Medicine in Ethiopia
I've been meaning to write a post on this topic for a while, but it's a daunting subject. Expect revisions to come!
To understand the practice of medicine in Ethiopia, you first have to understand the country's condition. My take - Ethiopia has been in the dark for the last 30 years and is now trying to match modern innovations with the old technology/infrastructure. This feeling is prevalent everywhere in the country, from the Mission, to the internet cafes, to the hospitals, and the banks. They build 10 story buildings, but the scaffolding is made from tree branches 20 feet long nailed together, not a single one thicker than my arm, and some as crooked as a question mark; it sways in the wind and it's amazing that it stands up at all. Internet cafes are everywhere with brand new computers, but internet no faster than 40 kbps (slower than old dial-up). Government officials drive brand new Cadillac Escalades but there are holes in the street 2 feet deep. MRI's and CT scans are available, but too expensive for most people to get. If they install a pacemaker in a patient in this country, I'd expect it to come with a hand crank. In addition, the government bureaucracy/corruption is so rampant and convoluted that there is very little foreign investment. In general, most people seem to be very unhappy with the current government (in power for the last 15 yrs) and the rules that are passed every day ensure their continued rule (jailing opposition leaders, rigging the election board, etc.). For one example, the Health Minister, who has held the position for 2 yrs, made his first visit to Yekatit Hospital on Monday (Africa's best burn unit and one of less than 20 public hospitals in the city). The sentiment seems to be constant between all of the Ethiopians I've talked to (Dr's, nurses, avg. citizens) and I think it's because this government isn't getting much done. Unemployment is >60% and basic services are sub-par to say the least.
It is into this landscape that medicine fits. My take - The general attitude is that medical care is a privilege, not a right. Seeing a doctor is the privilege of those only with enough money, enough pain, or disability to seek out their services. As I've said before, most of the things we see are late-stage infections, cancers, and injuries that have been neglected for years and years and only when they are the size of footballs and draining fluid do they go to see a doctor. A part of this is also that often if people do go to see a doctor, MD's here either will tell the patient that there is nothing they can do to help, give insufficient care, or give the wrong, harmful care - the best example of this is a college chemistry professor who developed TB, then b/c his Dr. only had 2 of the 4 drugs, took only those two and developed Multi-Drug Resistant TB; much more severe and harder to treat.
Add to these incompetent doctors the widespread beliefs in holy water and traditional healing and you have a holy mess. One boy presented in the mission with multiple lesions and sores on his back and legs. When the father was asked what treatment the boy had been given, he said holy water. The first well wasn't good water, but the new well is very good. "Has he been getting better?" "No" "Have any new sores opened up or did these all open at the same time?" "The holy water is inside his body looking for the disease and that's why the new sores are opening, so the disease can leave" Oy-Vey (wow...almost got attacked by a stray chicken that waltzed into the cafe and made to peck my eyes out; one more thing to worry about now - killer chickens). The holy water boy has progressive paralysis and now can't leave his bed. Nearly everyone who comes has first visited a holy well of some kind. The uvula (the dingaling that hangs in the back of the throat) is often cut out of babies when they are just weeks old, by a traditional healer of course, because the common belief is that if you have a sore throat, the uvula will get stuck in your throat and cause you to suffocate...crazy?!
And then there is Rick. Rick's medicine is a double-edged sword. Many of the treatments he gives to his most complicated patients have never been tried on humans before; they work in vitro and in animals. Often his patients are the first people in the world to try these regimens, often with great success. Exciting isn't the right word, but Rick's medicine is on the cutting edge of medical discovery and his treatments could be considered pioneer in many cases. In the past, doctors have criticized him for his "irresponsible" tactics and his aggressive treatments - there was one study where adults took small doses of a new drug and nearly 100% of them were cured; Rick gave a stronger dose for a longer period of time to one of his child patients who then made a miraculous recovery and when Rick wrote to the author of the study, he was scolded in response. The justification for the risks taken is that these patients will die without treatment for sure and if the only way to possibly save them is by trying new theoretical cures, Rick is willing to do it. A possible cure is better than giving up. I don't know if any of his methods have had adverse results but he has saved many patients from the cusp of death and restored them to full or near-full health. The other side of this sword is that it is very easy to forget that these patients are people and not just medical anomalies; sometimes this isn't so easy, but I have never seen Rick forget this and he goes out of his way to humanize his patients, especially when sending their cases to other MD's for opinions (he always includes a picture of the patient's face first). Unless things go drastically wrong, the risk of a lawsuit is close to nil and oversight of any kind is negligible. As terrible as it sounds, Africa is an amazing place to come and "practice" medicine. The things you see are often textbook cases, the freedom to treat as you wish is apparent, and the downside legally doesn't exist. It is easy to imagine a maverick doctor or drug company coming to Africa to test new treatments (I know it's been done but don't know the details...check out the book The Bodysnatchers). Rick is not a maverick for his treatments should all work in theory and without any treatment his patients would surely die. As with nearly all medical practices here, they would be condemned in the US (sterility, safety precautions, and cleanliness are not the reality here), but it fits with my motto:
We do what we reasonably can with what we've got
In the dressing room we have saline solution, hydrogen peroxide, alcohol, iodine/betadine, gauze (folded every afternoon and sterilized overnight) and bandages. A few fancy accoutrement's here and there but this is the foundation. As Rick once said, it's like practicing medicine immediately post-WWII. It's not advanced and it's not perfect but it's better than nothing and considering the alternative of using holy water, it's a major improvement. That is the attitude one must take to practice medicine here. You can't save everyone. You don't have the technology, the money, nor the support to save everyone. Often the care you give is better than nothing but far from good by western standards because you don't have the supplies. Do No Harm is the theme of the day and while you may not be able to do much good, nearly any and every treatment here is better than nothing. It's hard to send a boy on his way with a patch of gauze taped onto his draining, swollen thigh, but then you have to think that if he didn't have that gauze, when he sits down in the street, his open wound would be lying in the dirt. Again, the treatment is far from adequate but it's better than nothing. It's a tough concept to get used to and you quickly find out that you're not superman.
When I first started at the mission, people would ask me if I thought it was depressing. I always answer that if you are just stopping by to sight-see and not to help, yes it's depressing; but if you come to help, it's an exciting feeling walking through the gates and knowing that you will be able to help so many people who need it so desperately.
(update: a side note on the legal issue - A man once walked into the mission with a bleeding, gaping wound sustained in a car crash. Abebe assessed the injury, cleaned the wound, stitched the man up, and sent him on his way. One week later, the patient shows up at the mission with 3 policemen in tow and fingers Abebe as the one who sewed him up. Turns out that he was a government guy of some measure and the policemen questioned Abebe for hours (if not days...tough to tell from his english) demanding to know why he sewed the man up and how he was qualified to do it and other things in that vein. The care Abebe gave was entirely adequate and appropriate but because the man was in government and raised a fuss (I don't know about what), the police came and terrified this nursing student who did everything right. Needless to say, now he's much more hesitant to stitch up walk-in patients)
To understand the practice of medicine in Ethiopia, you first have to understand the country's condition. My take - Ethiopia has been in the dark for the last 30 years and is now trying to match modern innovations with the old technology/infrastructure. This feeling is prevalent everywhere in the country, from the Mission, to the internet cafes, to the hospitals, and the banks. They build 10 story buildings, but the scaffolding is made from tree branches 20 feet long nailed together, not a single one thicker than my arm, and some as crooked as a question mark; it sways in the wind and it's amazing that it stands up at all. Internet cafes are everywhere with brand new computers, but internet no faster than 40 kbps (slower than old dial-up). Government officials drive brand new Cadillac Escalades but there are holes in the street 2 feet deep. MRI's and CT scans are available, but too expensive for most people to get. If they install a pacemaker in a patient in this country, I'd expect it to come with a hand crank. In addition, the government bureaucracy/corruption is so rampant and convoluted that there is very little foreign investment. In general, most people seem to be very unhappy with the current government (in power for the last 15 yrs) and the rules that are passed every day ensure their continued rule (jailing opposition leaders, rigging the election board, etc.). For one example, the Health Minister, who has held the position for 2 yrs, made his first visit to Yekatit Hospital on Monday (Africa's best burn unit and one of less than 20 public hospitals in the city). The sentiment seems to be constant between all of the Ethiopians I've talked to (Dr's, nurses, avg. citizens) and I think it's because this government isn't getting much done. Unemployment is >60% and basic services are sub-par to say the least.
It is into this landscape that medicine fits. My take - The general attitude is that medical care is a privilege, not a right. Seeing a doctor is the privilege of those only with enough money, enough pain, or disability to seek out their services. As I've said before, most of the things we see are late-stage infections, cancers, and injuries that have been neglected for years and years and only when they are the size of footballs and draining fluid do they go to see a doctor. A part of this is also that often if people do go to see a doctor, MD's here either will tell the patient that there is nothing they can do to help, give insufficient care, or give the wrong, harmful care - the best example of this is a college chemistry professor who developed TB, then b/c his Dr. only had 2 of the 4 drugs, took only those two and developed Multi-Drug Resistant TB; much more severe and harder to treat.
Add to these incompetent doctors the widespread beliefs in holy water and traditional healing and you have a holy mess. One boy presented in the mission with multiple lesions and sores on his back and legs. When the father was asked what treatment the boy had been given, he said holy water. The first well wasn't good water, but the new well is very good. "Has he been getting better?" "No" "Have any new sores opened up or did these all open at the same time?" "The holy water is inside his body looking for the disease and that's why the new sores are opening, so the disease can leave" Oy-Vey (wow...almost got attacked by a stray chicken that waltzed into the cafe and made to peck my eyes out; one more thing to worry about now - killer chickens). The holy water boy has progressive paralysis and now can't leave his bed. Nearly everyone who comes has first visited a holy well of some kind. The uvula (the dingaling that hangs in the back of the throat) is often cut out of babies when they are just weeks old, by a traditional healer of course, because the common belief is that if you have a sore throat, the uvula will get stuck in your throat and cause you to suffocate...crazy?!
And then there is Rick. Rick's medicine is a double-edged sword. Many of the treatments he gives to his most complicated patients have never been tried on humans before; they work in vitro and in animals. Often his patients are the first people in the world to try these regimens, often with great success. Exciting isn't the right word, but Rick's medicine is on the cutting edge of medical discovery and his treatments could be considered pioneer in many cases. In the past, doctors have criticized him for his "irresponsible" tactics and his aggressive treatments - there was one study where adults took small doses of a new drug and nearly 100% of them were cured; Rick gave a stronger dose for a longer period of time to one of his child patients who then made a miraculous recovery and when Rick wrote to the author of the study, he was scolded in response. The justification for the risks taken is that these patients will die without treatment for sure and if the only way to possibly save them is by trying new theoretical cures, Rick is willing to do it. A possible cure is better than giving up. I don't know if any of his methods have had adverse results but he has saved many patients from the cusp of death and restored them to full or near-full health. The other side of this sword is that it is very easy to forget that these patients are people and not just medical anomalies; sometimes this isn't so easy, but I have never seen Rick forget this and he goes out of his way to humanize his patients, especially when sending their cases to other MD's for opinions (he always includes a picture of the patient's face first). Unless things go drastically wrong, the risk of a lawsuit is close to nil and oversight of any kind is negligible. As terrible as it sounds, Africa is an amazing place to come and "practice" medicine. The things you see are often textbook cases, the freedom to treat as you wish is apparent, and the downside legally doesn't exist. It is easy to imagine a maverick doctor or drug company coming to Africa to test new treatments (I know it's been done but don't know the details...check out the book The Bodysnatchers). Rick is not a maverick for his treatments should all work in theory and without any treatment his patients would surely die. As with nearly all medical practices here, they would be condemned in the US (sterility, safety precautions, and cleanliness are not the reality here), but it fits with my motto:
We do what we reasonably can with what we've got
In the dressing room we have saline solution, hydrogen peroxide, alcohol, iodine/betadine, gauze (folded every afternoon and sterilized overnight) and bandages. A few fancy accoutrement's here and there but this is the foundation. As Rick once said, it's like practicing medicine immediately post-WWII. It's not advanced and it's not perfect but it's better than nothing and considering the alternative of using holy water, it's a major improvement. That is the attitude one must take to practice medicine here. You can't save everyone. You don't have the technology, the money, nor the support to save everyone. Often the care you give is better than nothing but far from good by western standards because you don't have the supplies. Do No Harm is the theme of the day and while you may not be able to do much good, nearly any and every treatment here is better than nothing. It's hard to send a boy on his way with a patch of gauze taped onto his draining, swollen thigh, but then you have to think that if he didn't have that gauze, when he sits down in the street, his open wound would be lying in the dirt. Again, the treatment is far from adequate but it's better than nothing. It's a tough concept to get used to and you quickly find out that you're not superman.
When I first started at the mission, people would ask me if I thought it was depressing. I always answer that if you are just stopping by to sight-see and not to help, yes it's depressing; but if you come to help, it's an exciting feeling walking through the gates and knowing that you will be able to help so many people who need it so desperately.
(update: a side note on the legal issue - A man once walked into the mission with a bleeding, gaping wound sustained in a car crash. Abebe assessed the injury, cleaned the wound, stitched the man up, and sent him on his way. One week later, the patient shows up at the mission with 3 policemen in tow and fingers Abebe as the one who sewed him up. Turns out that he was a government guy of some measure and the policemen questioned Abebe for hours (if not days...tough to tell from his english) demanding to know why he sewed the man up and how he was qualified to do it and other things in that vein. The care Abebe gave was entirely adequate and appropriate but because the man was in government and raised a fuss (I don't know about what), the police came and terrified this nursing student who did everything right. Needless to say, now he's much more hesitant to stitch up walk-in patients)
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