Monday, 30 April 2012

Ethiopia April 2012: Interactions between The Gulf, Buildings and Health services

I visited Ethiopia to see how Saba and her project for improving the treatment of leprosy reactions was progressing. When i last visited in July 2011 the drugs had only just arrived and she had to negotiate their release from the airport. The study is now in full flow. We had expected difficulty in  recruiting patients for the study on one of the chronic complications of leprosy, erytheme nodosum leprosum but these studies now have recruited enough patients. The other study on type 1 reactions  needs 100 patients and is accruing patients far more slowly. We talked about ways of improving the patient numbers and as well as talking to local referral centres Saba will also do a radio broadcast. Every week there is a half hour broadcast on leprosy on the Addis Ababa station contributed by the leprosy patients association and she will talk about the trials that we are doing. Hopefully this will encourage patients who at sitting at home ill to attend the hospital. 
As soon as I arrived  at the hospital i was shown patients with difficult or unusual problems.  I saw patients with all types of leprosy reaction. Two patients had been on steroids for years but their immune systems are still reacting and their skin was inflamed and their nerves tender.  There is still a steady flow of leprosy patients into the hospital. Diagnosis and treatment of leprosy has been delegated out to the primary health care posts and now we are seeing many patients with advanced leprosy which  suggests that patients are not being diagnosed out in the periphery. I gave a talk on how diagnosis of leprosy is delayed in London and mused on the parallels between Ethiopia and London, in both places health workers need to be aware of the possibility of leprosy. In India new surveys have been done and many undiagnosed patients have been found. I suspect that if we did such surveys in Ethiopia we would also find many patients.  It is going to be a huge challenge for the next twenty years to try and diagnose patients. I can see that the last decades of my work will be concerned with enhancing leprosy diagnosis in different settings.  This partly a result of the premature announcement by WHO in 2004 that leprosy is eliminated s a public health problem. .
I again enjoyed Saba’s warm hospitality. Last time i wrote about the nanny who wanted to go to the Gulf to work. She got a job with a family and went with high hopes. There was then a seven  month silence and then she rang Saba one day. She had a sad tale to tell, she had been treated like a slave, working  18 hours a day with no breaks and she was not paid and imprisoned in the house. Fortunately she escaped, with her passport, and found refuge with helpful Ethiopians.  She now has  another job and is not  back in Ethiopia. I suspect that Saba only heard part of the tale and she was probably sexually abused as well. The new nanny, Alem, is another nice girl, she has just completed her education Alem’s sister who is working in the gulf is warning her not to go there. But the lure of the money in the Arabian Gulf is irresistible for Ethiopians.   Leo is now a fine 18 month old running around everywhere. He loves books and was delighted with the suitcase fo books that i brought from Saba sister here in London.  Less flatteringly he called me nona the Italian for granny. He clearly has a sharp sense of age. 
Addis is booming, with buildings going up everywhere, much of this work is funded by money from The Gulf  notably from Mody, a Ethiopian Saudi and the richest man in Addis . His building sites are badged with green and yellow painted hoardings and much of the town was encased in the Mody colours.  He also imports Filipino workers who work to a higher standard than the Ethiopians, as the poles do in London They also live in dormitories and have a minimal life style. The new Africa Union building is being built by the Chinese.   Mody  built the Sheraton  ten years ago and i was given a ticket for the very glamorous opening with Didi bridgewater singing jazz.  On The edge of town are acres of new six storey condo buildings, in the rain these look oppressive and East German like but In the afternoon these become lively vibrant spaces with all the ground floor being used as shops selling piles of fresh vegetables and newly butchered meat. Boys play football on the larger spaces and people sit on yellow plastic chairs at open air bars.  The nicest ones are painted grey and pink colours which give attractive local colours
We also had some time relaxing and swam in the hot volcanic spring fed pool at The Hilton. The outside air was cold so it was very refreshing. Afterwards we showered in the communal shower and i was surrounded by black voluptuousness and felt very white and stick-like.  We also visited the Taitu hotel ,  a large colonial style building form the 1930’s in the central piazza area. It still has a beautiful large wooden staircase and verandah that will be perfect for a post work drink on another visit. We spent an evening in a jazz venue hearing a group play 60’s style Ethiojazz which fuses jazz and traditional Ethiopian music. The line up was a little reminiscent of Buena vista social club but not quite so old.
I read Peter Gill’s book “Famine and Foreigners,  Ethiopia since Live Aid” and learnt a lot about the repression of democracy in the 2005 election. I had seen how little opposition there was in the 2010 election, this was not surprising because they have been driven overseas by violent repression. The absence of a free press is noticeable, the Ethiopian Daily Herald is clearly a mouth piece for government views and has such a tedious style that I barely stay awake to read about the latest government successes.  Soviet style central planning is still being used here.  In March 2012  DrTedros Ghebreyesus, the Ethiopian minister of health visited LSHTM and enthused over his plans for fast development of the health service. 2,000 new health posts have been established over the last 5 years each serving 25.000 populations. The health workers have many tasks including detecting leprosy, but the patients report that the health posts are often not staffed or the drugs are not available.  The other plan is to train 3000 doctors per year and flood the Horn of Africa with Ethiopian graduates. The difficulty is that no thought has been given to the curriculum or teachers in these new institutions. I met a very lively American trained Ethiopian returnee doc who was part of this programme. He exuded the enthusiasm of youth but i could see that he would probably not be around for troubleshooting in these new institutions.  I wonder what measures of outcome are being used to asses these projects. Alem , the new nanny has eight years of education but is functionally illiterate so the omens are not good.  I also saw signs of totalitarianism, all the hospital staff were taken off the hospital site for a day and a half in which they were harangued by the minister of health over their apparent poor performance of the hospital, attendance was compulsory and Saba was one of the few people left behind to look after the patients. This did not appear to have motivated people in the hospital.
So i had another interesting visit to Addis,  I enjoy staying in Saba’s household and getting  an inside view on Ethiopia. There visible improvements in the country but also worrying signs of repression and democratic development t here looks less likely.

Diana Lockwood
May 2012     

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