The Unbreakable Spirit

On Sunday of the week we returned to Mekele, Braveen, Mohammad and I decided to go do some sight-seeing and visit the rock churches located in Abreha Atse-Beha. Ethiopia is well known for its rock churches, many of which are located in the Tigray region and since Atse-Beha was the closest one, we thought it most convenient to visit that one. Everything seemed to be going according to plan as we set off from Mekele. We got on our mini-bus taxi and arrived at a town called Wukro, located about 45 minutes away from Mekele. We got off at Wukro to take our next bus to Atse-Beha. From here-on, things didn’t really happen as we imagined. We were told to wait for the next bus to Atse-Beha, but we had no idea that the wait would take about 2 hours. When a bus did finally arrive, we were too late to get on it as it filled up instantly. We waited for about another 30 minutes, until the next bus going towards our destination arrived. This bus was larger than the mini-bus we had missed earlier and we were sure that we would soon be arriving at our destination in no time. Of course, we were wrong. The bus did not completely fill up as the conductor wanted. After a few minutes of sitting around, he asked Braveen and I whether we could pay for the remainder of about 6 seats in addition to our own. Each seat is about 5 birr and we flatly refused. Looking back on it, we probably should have taken up on his offer, as we had to sit around in that bus for another hour and a half for it to be completely filled up. When we finally set out, the conductor asked the driver to stop at random sites along the way in order to continue filling the bus to maximum capacity. It soon became cramped as some people were squished together along the aisle for about 15 km. Since we had seats, the journey was relatively comfortable for us. When we arrived at the destination, we looked around and I saw a rock church located a short distance away. I had originally imagined the place to be filled with rock churches and caves with built-in churches like the ones one would find in Geralta. However, Mohammad informed us at the present moment that there were only about two rock churches in this small country-side town. We were immediately escorted by a guy, who spoke some broken English and who seemed to be keen on being our guide to the church. He said he was from Wukro and that he was an accountant at a health office located in Atse-Beha. The church was located on top of a rocky mountain and once we summitted the steps made from the mountain rock, we gained a good view of the entire countryside surrounding the church. When we entered through the church gate, we saw the small white entrance of the church building that had been built into the rest of the church building extending into the mountain rock. Once we had paid the entrance fee, about a 100 birr for foreigners and free for residents, we saw the inside of the church. The entrance of the church had walls that were filled with all different sorts of paintings. Deeper into the church, we saw different columns extending up onto the roof which had been built to support the church against the mountain rock. Our guide told us that there were about 41 columns in total and some of them had the shapes of crosses. He also told us that the church had been built around the 4^th century during the time of two kings known as Abreha and Atse-Beha. On a colorful painting positioned against the wall, we saw the images of in a colorful painting the two kings and the priest who had played a key role in baptizing the kings and establishing the church. I saw two doors located on each side of the far wall and I was told that they were prayer rooms that could only be entered by the priest. After we had viewed the church, we set out back to the country-side where our bus had stopped and moved on. Once we arrived at the stop, we were at a loss of what to do as no-one knew when the next bus would arrive and our guide told us that it would be best to wait at a nearby café. The cafe was round and had a continuous round stone seat that was covered with sheep/goat skin. Although it was lunchtime, there wasn’t much to eat so we just had some soft drinks and watched the English movie that was playing on the TV.

About 20 minutes later, we heard the sound of the bus going past our café and we rushed outside the café to get it. The driver refused to take us on at that location. We decided that it would be better to move on and to start walking so that we could at least take the next bus. When we arrived near the bus stop, we saw the same bus that had refused to let us in taking on passengers, so we sprinted flat out for about 100 m. The bus seemed to be packed and I was reluctant to get on. However, it seemed like the only bus that would be going back from that town for that day and so we had to find some way to get on. After much hassling with the conductor, at one point during which Braveen shouted that he would be willing to pay the conductor 100 birr to just let us in, we were finally squished in with the rest of the passengers onto the aisle. The conductor still added on a couple of passengers and soon I found myself squished and pressed from all sides by a sea of bodies. I was standing on the steps, right next to the entrance of the door and I pretty much stood on one foot for the entire journey. At times, there was a good shortage of fresh air to breathe, but we somehow hung on for about 30 minutes.

On any other day, I would be terribly irritated and angry about the whole affair of having to stand for more than half-an hour on this cramped and sweaty bus-ride, jostled and pushed from all sides by unknown persons. However, sometimes it might be a simple bus-ride like the one I just described above that can jolt you back to your reality. Only earlier that day had I re-read a small passage written by Dr. Rachel Remen that I had originally read back in May during my Duke Engage Academy training. The essay talked about the difference between helping/fixing and serving. One of the key points she makes is that when someone is helping someone or fixing something for someone, there is a sense of inequality and judgment. One is aware of his/her own strength while one is helping/fixing and this in turn creates an “inequality of expertise that can easily become a moral distance.” However, she goes on to say that “we cannot serve at a distance. We can only serve that to which we are profoundly connected, that to which we are willing to touch.” During the first few minutes of standing on foot on that tightly cramped bus, I was fighting and struggling with all my strength to get my own share of space and breath of fresh air. I didn’t want my hair to be touched and I didn’t really want to be pushed. I didn’t really care what was happening to anybody beside me or how they were feeling. All that I really wanted was to be comfortable. After a while, I just gave in. I realized that my very own attempt to get a better footing above others, who were as equally cramped and pushed, was due to my inbred belief that I was better than the others who were surrounding me. Here was I, a foreign student from the U.S., who had left the comforts and pleasures of his home and family all for the cause of helping the very people between whom I was now being cramped between and being given no respect. I thought I deserved better. But why? I soon realized that I was doing the very same thing that Dr. Remen had mentioned in her essay about the difference between helping and serving. I had sort of created a moral distance between the people I was supposed to serve and myself. While I was eager for any opportunity that would be related to our deworming project or that would help better educate us about health-care delivery in these settings, I didn’t really want to share in the daily struggles of these very same people. I was living in a good hotel that had a good shower, a comfortable bed, and an easily accessible restaurant. I still hadn’t really felt what it would be like to live and share in the struggles of the common people in Ethiopia. Only now was I beginning to realize this. Experiencing the struggle on that bus made me realize that for many simple Ethiopians, this was a common form of transportation. If you’re living in a rural village that has no real connection to any of the modern comforts one can find in a city, this was how life worked. I felt quite grateful for the blessings of transportation and other comforts I have in my life.

Travelling across Ethiopian roads by bus is not one of the most pleasant things one can do. The bus often travels uphill on steep mountain roads that are quite curvy and narrow. Standing close to the cramped entrance, I thought at times that it wouldn’t be too hard for the bus too simply tip over the edge during one of its sharp turns due to the large amount of weight the bus was bearing. However, I didn’t really feel any great fear. It’s odd how fear can become a desensitized concept when one has to adapt to an environment filled with struggle and strife. I recalled Gandhi’s quote about how even if the British were successful in destroying everything he held dear and even in having his dead body, they would never capture his obedience. It was this very unbreakable spirit, the willingness to never give up in the face of adversity and to face the challenges of the world with an unfathomable resilience, that I saw in the people on that bus. Although they didn’t have much and struggled to live, they saw life for what it truly was and faced it. They didn’t hold any obscure fantasies or try to mold life into the way they wanted to see it. Rather they lived and faced reality with a sense of calm and of simple happiness.

Once again, it’s odd how one simple bus ride can open your eyes to many things. In the Western world, we are often enclosed in a sphere of fast-paced life. Often times, we take on more baggage in the form of stress than we are meant to bear. We become so strung up with the course of our fast-paced life that we are prone to quick moments of anger and irritation, if something is not going according to plan or something is taking too long to accomplish. Traveling through the countryside on that bus, you begin to learn how to find peace or in Braveen’s terms “chill” amidst those moments of anger and irritation. I’ve slowly been learning this very important concept through the course of the summer. Patience doesn’t spring forth automatically one night, but it takes time and learning to understand the simplicity of life. A wise man once said, “All things under the sun fade, but God is constant.” Holding onto that faith is critical when moments of struggle come up and it often works wonders in calming the inner mind.

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, 3^rd 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.

Defining True Service: Mother Teresa Orphanage

Since our return to Addis from Zuwai, we had a couple of days to rest from our adventurous journey to grass-root Ethiopia. Although I was still feeling the aftershock effects of my illness, mainly in the form of diarrhea, I soon got better after taking one day's dose of Cipro. On Tuesday, our deworming team received the chance to meet with the executive director of Mekedim, Mengestu, an HIV patient himself. Mengestu was responsible for making sure that Mekedim's activities were moving in the direction of fulfilling its vision and goals to fight HIV in the area. Mengestu told us that Mekedim was facing challenges in terms of paying its employees and that the lack of a CD₄ machine in the Mekedim clinic meant that patients had to be referred to the hospital to receive an accurate antibody count. However, progress had been made in the deworming effort, as the number of HIV patients infected with NTDs had decreased from 30 to 15 percent. We thanked him for all the help and cooperation he and his team had provided us in collecting samples and in organizing the volunteers. Due to issues of privacy and stigma, we were unable to go with the Mekedim volunteers house to house to distribute deworming drugs. However, in place of that we got the chance to observe one of Mekedim's physicians, Dr. Dagnachew, treat Mekedim's HIV clients for various illnesses. We learned from Dr. Dagnachew that ART drugs are freely accessible and provided at no cost, but some patients refused to take them due to their belief that they are healthy and that there is no need to take them. We saw one patient who had a HIV induced neurological disorder known as peripheral neuropathy, which was caused by an opportunistic infection known as topoplastic gonde and was associated with the patient constantly shivering his hand. In another case, we saw an example where ART was doing more harm than good. The side effect of an ART drug known as D-40 was causing severe side effects of muscle dystrophy and metabolic disorder in the patient. Dr. Dagnachew, also a senior cancer oncologist at the Blackline hospital in Addis, told us that cancer was a growing problem in the country and is currently more expensive and harder to treat than HIV. In addition, he mentioned that care for the terminally ill was very scarce and that in fact, there is only hospice in the whole of Ethiopia that was located in Addis. There was also a complete absence of soup kitchens and homeless shelters in the country, which explained the constant presence of street beggars in the city.

For the remainder of that week, we volunteered at the Mother Teresa orphanage, also known as the Missionaries of Charity Children's Home. Almost everyone at some point in their life has come across the name Mother Teresa. Many more are well familiar with the inspiring work that she undertook as a missionary in Calcutta, India to combat the violent forces surrounding the most vulnerable and needy populations: the destitute sick. Anytime one comes across one of the thousands of Missionaries of Charities houses for the destitute sick or a Missionaries of Charity orphanage, one can be sure that the experience, however brief it might be will be life changing. Our team received the opportunity to serve at the Missionaries of Charity Orphanage in Addis these past two days. Although I had on a couple of occasions visited a similar type of orphanage run by nuns in Kerala, India with my grandparents where many of the orphans were disabled, this was my first real experience of actually serving at one.

We arrived at the orphanage on the first day, a little late in the afternoon after our Mekedim meeting in the morning and our change of plan for drug distribution. We were immediately greeted by a couple of enthusiastic orphans. They were keen on asking us to either hit a soccer ball with them or push them on the swing. We also saw quite a few Europeans at the location, whom we would soon learn were a Spaniard team that had come to do physical therapy with the disabled kids. There was also a mother and daughter pair from Italy who had also come to serve at the house. After waiting for about half an hour, we finally met the sister in charge of running the orphanage, Sister Joan of Arc. She was a fair white woman, clad in the simple blue and white striped dress pioneered by Mother Teresa and worn by all the Sisters that belonged to the Order of Missionaries of Charity. She was happy to have us there, even though it was only for a couple of days and told us to come around 8:30 the next morning, which is around breakfast time for the kids.

When we arrived at our location the next day, all of the kids had just finished eating breakfast. The Spanish team, which consisted of about 10 or 12 people in total, was helping to feed the kids and in the process of cleaning them up. As we awkwardly stood there, wondering what our next step should be, a really kind and warm voice greeted us. It was a woman by the name of Julia, who apparently seemed to be leading the Spanish team and who told us that we could help cleaning up the kids who had finished eating their breakfast.

Once this was done, those kids who could freely walk and run went out to play soccer or ride on the merry-go round or on the swing, while those kids that were disabled were taken by the Spanish team for physical therapy. I found it really interesting to watch the Spanish volunteers do the therapy and was totally engrossed by the whole affair. At each bed, there was a team of two, one man and a woman. Each pair was doing a series of therapy procedures on a disabled kid that began from the leg up, all the way to the eyes including the upper body and arms. Many of the volunteers were softly singing to their therapeutic subjects, as this also helped in the healing procedure. I was really impressed by how organized and smoothly they carried out the whole procedure. Ever since they were orphaned at a young age, many of these kids had never received adequate physical activity or care. Therefore, their muscles had atrophied and their joints stiffened, which immoblized them from freely moving around.

I spent the whole day alternating from watching the Spanish volunteers carry out the therapy and questioning them about what they were doing, as well as playing soccer and basketball with kids, swinging them on the swing, teaching a couple of them some English, and making new little friends. We got to feed the kids during lunchtime. Although the two kids I tried feeding at first was a failure, as they either didn't want me to feed them or just rejected the food, I was quite successful on the third one, who seemed to be quite hungry and finished his entire bowl of pasta.

One of my new and tiny friends I had made that day was a cute and chubby bald headed kid by the name of Amitu. Although he was restrained constantly to a stroller, he always seemed to be happy and was quite enthused to learn Mary had a little Lamb from me. It was so heart-warming to hear his toddler voice try to repeat ‘little lamb, little lamb’. He also kept on repeating Eya Eya yo and although at first I was a little unsure about what he was trying to say. However, I soon understood that he was asking me to sing Old McDonald had a Farm, after he followed the Eya Eya yo sounds with a long moo. Another one of our little friends, who was equally as cute as Amitu and who was quite eager to say Hello all the time and to play around with us, was Dembelash. Although his mother was alive, she was a patient in the neighboring house for the sick, as she was living with TB. We all came back home after our first day, thoroughly exhausted but truly fulfilled.

On our second day, we arrived around the time when breakfast was finishing up and helped to move the disabled kids for therapy. Next, I went to the classroom where Braveen and Thanurshan were teaching kids some math and I decided that I would spend some time with one of the naughtier kids in the group. It seemed that he had a form of attention deficit disorder. One of the girls signaled to me that he didn't belong in the classroom, as he didn’t know his alphabet and was always up to some mischief. He had a hard time sitting down even for a second and in concentrating on any one task. It seemed that the rest of the kids were happy enough to learn from us and that he was the only presence of chaos in that classroom. After the girl had kicked him out of the classroom, I decided that it was only right that I spent some time trying to educate this outcast among outcasts. My efforts with this kid were comparable to a scene from the movie, the Miracle Worker, except for the fact that this kid wasn't blind and deaf like Helen Keller. I had to use all my strength to keep the kid in one place and from running around the classroom. Even then, he had a hard time listening to me or following the trace of the alphabet A. Eventually I had to give up and helped Dembelash, who was sympathetic with my attempt and jumped onto my lap to learn how to trace the letter A.

Around this time, there was quite a commotion near the compound gate and I saw a couple of the girls in the classroom dash out to join the crowd of mothers and children crowding around a group of sisters that had just arrived. After the commotion had subsided, I went out to meet them and soon to my astonishment I met two sisters from India, one who was actually from my state of Kerala. It fell surreal to speak a few brief moments of Malayalam with her. The other Indian sister was named Sister Deepthi Priya was originally from Calcutta. While she was the superior sister at the house in Mekele, the other sister from Kerala was the superior for the house at Awasa.

After this, I spent some time swinging a couple of kids, but when one fell off from the swing and scraped a good amount of skin right above his right eye, I decided that I had enough of pushing swings and see-saws. I went with one of the sisters to bandage up the kid. After she had given him a lollipop and he had quieted down, I went to watch and learn the therapy procedures from two of the Spanish volunteers. I helped them to stabilize the kids on the mats and held the kids still, while they carried out their procedures and sang their almost never ending list of Spanish songs. Soon, it was lunchtime and after all the kids had been assembled in the dining room, we fed them lunch as we had done the previous day. Again, I was only successful on the third attempt and a little later, I was feeding the very same kid who had fallen off the swing.

In the afternoon, Braveen and I along with another Indian medical student from the U.S., attempted to do the therapy procedures we had watched earlier that day and soon realized that some of these kids were just too stiff to fully carry out the therapy. I also realized that I needed more observation and practice, before I fully learned the complete list of procedures that the Spanish team conducted. I spent the majority of the afternoon as a guard for the Spanish team trying to keep out a couple of the naughty kids, who were keen on disrupting the therapy procedure. One of them was my attention deficit friend from the morning, who once caught with his accomplices, pretended to be disabled and crumbled to the floor. It was quite a tiring yet amusing experience watching one of the kids steal the glove bag from the volunteers, being stopped and then being carried out, only to reappear a few moments later through the easily swingable door through the therapy room.

One of the last, but most heart-felt experiences I had that day was when I had to hold a tiny new baby that had come from another house with the contingent of visiting sisters. I don't think there are enough words to describe the moment, but I realized that just holding that tiny baby and later keeping his attention with a play toy was one that I will treasure. All in all, it was again a most tiring day, but again so fulfilling.

During the weekend, the weather cleared up and was actually sunny enough that the Spanish team decided to move the beds outside and conduct therapy there. This time, I actually received the chance to do some of the therapy procedures. I got to help with the butterfly extension that included moving the arm and leg in one fluid motion, rolling the child on the bed and conducting the finger exercises.

Monday was our last day at the orphanage. We helped as usual with the physical therapy, helping to feed the kids and playing soccer with the kids. We also met with Sister Carmen to see what we could do in the future. She gave us the address to which we could package books, toys and other items for the orphanage. We also received the chance to see the extent to which Missionaries of Charity outreach reached throughout the world. A world map showed that a total of 710 houses existed throughout the world, across 5 different continents. Most of them were in India. We also saw some pictures of sisters, mostly Indian that had been martyred in tough locations such as Sierra Leone and Yemen. Finally, we bid good-bye to the Spanish therapists, the sisters and the children, all of whom we had really gotten attached towards in a span of few days.

Even though I've always had high respect for nuns, my respect for the sisters at the orphanage and the other women who look after these children on a daily basis grew to a new peak. The work that they do is so totally selfless like the very example they follow from Christ. It's perhaps one of the few types of work that one can truly feel a sense of inner peace and calm at the end of the day.

I realized as I left the orphanage that there is quite no other place like that home. It seemed to be in a world of its own. It was a magical place filled with the charming innocence of orphaned kids and with the selfless service of the sisters and the unity of volunteers of all color and race for one common cause: to make the day of an orphaned child a little brighter. Here, there were no wars, except for the occasional, amusing ones with a naughty non-disabled kid pretending to be handicapped in order to get some attention from the assorted team of ferengi volunteers and trying to stop these very same naughty ones from stealing and running away with the physical therapy supplies. Although we returned each day from the orphanage totally exhausted, we always left with a sense of unique satisfaction and fulfillment. I will never quite forget the connections we made with the other volunteers, the sisters, and the children all in the course of service.

Adventures in grass-root Ethiopia: The Road to Southern Ethiopia and Zuwai

On Monday, we set out from Addis on a mini-bus ride to a town called Zuwai, located about 3 hours south-east from Addis. After multiple delays and stops, during which the bus conductor extended our three person seat ride to cramp about 4 people, we finally began the journey. The trip through the country-side was really scenic and beautiful. We flew past endless fields of corn crop and these unique, lanky-looking trees that quite uniquely symbolized Ethiopian grassland scenery. In between the fields, I could see the cone shaped huts of farmers and other stone and brick houses that had clean grass courtyards in front of it. Many of these courtyards were either filled with little kids playing or cattle grazing. All throughout the ride, the roads were sometimes blocked by the odd donkey wandering across the road to look for a fresh grazing patch or a band of crossing cattle.

When we finally arrived at our stop, I looked about our surroundings and realized that no-one from the local health office with whom we were supposed to work with during the week hadn't come to receive us. Herein, began the first of our many impediments. After we regained all our baggage from the bus, we stood around the site not quite sure what our next step should be. I tried calling our local contact and the unpredictable phone network promptly gave me the message that the call could not go through. We decided that we would wait at a nearby hotel until we could get a call through our contact. The closest hotel we saw was one called Hotel Jibril and since it was already lunchtime, we decided to go ahead and get lunch. I ordered a local dish called lamb tibs and although it looked and tasted good at first, I realized half-way through that some of the meat was not cooked well. Right when we were finishing our lunch, we finally met our contacts from the local NGO with whom were doing the deworming campaign. After we booked our rooms at a hotel called Bakkala Molla, which was supposedly the best hotel that the town could offer, we left with our guides to the NGO office.

The NGO is named Rift Valley Children and Women's Development Association (RCWDA). It was established around 1993 and was funded by numerous foreign aid sources including Oxfam and CEMTA. Our guides gave us an orientation about the NGO and its work. We soon learned that RCWDA wasn't just involved with health sector development, but also actively involved in many other development activities. Some of these projects included livelihood promotion through saving and credit programs, and building farm initiatives such as new irrigation canals. Other income generation programs included non-farming activities such as educating women about saving and through a goat-provision scheme that allowed a family to jump start a cattle-raising business, which was then sustained with the family offering one offspring of their cattle to another family. There were also programs that focused on education, especially for those marginalized populations such as women and the poor through implementation of different tutorial programs, school capacity building, and through community meetings that focused on discussions about local programs and teaching the citizens to write letters to local officials. In the health sector, the organization was involved in HIV prevention and outreach programs, building of health posts that provided basic health services at the grassroots level and the deworming project.

We learned from our guides, Segni and Beyen, that Ethiopia is structured on many different levels. The country is split into different regions, which are then divided into different districts known as woredas. Each district has a certain number of peasant associations (PAs) also known as kavales, which are at the heart of grassroot, rural Ethiopia. Zuwai was one of the bigger towns in the Adami Tullu district. While RCWDA's overall development work extended to 43 different kavales in the Adami Tullu district and a couple of kavales in two other districts, our deworming work would only focus on four different kavales in the Adami Tullu district. The deworming project had already made considerable progress, since about 10,000 people had already received albendadazole and praziquantel treatment on two different rounds. Our arrival in Zuwai marked the third follow-up survey and drug distribution phase. Segni and Beyen mentioned that the major challenges facing the drug distribution were delays in getting drugs to the community, lack of materials such as care kits during drug distribution, greater community request from neighboring villages and recurring health behavior of communities that made them susceptible for re-infection.

We began the next day at the RCWDA doing data entry for the KAP surveys of the Mekele school kids and the Mekedim volunteers. Later that morning, Segni and Beyen took us for a sight-seeing tour to various different kavales where different RCWDA initiatives like the irrigation canals had been implemented. The kavales are some of the most scenic and beautiful areas that I've ever come across. One can see acres of green farmlands arranged in neat squares, which are interspersed with the thatch huts of farmers and those lanky-looking trees. There are lots of cattle everywhere, ranging from cart-bearing donkeys and horses to cows, goats and sheep. We were especially impressed with the tiny kids operating the donkey-led carts down the main road, where numerous cars and trucks were speeding by in all directions at all different speeds. As we were driving down the main road, we saw a 1000 hectare private flower garden that was owned by a businessman from the Netherlands, which was adjancent to a winery owned by a German investor. Segni told us that while these investments had helped to create jobs for people, it hadn't done much good for the local markets as most of the products from these initiatives were exported.

Our next stop was at a healthpost in the Anano kavale serving about 9000 people. This very same health post would later become our headquarters for collecting and preparing the stool samples for microscope analysis that week. Here, we had a good conversation with Segni and Beyen and we learned that this rural community health post served people from about four different kavales. It primarily focused on maternal and child health and in providing immunizations, heatlh education, family planning and other essential drugs. It seemed that each health post was staffed by health outreach and prevention workers, but not by any real physician. It could be that at this extreme grass-roots level, physicians would be underpaid and since the government hasn't taken any initiative to increase salary for those serving at the rural level, there was no real incentive for physicians to serve populations in this rural area. At the health-post, treatment was provided for malaria, but other more complicated cases were referred to higher health centers. Braveen asked a really interesting question about HIV testing and they told us that HIV testing wasn't currently provided. In fact, HIV patients were only provided awareness and counseling. Braveen mentioned providing VCT testing, as this is a really cost-effective, fast and accessible method for HIV testing. Braveen also suggested the possibility of providing essential nutrient supplements such as vitamins for mothers and kids. Since malnourishment is a big problem for kids in these areas, implementing such an initiative would be big step in combating this problem. However, the impediment that comes along with implementing any new imitative is the question of funds. When I asked Segni about possible government support, he told me that the government actually takes resources away from NGOs in the form of cars and money. Segni and Beyen mentioned that the other challenges facing provision of community health care included lack of proper waste disposal and latrines. For immunizations, even though 8 different types of vaccines were provided for mother and children every 20 days, the challenge was to get the people in the community to get the complete dosage, as many are nomads and move from one place to the other.

However, there have been many positive improvements. Cooperation between health post workers and traditional healers has led to a reduction in practices like female genital mutilation in the area. Since traditional healers are a very popular source for many of the rural people to receive health care, critical strides have been made in training and educating traditional healers. Now, many are combining modern treatment to their practices.

That evening, we had pizza without cheese for dinner as our waiter told us that cheese hadn't arrived from Addis yet. The dish was good, but later that night I found myself throwing up the remnants of my dinner. I had fallen ill for the first time since I arrived in Ethiopia. It seemed that the stomach bug had finally gotten me the previous night, during which I threw up multiple times and went sleepless. Waking up the next day was a challenge, since I was feeling a shortage of energy that I hadn't felt before and I decided I would just spend the day recovering. At times, I would start to feel better, only to realize that it was short-term as my appetite was still very weak. I would still feel tired the rest of the week.

During the next few days, we spent time traveling to the different kavales (there were four in total from which we were collecting our data). At each of these kavales, which were located deep in the heart of rural Ethiopian farmlands, we received the unique opportunity to see life functioning in a way that some in the western world would still find hard to believe. Here, in one of the kavales known as Woiso, there was the traditional meeting of the elders, where the older men of the village would sit around in a circle discussing matters of importance to the kavale, while the women would sit in a neat line a little further from them. Our deworming team had to get their permission to do the survey work, even though it was just formal as drug distribution had occurred previously. Tradition and culture are so important and again the single most important thing that struck through my mind was the importance of community and family. Here, family isn't just restricted to your immediate bloodline. It extends to all those who are around you and those who are in your sphere of daily life. Maybe it could just be that we were foreigners and these villagers were simply just friendly and kind to us. However, my own observations as I traveled through three completely different regions of Ethiopia show that is not the case. People in this part of the world still retain what we in the western world now read in cultural anthropology texts about Africa's once strong presence of community. An ideal, which was obliterated with the advance of colonialism and now with the advent of modernization. Maybe, it could be the fact that Ethiopia was never colonized, and maybe it could be that in this small kavale, people had yet to see true development. Whatever the case, here one could truly see and sense the presence of community fellowship with every breath.


Although our experience at these kavales collecting stool samples and administering KAP surveys were truly enriching, we did run into some roadblocks. During the talks with our elders at the Woiso kavale, Beyen mentioned to us that the elders feared that some people were re-infected with the parasites despite the past drug distribution, since people were carrying on the practice of eating uncooked meat and other foods. In addition, we didn't have enough pens for all of the people to finish our surveys and many were completing the surveys in groups even though the survey was meant to test the individual's knowledge. However, we did manage to collect the 200 stool samples we needed from all four kavales and we were able to help out with preparing the slides for microscope analysis.

During our last day, Yonat returned to Zuwai from her trip to Mekele with a sizeable mini-van and told us that we would be going with her on a trip to Wondo Genet, also known as Paradise in the local language. Two Israeli girls, one who was a medical student from Israel and the other doing some teaching work with kids in Addis, accompanied us on our journey. The whole trip was so much more relaxing for the three of us, as we no longer had to sit cramped for 3 hours straight. Touring Wondo Genet was amazing. The place is so scenic and doing the hike was quite fun, especially as there was a group of kids who were keen on showing us around and explaining the significance of our surroundings. It wasn’t completely fun though, especially when I had water rush into my shoes as we were crossing a stream. The capstone moment came in the end, when I finally got to take my first real hot shower in days. Wondo Genet has many hot water springs, some of which flowed into an area where they formed a free falling shower.

Looking back on my experience in Zuwai, I feel that it was truly a challenging time since my arrival in Ethiopia. Like the rest of this trip, it was a growing experience, not only in terms of dealing with illness, but also in experiencing the calm simplicity and resilience of the people we served.

Back on the deworming trail

We finally picked up on our deworming work again on Wednesday and the last couple of days have been a replica of the work that I was doing in Mekele, except now it's been expanded to adults and is centered on a NGO named Mekedim. Mekedim is a NGO that is focused on reaching out to the HIV/AIDS population here in Addis and since NTDs are known to be co-endemic with diseases such as HIV, the deworming campaign will go a long way in helping to alleviate some of the already heavy health burden facing these populations.

We began the last couple of days by driving to the Mekedim office and administering KAP surveys and gathering stool samples from the volunteers. Most of the volunteers were mobilized by the Mekedim health staff and many have been part of Mekedim's health outreach in the past. We mostly helped out with labeling the stool cups and ensuring that all of the labeled samples were returned and arranged in order. Next, we went to the parasitology lab located on the Lideta campus of Addis Ababa University. The lab apparently does a lot of Schistosomiasis and NTD work of its own, primarily through research. Since the lab team hadn't arrived yet, I was able to jump right in and show Braveen and Thanurshan the ropes on how to prepare the wet mount slides from the stool samples. They picked up quickly and we prepared all of the wet mount slides that then Jemal analzyed by himself for parasite prevalence. Although here the prevalence of Schistosomiasis mansoni is really low as it's more commonly transmitted through children, we were still able to discover the presence of other infectious parasites such as Ascuriasis, taenia, hookworm, trichurias, S. vermicularis, and S. stronglytis. In addition, we helped to input all the data from the survey work done in the 16 schools in Mekele, which will then be further analyzed for the deworming campaign's impact. The preliminary analysis had showed approximately a 50 percent reduction, but this data will be used for a more detailed and precise analysis as to which schools are showing the most improvement.

This coming week, we will be leaving Addis and travelling to Zuwai, which is one of the more poorer regions in Ethiopia. We get the unique chance of helping to mobilize the volunteers for the survey work there and we are excited and hopeful that this phase of our work will go well. Until next time, goodbye.

Goodbye Mekele, Hello Addis

It's been a week since I arrived here in Addis. My initial afternoon flight from Mekele to Addis was canceled so I got to spend an extra day in the city that I have slightly gotten attached towards. Ethiopian Airlines housed all the passengers in one of the best hotels in the city called Milano and despite the high quality, I got the least amount of sleep that night due to the constant pestilence of a mosquito flying and buzzing around my ears all night. I finally killed it on my third wake-up call and realized that I had only a couple of hours before I had to wake up and depart for my early morning flight. The previous night, I had met with a team that was part of the Himalayan Cataract Project, who were involved in providing mass cataract surgeries to hundreds of blind patients from all around the Tigray region at the Quiha Eye Hospital. Blindness is a huge problem in Mekele and in the surrounding Tigray region and some of it is caused in part by a parasite transmitted NTD called river-blindness. HCP is well-known for its super-efficient cataract procedures that save a whole lot of time and money, procedures that would perhaps cost twice as much to conduct in a Western health-care setting. Apparently, one of the leaders was a Duke graduate by the name of Matt and happened to be in Mekele with a team from the U.S. Therefore, they had organized a mass camp at the hospital that bused hundreds of blind people from all across the Tigray region and provided food and cataract procedures free of charge. The great thing about this project is that the U.S physicians also train the local physicians the techniques of the cataract procedure so that once they leave the local physicians can continue the same work, albeit on a smaller scale. It would be great to see how some of these procedures done, the next time I return to Mekele.

My second arrival at Bole Airport in Addis was so different from my first one. This time around, it was bright and sunny and I was greeted by another one of Jemal's 16 siblings, Suleiman, who worked at the airport. We drove through the city during heavy afternoon traffic and it made me so happy to finally join and catch-up with my good friend and project partner, Braveen. I was just so glad to see him after all my solo time in Mekele and couldn't wait to get started on the next phase of our project. The next day, we were joined by Braveen's cousin from the U.K making our team a total of three. Jemal also joined us that night from Gondar. In addition, Dr. Bentwich, our project sponsor and mentor had sent one of his assistants named Yonat, from Uganda to check up on us and on the current progress of the deworming project.

We spent the first few days mostly exploring the city, making new friends and contacts such as Thwi, a second year medical student in Portland and who co-incidentally was also from Raleigh, NC and was doing research at the Black-line hospital here in Addis. We've also found a good contact in a taxi-driver named Getachew George, who has been great in finding us good taxi deals and in teaching us basic Amharic. The internet here is so much faster and accessible than Mekele and I'm amazed by the other vast differences found between the two cities. In Mekele I had lots of warm sunshine, but here its been constantly raining and is a bit chilly as well. Addis has a lot of taller buildings and is more developed than Mekele, but more polluted and the streets dirtier than the ones in Mekele. However, there are so much more dining options here in Addis as well, including a really good Indian restaurant by the name of Sangam. Foreigners from U.S and Europe also seem to be constantly flooding our hotel. Just the other night, we met a large church team from Texas. We also met a couple from London who was driving all the way to South Africa, quite a challenging task.

All in all, my first few days in Addis have been great and I can’t wait to get started on our deworming campaign in this new setting with our team. I learned much during my time in Mekele and I’m excited to see what new challenges and adventures will face our deworming team these coming weeks.

Week 2 at Ayder

On Monday, I began my shadowing work at the Surgical Unit of Ayder Hospital. I had already been introduced to Dr. Grimay, the chief of surgery, on Friday by Dr. Lulu as I wrapped up my work at Internal Medicine. I was a bit late to the daily morning sessions that each unit holds with its interns to check up on new admissions and to follow-up on exisiting ones. However, the minute I entered, Dr. Grimay paused talking, smiled at me and welcomed me to the session. He also asked me to introduce myself to the interns and I recited the usual details about who I was and what I had come to do. After the session, I followed Dr. Grimay to begin the bedside teaching rounds with first year clinical students. Unlike medical education in the U.S., medical education begins right after grade 12, that is if you're one of the fortunate and intelligent ones to get accepted out of thousands to one of five medical schools in the country. Dr. Grimay, himself was educated in ferengi-land (abroad) in Cuba and Mexico. He is one of the few physicians in the country and the only one in Tigray region that specializes in cardio-thoracic surgery. Perhaps, it's his personality more than his academic and professional accolades that gravitates his students and his patients towards him. Despite his extensive clinical and surgical knowledge, he is humble and patient as he teaches his students and always finds a way to make an otherwise awkward or serious moment for a student into a humorous one. Many of the patients that I saw in the ward were cases of appendicytis that had just gone through appendectomys. There were also many variations of gastro-intestinal obstruction cases, with one of the more serious cases being a patient who had an interocutaneous fistula, which failed to close despite being operated twice. There was nothing left to be done for this patient. There were also some cases of amputation, patients who had severe electrical burns while doing their jobs and with no other surgical option other than contain the spread of the harmful burn effects to other tissues through amputation. Some of these patients were young and it was tough to imagine what kind of a life they would be able to lead without the use of their limbs and hands.

I observed a total of seven procedures the next day at the OR. Despite a lack of the most up-to date surgical technologies that are available in the U.S., the surgeries were quick and went smoothly. One of the three interesting cases I saw that day was a procedure known as patent process vaginalis. This procedure was conducted on a child, who had a right sided hydrocephale, or accumulation of peritoneal fluid on the left side of his testes. This procedure would ligate the vaginalis nerve carrying the fluid to the scrotum to eliminate the hydrocephale. The second procedure was something unique that is now almost rarely performed in the U.S. It was known as a partial thyroidectomy, which was conducted on a patient with goiter and consisted of removing the majority of the enlarged thyroid tissue around the neck. The final and one of the more prolific surgeries conducted that day involved the removal of a large malignant mass that was obstructing the gastro-intestinal system. I thought that the mass they removed during the first case was big, but as they repeated the procedure on another patient, the mass was twice as huge and looked like something you would see in a sci-fi movie. I was surprised by how efficiently the residents and interns worked to wrap up all the procedures by lunchtime.

I spent my last two days in the Pediatric Unit. This was perhaps my favorite unit to shadow and to learn as the interns were so knowledgeable and so friendly that they not only shared all their extensive knowledge about the various cases in their unit, but they allowed me to see and experience the team-work, camaraderie and fun they had with each other in their work. Many of the kids were admitted due to mal-nutrition and anemia and several were only around the age of 1 or 2. Some of the harder cases to observe were young patients who were co-infected with multiple deadly conditions. One of them was a 14 year old boy, who looked like he was around 10 and was co-infected with HIV, TB, and was mal-nutritioned as well. Another patient who was only about 3 years old and already in the most advanced stages of HIV infection was slipping in and out of a coma during the first day I was at the unit. During the second day, she died. This was the first time I was experiencing death of such a young patient with whom only a day earlier I had held her hand and smiled reassuringly at her mother. It made me stop and realize how fragile life is and hearing the mother’s heart-break revealed to me the limits that medicine had in preventing death. Despite this, I was amazed by the humility and clinical knowledge that both the physicians and interns possessed at Ayder Hospital. Even though there was a severe shortage of life-saving drugs and technologies, resources that are so easily accessible to physicians and students in the U.S., the medical students in this resource-poor setting are so rigorously trained and have the capacity to identify, examine, and treat the various challenging cases of their patients.