nurses who focused on delivering basic household and community based health services. Each government health center was run by an administrative heatlh coordinator.

Once we had received this information, we set out to visit our first health center known as Kassech Asfaw health center. Kassech seemed to be the most uptodate government health center in Mekele and we were told that it served as a model for the other health centers in the city. Upon arriving at Kassech, we met with the coordinator of the health center, Etsedingel. Etse was pleased to show us around the health center. The health center offered various facilities including the OPD ward, antenatal care, postnatal care, under age 5 ward, adolescent education and family planning,a lab for stool and urine analysis, a regular pharmacy and an ARV pharmacy, and even an abortion clinic. He told us that the health center currently served a catchment area of about 60,000 people.

The OPD ward was run by 3 or 4 of the health extension package nurses. Even though they don’t have the credentials of a physician, their job entails pretty much everything an OPD general practitioner would be responsible for, including prescribing drugs and ordering services. Any cases that were more emergent or complicated were referred to one of the two government hospitals in Mekele. We shadowed a nurse known as Sister Teverih for the next two days and observed a wide variety of cases.

Most of the people that came to the clinics were from a modest socio-economic status and could not afford to go to a more expensive private clinic for treatment. In addition, services were offered free of charge for HIV patients and pregnant mothers. We observed a wide-variety of patient cases ranging from TB and HIV, to intestinal parasites and with other gastric and respiratory illnesses. A rough tally of OPD diagnoses showed that many patients who visited the health center had upper respiratory disorders such as bronchitis. Among females, there were a high number of digestive and obstetric disorders along with urinary tract infections. The clinic provided two means of testing patients for HIV infection. One was known as PICT or Provider Induced Counseling Test, which was initiated by the health provider, if he/she suspected the patient of having HIV. The other was the VCT or the Voluntary Counseling test, which was initiated by the patient themself. These HIV tests were conducted with a rapid test kit, which used the blood of the patient and provided the results in about 20 minutes. Pregnancy tests were conducted in the OPD and if tested positive, patients were referred to antenatal care and if negative, they were referred to family planning. Some of the interesting cases that we saw during those two days included a young girl who was on ART medication for HIV infection and who also had meningitis, thereby debilitating both her immune and nervous systems. Another was a 75 year elderly woman, who was extremely weak and atrophied. She had abdominal distension, 3rd degree edema or extensive swelling of her leg, diarrhea, arrhythmic heart murmur and an enlarged liver. It was astonishing that she was still managing to stand on her two feet, albeit with the help of her sister. Nurse Teverih referred her for admission at one of the government health hospitals.

During the time we spent at the health center, we had noticed a Red Cross ambulance that was responsible for transporting emergency cases from Kassech and other government health centers to either Ayder or Mekele hospital. We decided it would be a neat experience to go on rounds with the ambulance and to get a better understanding of how emergency medicine functioned in Mekele. We met with the emergency coordinator at the Red Cross Office in Mekele, which is affiliated with the International Committee of the Red Cross. His name was Grimay and he told us that the Red Cross Ambulatory services were provided in Mekele with one ambulance that had a rotation of 3 drivers. Services were targeted around a 24 km radius from the center of the city that reached approximately 90% of Mekele’s 250,000 population. During the afternoon, we joined the ambulance driver known as Akililu and a young volunteer known as Samson, who became our guide and information source during the entire ride. The whole experience can be summed up as an adrenaline pumped thrill ride. We had to drive at top speeds across the unruly roads and streets of Mekele, which had little to no traffic regulations in the first place. In addition, the sites we travelled to transport patients included prisons. For one of these prisons, we actually got to go inside the prison compound to carry out the patient who had been involved in a fight with another jail mate. Another one of the prisons we visited was a high security one located farther on the outskirts of the city. There were also some other emergency cases of delivery, which we transported to either the nearest hospital or health center.

The following week, we spent most of our time shadowing at Ayder hospital. This time, we mostly focused on the male side of the Internal Medicine Unit and the Infectious Diseases unit, which contained mostly visceral leishmanias cases. Dr. Malako, the chief Internist on the male side and who did the bedside teachings for medical students, was an extremely young guy for his position. He seemed to be a walking encyclopedia of medical information. Unlike the female section of Internal medicine, the male side had more patients with HIV and other co-infections like TB, bronchitis, PCP, meningitis, and DVT. One of the patients we saw had the latter two illnesses, along with an inhibited immune system from HIV infection. In the visceral leishmaniasis unit, we learned from Dr. Malako that most cases originated from the north-western area of Ethiopia, close to the Sudan border where the vector of transmission, the sandfly was more endemic. Patients with leishmaniasis presented an enlarged spleen along with other symptoms of high grade fever, weight loss, anemia, and loss of appetite. The parasite also has the ability to infiltrate the bone marrow and to reduce the production of red blood and white blood cells. Thus, results can be quite deadly,if a leishmaniasis patient is already co-infected with a disease like HIV/AIDS that heavily suppresses the immune system. Leishmaniasis can have a case mortality as high as 100 %, if not treated adequately at the right time. However, if treated early, mortality is low as 5%. Although the primary focus of our project this summer has revolved around deworming and eradication efforts against the soil-transmitted helminth NTDs, it was interesting to observe these patient cases of leishmaniasis and to learn about the complications that another NTD like leishmaniasis presented in these resource poor settings.

We also spent one day in the OR back with my old guide, Dr. Grimay. We observed two procedures that day. The first was the removal of a hydadic cyst located on the liver wall of a patient. The procedure consisted of draining out the inner layer of the double-walled cyst with the insertion of a tube. On the second procedure, we watched Dr. Grimay perform a procedure in his specialty of thoracic and vascular surgery, known as Thoracotomy. He operated on a patient who was stabbed in the chest and had a hematoma consisting of tangled, dead fibrous tissue that had accumulated around the wound site. It’s quite amazing to see the range of surgeries that a specialist like Dr. Grimary performs on any regular day. This may include something as minor as removing a tiny object imbedded deep in the ears of a young girl, a procedure which we saw him do at the end of the day, on the spot with the help of some local anesthesia.

On Monday of that week, we finally gathered our two carton supply of 20,000 praziquantel from the office of Aberash Abhay, who is the primary coordinator of the Millenium Development Initiatve run by Columbia University here in Mekele. Millenium Development Initiative had donated the drugs for the distribution in Zuwai.

It has been a refreshing experience to be back in Mekele, this time with Braveen. During the last few days, we had to say multiple good-byes and in the process drink multiple cups of tea. Having come here now two times, the city has almost become like a home to me. The simplicity, kindness, and generosity of the people here constantly amaze me. I hope that I receive the chance to return here again as a physician and serve the needy and ill populations in this area.

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