Coffee is such an essential part of life here that after 8 ½ months I really couldn’t go any longer without writing about it. Coffee is found in many different forms – unroasted beans, roasted beans, ground coffee, flavoured chewing gum, and incense sticks to name a few! The majority of coffee or ‘bunna’ is drunk black from small cups after being prepared in the traditional way.
It is claimed that the origin of coffee is in Ethiopia with legend saying a goat herder from Kaffa (where coffee grows wild) discovered the berries after his goats became excited following eating it. He then took the berries to the monks who threw the beans on the fire calling them the devil’s work. Following smelling the aroma of the roasting beans though they crushed the beans and distilled them in boiling water thus creating coffee. This gave them renewed energy for their holy devotions and the tradition continued.
The coffee ceremony is a routine part of daily life as well as part of all celebrations. It is a way to entertain friends and family, welcome people and celebrate. Only women know how to perform the coffee ceremony. The men don’t have the skill and are often found getting their coffee fix at pop up coffee stalls by the side of the road. You need to make sure that you leave some time free for the full ceremony though as it can take an hour or more to complete.
For the complete ceremony the ceremonial apparatus is arranged on a bed of long scented grasses. First the green coffee beans are roasted over a charcoal fire.
Once they have obtained the colour needed the pan is brought round for everyone to take some of the coffee scented smoke. The beans are placed into a pestle then and pounded by hand into the ground powder (the nurses on the paediatric ward use the modern technology of a food blender for this part!).
The water is placed on the stove to start heating in the traditional coffee pot (jebena) on top of the charcoal. Once it has started to warm the coffee is added. The coffee pots all have a similar design but there are differences in the style in different regions in Ethiopia.
The coffee is allowed to boil over a few times and then returned to the pot before the first cup (awel) is severed. (You need to be quick to say if you want it without sugar as this is added as a standard – sometimes up to 3 spoons into the very small cup.) More water is added to the pot again and it is put onto boil while everyone drinks. The second cup served is called the ‘tona’. Following more boiling the final cup (bereka) is served. This is the mildest cup and least bitter. Chatting, dancing and popcorn or bread accompanies the coffee. Frankincense is also burnt on the charcoal to add to the atmosphere. Once the third cup is completed it is time to go back to the tasks of the day.
And yes, for all those I know at home, I do drink a lot of coffee here in Ethiopia! It’s impossible to refuse and I’m getting to like the taste (although that may be due to the sugar ;))
What have I been spending three out of the last four weekend’s doing? I’ve been training 60 hospital staff (mainly nurses and midwives) on newborn resuscitation and care. Using many different resources I created a two day training course which was delivered with the help of the paediatric masters translating and my fellow volunteers, Romil and Claire, helping with the practical sessions.
The training course is part of the project I’m working on to improve neonatal health. The training on newborn resuscitation on the first day gave people the knowledge and skills needed to resuscitate a baby. Everyone was great at taking part in the sessions, which included resuscitation scenarios – something that was completely foreign to the staff as it is not a teaching method used here. In the UK no training is complete without practice scenarios! We even had proper resuscitation mannequins which moved their chests when effective ventilation breaths were given. These were a mixture of the types we use in the UK and also a special mannequin called a NeoNatalie. These great dolls are blow up resuscitation dolls! They are fabulous to use and a great solution for resuscitation training in many countries.
The second day was for teaching about universal newborn care practice, Kangaroo Mother Care (skin to skin with the mother wrapped in clothes and perfect for keeping babies warm), breastfeeding (everyone needs help and no matter where you are it doesn’t always come automatically to every mother and baby), neonatal sepsis, jaundice and the special care that preterm babies need.
At the end of the course we had practical and written tests. Some difficulties were created as not everyone can read English well and unfortunately I didn’t have a Tigreyan translation. Everyone did well on the practical section of the test and successfully resuscitated a NeoNatalie! The enthusiasm and active participation from everyone involved was fabulous to see. Hopefully the information and skills learnt will be taken back the wards around the hospital and put to good use. As one of the participants commented – “the babies born after this course will have a great advantage.”
I saw an article recently in the British press about the high under five child mortality rate of the UK (www.theguardian.com/society/2014/may/02/uk-child-death-rate-western-europe-health). It caused me to reflect on the differences between child death in the UK and Ethiopia. The UK under five child mortality rate in 2012 was 4.8 per 1000 (30th in the world). This is high compared to other western European countries (Norway’s rate is 2.8 per 1000) and I agree needs to be improved. However for other countries, like Ethiopia, this rate is something to aim for. In 2012 the under five mortality rate in Ethiopia was 68.3 per 1000 (156th in the world). The rate in Ethiopia has fallen dramatically from 204 per 1000 in 1990. A child mortality rate of less than 5 per 1000 is just a dream currently for health professionals working in Ethiopia and other countries round the world.
It is a tragedy when any child dies anywhere in the world. The aim should always be to reduce the number of children dying and examine the causes of deaths so action can be taken. The lower the child mortality rate gets though the more difficult it is to affect it. Ethiopia has taken significant action to try to reduce the under five mortality rate and meet the Millennium Development Goal to reduce the under five mortality by two thirds. It was announced in September last year, not long after I arrived in the country, that the MDG for under five mortality had been achieved. This is fantastic as it makes Ethiopia one of only a handful of countries currently to achieve this MDG.
Behind the headline figures is another story though. Ethiopia is a federation of 9 regions and 2 city administrations. The rate of child mortality varies considerably between each region with some still having an under five mortality rate as high as 169 per 1000 in 2011, while others have a rate as low as 53 per 1000. You also have to look at the age under five of the child when the death occurs. The rate of neonatal deaths is still high. Although child mortality decreased rapidly, neonatal mortality (death in the first month after birth) has not decreased as rapidly. The neonatal mortality rate was 3 per 1000 in the UK in 2012 (34th in the world) compared to 29 per 1000 in Ethiopia (168th in the world). In comparison to the under five mortality rate as a whole the neonatal mortality rate in Ethiopia has decreased by less than half from 54.2 per 1000 in 1990.
Death is more common here but there is always sadness when a child dies. Families mourn their children no matter how old the child is (newborn or older). Just because families often have many children doesn’t meant that life is seen as cheap or not as important because they are only children. It is particularly hard for me when a child dies who I feel that if they had been in the UK I could have done more to save the child’s life.
Events around a death in hospital follow a different pattern here. In the UK resuscitation attempts are prolonged with the family present and kept informed throughout. I found when I arrived that resuscitation was not always attempted for babies and children, although this has improved since my arrival with nurses now attempting resuscitation even if there is no doctor present. The family is often in a different part of the ward and do not always want to be present with the child. After the child dies they are wrapped in white clothes and given to the family for burial. Usually the male relatives will leave the ward with the child and the shovel and pick axe that are kept on the ward. After the child has been buried they return the tools and the family will leave to mourn in private.
There is still plenty to do in Ethiopia that will affect the child mortality rate. Reducing the neonatal mortality rate is a major part of the challenge and one of the reasons that I am working here in Ethiopia is with the aim of establishing a neonatal unit here at Axum St Mary Hospital. The neonatal deaths here occur mainly due to infection or prematurity and low birth weight. Basic care can help a lot of the babies who currently die. Keeping preterm babies warm, making sure they get the right amount of feed to gain weight and supporting their breathing can save a lot of babies who otherwise wouldn’t survive. For infection it is about recognizing a child is sick and starting antibiotics early. Stopping some traditional practices (uvulectomies and use of traditional medicine) that often lead to infection would also help. Education of mothers and families is essential.
Through improving nursing care, giving guidelines for neonatal care, training staff in newborn resuscitation and care, creating a neonatal unit with the equipment needed we hope to help to reduce the neonatal mortality rate here in this small corner of Ethiopia.
Every town in Ethiopia, large and small, has a market day. This is a chance for people to come into the town from rural areas to sell what they have grown and made as well as buy goods that cannot be found locally. Saturday is market day in Axum. Although we don’t need to visit every week it has become a regular trip for my housemates and I. We have our favourite stall that we visit to get our vegetables (some like carrots are only found in the market). The whole shop normally comes to around 40 – 50 birr (which is about £1.50). As well as the vegetables there are many different spices sold (I’ve got no idea what most of them are – labels don’t exist!).
There is a kitchenware section and an ironmonger area, nearby which injera cooker lids are on sale.
With an animal area, a grain area,
a cotton area
and even sometimes an area for wood for your plough!
There are other markets too here. In the centre of the older end of town is the basket market where women gather to sell the injera baskets they have made under an old fig tree. The different colours as well as the time and skill involved to make the baskets is amazing.
Further up into the old town under another fig tree is the firework market. The wood is all transported in by the camels.
On the outside of town is the animal market where you can pick up a donkey, cow, sheep or goat. The chickens are part of the main market in town.
On special religious holidays another market takes place selling crosses, drums, vestments, paintings, bells and books for use as part of the church services.
All in all the markets are full of different sights, sounds and smells, which make them an experience not to be missed. It’s just not the same popping down to the supermarket at home and they are definitely something I’ll miss visiting after I return to the UK.
I had a second visit from my family just before Easter. It was wonderful to see them all and spend time together. I took the opportunity to take a couple of days off and visit another beautiful area of the country with them. We went to see some of the Tigray rock churches, which are in the eastern part of the region. These were unknown by the outside world for a number of years and were built before those in Lalibela on the top of mountains throughout the area. I enjoyed visiting these churches far more than those in Lalibela – they are a treasure unexplored by many who come to Ethiopia.
We stayed at the wonderful Geralta Lodge which has fabulous views across the area.
The first church, Debre Tsion, we went to involved a bit of a climb up. It was well worth it though for the views and also the spectacular church. There were still original wall paintings visible as well as water-damaged pillars on the inside of the church.
The crosses and symbols used show the history of Christianity with Celtic and Maltese crosses present as well as the more traditional cross and local symbols. The main treasure of the church is a fan made in the 15th century. It was brought out by 2 monks and opened up very carefully!
The second church, Abraha Atsbeha, was closer to the road so no real climbing this time. We were lucky enough to arrive at the end of the mass. We crept in to see and hear the congregation and choir of priests for the final chanting. Following the end of mass we explored the church while the people enjoyed a meal together outside the church celebrating the monthly festival of the Saviour of the World.
On the way back to Axum we stopped at Debre Damo, a well known monastery here which is on top of a hill. Thank goodness women aren’t permitted to go up but my brother and father made the trip up and down with a rope tied around their waist!
The rest of the week was spent in Axum with my family exploring the sights and visiting schools while I was working. They did stop by the hospital though and bring a delivery of toys from the kind children of St Joseph’s Primary School, Wetherby. These have been much appreciated by the children and given them something to do while on the ward so thank you very much for your toy donations.
This weekend’s plans were unexpectedly changed at the last minute. We had planned to go and visit friends in Adigrat but that trip was postponed and cleaning of what will be the new neonatal unit at Axum St Mary hospital took place!
After we found out on Friday morning that the painting was due to start that afternoon we had a discussions about how nice it would be if we could clean the rooms first instead of just painting over the dirt – this was deemed to be a good idea. So on Friday both the ward cleaners cleaned a room each and today myself and the other two VSO volunteers working at the hospital went in to do a second scrub down of the walls and floor. We were helped by the two nurses on shift and the head paediatric nurse (wearing his best clothes). It was a great effort by all involved with lots of bleach, scrubbing, and water splashed around.
Below are some pictures of all the activities featuring some of the people who helped out. Also featured is the new sink installed this week at the entrance of the unit for everyone to wash their hands and yes it does work!
The reward at the end of a hard morning’s work – a chocolate covered doughnut from the local pastry shop of course.
I’m now half way through my time in Ethiopia with only 6 months left before I return back to the UK and paediatrics in Yorkshire. The range of cases that I’ve seen since I started working in Axum is very different to what I would normally see in the UK. Some of the cases are the same as the UK, for example gastroenteritis and pneumonia, but others are very different. I’ve learnt a lot about managing different tropical diseases as well as other conditions which are a lot more common here compared to the UK like acute glomerulonephritis. I have become experienced in dealing with children with malnutrition. I know how to clinically diagnose and treat acute rheumatic fever. Children with a haemoglobin of 1.6 g/dL (the normal is about 12) no longer make me panic even when it takes us 3 days to get blood to transfuse the child. I’ve seen too many cases to count of malaria and visceral leishmaniasis. I’ve seen a handful of cases with cutaneous anthrax too (make sure you wear gloves when you examine the lesion is one of the important lessons here). TB and HIV also occur although not as frequently as in other countries. Neonates (babies) make up many of the admission here. The main problem is infection but there is also a lot of premature and low birth weight babies under 2.5kg who get admitted. Without folic acid supplementation of food I have also seen many more cases of spina bifida and encephaloceles in the last 6 months than I saw in 6 years in the UK.
Diagnosis are made using very few tests. We have FBC, urine microscopy and dipsick, blood films and stool exams, some serology tests for some of the infections. Cultures are not available and the only radiology is x-ray and basic ultrasound scans. We don’t have any biochemistry tests for electrolytes or kidney and liver function tests as they are currently non-functional due to a lack of distilled water I’ve been told. Even when results are given often they are repeated as the results from the laboratory are not always accurate. Diagnoses are made based on the history and examination findings with pattern recognition and knowing the epidemiology of, for example, where the malaria and visceral leishmaniasis endemic areas are. It’s frustrating when full histories of patient’s illness and examination aren’t done or recorded by staff as it’s assumed what the problem is from the presenting complaint.
Treatments are limited and everybody gets antibiotics. This depends on what antibiotics are available as there has been a shortage of some of them. There are limits to what can be done in Axum and some cases need to be referred to Mekelle, a town 8 hours away with a large referral hospital, or even to Addis Ababa, the capital. What is difficult is when parents cannot afford this and so a child’s treatment is limited by the cost. Patients have to pay for each nights stay in hospital, any investigations done and any medications needed. A hospital stay can cost families a large proportion of their income. Neonates, HIV related illnesses and malnutrition feeds receive free care at the hospital at least.
Care on the ward is very different. Out of hours there is only 1 doctor for the whole hospital and sadly paediatrics often gets neglected. Nursing staff do not provide the same level as care and monitoring – children get observations done once every 24 hours instead of every 4 hours as in the UK. Even when done abnormal observations are not acted on often. It is upsetting to think that with more regular observations and if action was taken when they are abnormal more children may survive.
I have learnt a lot working with a lot fewer resources than I’m used to in what can be a very difficult environment. My clinical knowledge has increased and I don’t feel the lack of all the extensive tests that I could do in the UK apart from on a few occasions. There are frustrations when I know that with the care and resources available in the UK that a patient could have survived but here they do not. Although there are faults with the NHS we are lucky in the UK to have access to free at the point of care healthcare where you get whatever tests and treatments you need no matter what the cost with round the clock care from dedicated doctors and nurses.