Reflections

New technology for the Emergency Room is now in use.

I first visited Tikur Anbessa Hospital one year ago to work with colleagues from the hospital and Addis Ababa University.  My partners are exchange fellows with UW-Madison, and we are working together to develop healthcare quality improvement efforts in the hospital.  These are some of the most talented and well-trained health professionals  in the country, and I have had the privilege of  collaborating with them through shared work and study in both Madison and Addis for the past two years.

The Hospital, whose name means Black Lion in English, is a large public hospital and faces the problems you would expect in a sprawling African city with a high rate of traffic accidents.  This hospital receives those trauma patients, and serves as a referral hospital for the more difficult cases seen in other hospitals, ranging from emergency obstetrics, to pediatrics, to multi-drug resistant tuberculosis to HIV/AIDS, to advanced cancers.  So just about everything is happening here….

There are visible changes since my last visit.  Last year the pediatric emergency ward was really in disrepair and creating very challenging con!ditions for health care providers, patients and their caretakers.  There was talk that a new pediatric  was in the works.  As several people described it to me,  I looked at that patch of ground they were pointing at, trying to imagine the new building, and worrying that this “six month” project might take years…. Well, the good news is it did not take years!  I peered into the windows this afternoon!  It is nearly finished with the ribbon cutting soon (maybe this week?) and patients will be moved from the temporary ward early in 2012.

A 24 hour pharmacy is now in place in the ER.

The other wonderful development was hearing about how the QI program is moving forward and maturing.  There was no building to point to, but as I sat at the table with my colleagues, who shared their successes and honest appraisal of the things that had not worked, and how they would keep trying new strategies,  I realized that the reality of what they had  “built,” terms of improved care was just as impressive.  They have developed and implemented a functional triage system and are sharing it with other hospitals.  They have made huge strides in infection control.  While we can’t see the cases of infection that have been prevented (always a problem for successful prevention programs!),  the cleanliness is evident on the wards in the adult emergency room, and plans are in place to replicate this in the new pediatric emergency ward.  They are also improving drug distribution in the hospital (imagine yourself in one of the beds and then think more effective treatment and better pain management), and are improving a number of registration systems that will lay the foundation for better information for case management and planning at the ward and hospital level.  In addition to all the projects, they have developed their own capacity to train others and, appropriate to their role as a national teaching hospital,  they are looking toward sharing experience and skills with other hospitals around the country.

One of the really special aspects of this project is that it is a Twinning Program, (see www.twinningagainstAIDS.org),  which means that we work through mutual partnerships and exchange.  It is  really joyful to walk the grounds of the hospital, and see the familiar faces of the fellows who have shared experiences with us in Madison.  In addition to being part of the valuable medical exchange,  we have walked the Lakeshore Path together, and some have visited my home.  During one visit the  fellows experienced snow, and another visit coincided perfectly with the peak of tulip season, so we skipped out of class to visit a local tulip garden!  This week  I am on the other side of the Twinning the equation– in my visits to Ethiopia I have begun to experience the beauty and hospitality and incredible history of this country, and I hope to return many times myself, and with my family.

Everyone gets their daily fix of hope and inspiration in a different way I guess, but for me today it came from revisiting this hospital, and seeing what is needed, what is happening, and what is possible.  It was a visceral  reminder to me that small changes matter. Perhaps we don’t have to develop complex   plans  to  “scale up change.”  I don’t want to scrap that idea entirely because it is the  topic of the talk I am supposed to give at the ICASA Conference next week (!), but I am beginning to believe that the most important thing we can do is to let the reality and possibility of the tangible changes that are within our reach capture our imaginations, befriend us, get out of control, and enable us to work together to change the world around us.

I will be heading off to Ethiopia the day after Thanksgiving to do some teaching for the American International Health Alliance (AIHA).  That should be an interesting exchange related to quality improvement in health care, and I will be working with partners from Ethiopia.

I am also going to attend the 16th Annual Conference on AIDS and STDS in Africa (ICASA).  I”ll be involved in two sessions, one about quality of care and one about care for orphans and vulnerable children. I expect to learn a lot about HIV/AIDS and the most current issues and challenges.  (See ICASA website http://www.icasa2011addis.org).

While in Addis I have also arranged to visit some sites related to my work with Save the Children.  I’d like to identify a community to participate in the Wisconsin Without Borders Marketplace.  The hope is that we can support a community micro-enterprise effort designed to benefit vulnerable children (due to AIDS or other causes) by buying and reselling their products — scarves, jewlery, baskets — these are some of the crafts that I expect to find.

A few friends and students have suggested that I cover my field work and the conference on my blog www.globalhealthreflections.wordpress.com  so that I can share what I am learning with the UW community, especially our growing community of global health students. Please feel free to visit and see my posts about previous trips to Ethiopia.  And sign up to follow the blog if you want to get updates by email!

Ethiopian Masinko and other Traditional Instruments

I made it home from Ethiopia yesterday. It was a wonderful trip in so many ways.  I was so busy and with the time change and limited internet access I did not have a chance to write the usual news from the field to family and friends so I thought I would do so here now while everything is fresh in my mind.

I have been to Ethiopia before, so I had a good sense of what to expect and I knew it was a very interesting and hospitable culture.  However,  all the good expectations were doubled by the fact that I already knew 8 of the Ethiopian colleagues that we were working with since they had had fellowships at UW, and because the QA advisor working with me, Roman Aydiko, a UW-Madison student who I really enjoy working with, is from Ethiopia herself.  We trained 60 hospital leaders in quality improvement and followed up on 8 projects that were already underway. There has been good progress on all the projects but two have been very successful, one related to infection control (improvement from 33% to 69%)  and one related to fully implementing triage (from less than 10% to 100%).

The Black Lion Hospital is the largest hospital in the country, and serves the most serious cases and has the most active emergency department.  We are working with the emergency department and the pediatric emergency departments in particular.  During my first day I visited those wards which I have been hearing about for months.  I think you can imagine that visiting these sites is a powerful experience, with such serious resource limitations and lines of patients hoping to get care.  The health care providers are among the most talented people in the country –chosen for medicine because of their intellectual abilities.  It is hard to see them struggle to provide care in a ward where water systems for basic sanitation are not always working and there are shortages of basics like sheets, gloves, face masks, etc.  Roman and I brought 4 suitcases full of sheets and gloves and masks and hand sanitizer as a gesture of solidarity.  We thought this made sense because we know the hospital is working to get these things in place so jump starting them on something like sheets helps — they can manage replacement as they wear out etc.  We also brought scrubs which they were delighted with because they can use them as uniforms.  It was a very joyful thing for us to give them things that we know will be put to immediate use.

In addition to working very hard I got a chance to get a feel for Addis Ababa.  I went shopping and really enjoyed buying some beautiful scarves, wonderful Ethiopian coffee, and a drum and masinko — two traditional instruments.  I also visited the national catherdral and an old orthodox church.  Spent time strolling around Addis which is a really nice African City — so much that is ancient right along side modern buildings and city bustle.   In addition to eating great Ethiopian food every day at lunch time we also went to a traditional ethiopian restaurant that had all kinds of cultural dancing going on during dinner.  I loved the food and music and dancing!

The other wonderful and unexpected aspect of my trip was that two very good friends from the DC area  happened to be there.  Tessie and I had worked together and spent lots of time together when our children (now in high school) were babies.  Marie Eve and I had shared some very important work related to vulnerable children but we had lost touch -what a gift to reconnect with her.   She is now working for Save the Children and we enjoyed reconnecting as friends.  She, Tessie and I are hoping and planning to do more work for vulnerable children together  in the near future.

There were extremes to digest in all this as you can imagine.  It was quite something to be working in solidarity with the mothers in line at the pediatric ER by day, and dining at the what is reputed to be the best Italian restaurant outside of Italy with old friends in the evening!

One thing that has always bothered me about development assistant projects (and I have worked on many) is the way the money flows, as they are very strict about procuring items on the local economy, yet they give very generous allowances for hotels and lodging.  I decided to deal with this by using the food allowance for a local cause, and then I can buy my own food, which I would have had to do at home anyway.  A girl’s gotta eat, right?   I shared my plan with Roman who, through her Ethiopian network, knew a very worthy young man who is trying to get funds together to pursue a masters in development with a focus on environmental sustainability.   He is very smart but “behind” some of his peers because he had to help raise his 8 siblings before he could consider this.  He still has lots of family responsibilities, but is getting started with his studies.  I am using the food money that I got for the week to help him out (in installments with reports from him) and I am also going to find him an academic buddy at UW who has similar interests. We met twice during my visit and he is so appreciative of the help and so hard working and deserving. And the only cost to me is a cleaner (but not totally clean) conscience about how development assistance money is used.

This trip was full of things that I expected and I did not expect, both named and unnamed here.  I am considering it a message from the universe about my life and what I am doing and what I should be doing.  Unfortunately, I cannot actually decipher the scroll in my hand !   I am hoping that continued reflection and finding the right balance between planning  and being open to life will help me find out what it all means …

It was great to get home where job one is to decorate for Christmas and make a big pile of potato gnocci for my family!

Based on email December 2010.