Category Archives: Development

Handshakes not handouts

To expand on the comment ‘handshakes not handouts’; it’s a theme that traverses daily life and work here in my little part of Ethiopia. We are told before we come that the major nuisance is ‘verbal hassle although rarely offensive’. On the most part that means children excitedly running at you shouting ‘hello’, ‘ferenji’ and desperately wanting to shake your hand. Unfortunately, some of the older children including school children will shout ‘hello’ and then ‘give me money’ or ‘give me pen’, with a cheeky smile on their faces. Again not particularly offensive, unless you’re nearer the tourist attractions where they can be more persistent. Sadly it’s a learned habit because foreigners do handout money and do handout pens, and while for the most part seemingly innocuous, there are some older children who instead of attending school find it more lucrative to befriend well-meaning ferenji who supply money, pens (which are sold for money), and electronic devices such as laptops (which are again sold for money).

In terms of how this theme transfers to the workplace and the world of NGOs and volunteering was something I did not really understand before arriving here. VSO, the organization I am here with specifically aims to provide trained professionals as the resource to foster sustainable development i.e. VSO will not donate you money to build a hospital but rather give you a trained paediatrician to support your staff and improve systems and care within the hospital that already exists.   After spending some time here and working within the hospital setting, it has become apparent that some feel we would be best placed to simply donate a new building and new equipment, and that as volunteers we are a conduit for cash. I must stress that is not a universal opinion, and many of the fantastic staff I have worked with are delighted to have support and teaching.

Sadly however I think this is not a new phenomenon of foreign input serving as a means of cash flow, and there are preceding decades of examples from developed countries to support the belief by developing countries that the best ways to get things done are via donations. The biggest problem with this is that it bypasses the need to improve the infrastructure of the developing country to provide its own money to support adequate healthcare, to develop systems of reliable medical equipment and maintenance, and indeed make it easier for local medical personnel to access the supplies they need to run their hospitals effectively. After a discussion here with staff I was told that it is preferable to get money and equipment from NGOs as the process via government channels can take up to 2 years and is heavily bureaucratic. If it takes 2 years to obtain specific equipment, then it is not feasible to account for it in planning an annual budget. So are donations doing more harm than good? I don’t know the answer or indeed the solution to that question.

There is certainly an argument to support that donations are best served by research locally into what is required and appropriate within certain institutions. For example, does a hospital which serves 1.5 million population, has some beds in a tent due to overflow, no cardiac monitoring, not enough midwives to attend C-sections and no paediatric doctors really need a digitalized X-ray system which can only be accessed in the outpatient department? But if that’s what the money is donated for, then that’s what’s going to happen.

Since being here I have had a lot of time to read about the history of aid and development, and in particular the growing body of literature on why aid is no longer working. Dambisa Moyo (Zambian female economist) writes in “Dead Aid…” that aid is no longer working in Africa, that is promoting a culture of dependency and lack of development, and suggests different economic solutions to the problems in Africa, first of which is placing a time limit on aid and giving say 5 years to a country to sort out its finances and plan for withdrawal of aid over a set time period. She quotes figures stating that 97% of Ethiopia’s government budget comes from aid. The original argument for aid is based on the success of the Marshall Plan after the Second World War providing assistance to Europe. This example is entirely different from the situation in many African countries today as in Europe at that time there was infrastructure and a skilled workforce, which simply needed assistance to repair. In a number of African countries, they are requiring complete development, including adequate governance and infrastructure; and that’s why simply throwing money at the problem isn’t working.

Despite reading into the subject, I don’t believe all aid should be stopped, particularly in humanitarian emergencies; I believe aid still has a role to play. Again I don’t know the best solution or indeed whether we should stop donating entirely as it is always the poorest who suffer most from lack of resources. But I do know something needs to change and that development of independence and infrastructure will be the key to success.


12 Steps to Saving Mothers Lives (How to organize a training course in Ethiopia)

LunchDiscussing maternal mortalitySurgical Staff

One of the midwives demonstrating CPR in obstetrics
One of the midwives demonstrating CPR in obstetrics

So this blog post might give you a bit of an idea of what kind of work I’m up to here in Ethiopia. Training is probably my favourite part as the staff are really keen to learn and you feel like you might actually be doing something. As this post shows however there’s not a lot of glamour or life-affirming work, but I’m getting really good at admin and negotiation, skills I hope to promote in my next job interview…

  1. Identify topic for training – Note this may not necessarily be anything you have specialized knowledge in, but ultimately is determined by where the funding comes from (maternal and neonatal health being particularly donation-laden causes). Once you start researching however, you realize that the main themes for improvement are essentially the same in any area of healthcare: patient education, communication and good basic nursing and medical care.
  2. Prepare lectures – the main consideration here is how best to adapt the language for non-english speakers, some of the staff here despite completing their degrees in English, cannot speak English. Thankfully there is always someone on hand to translate; but I am always concerned when they ‘translate’ and there is laughter, particularly when I never made any jokes.
  3. Identify staff you wish to train – this is a trade off between whom you want to train (who you think will benefit most from the training due to their role), and whom the hospital management thinks should be trained (depends on who they will pay for and who is not too busy with clinical duties). There is also influence to train more women than men as traditionally they are under-represented. When you complete your reports you must count how many of each sex you have trained.
  4. Apply for funding – not actually a significant amount, just to cover manual printing and lunch/refreshments for the staff. Although you have to consider per diems (a lump sum staff expect for attending training – this is endemic in a lot of African countries as a result of NGO influence to encourage people to attend training).
  5. Funding part 2 – Haggle for a cheap lunch. As advised by the NGO; in order to secure funding for lunch I must first get 3 quotes from separate places to ensure I get the cheapest lunch. Have managed to secure lunch for 35 Birr (£1.10) per head, accepting increased costs to include meat.
  6. Print manuals – nothing like spending an afternoon in a print shop (supervision is required due to language difficulties). The afternoon is spent looking out the door, occasionally being shouted at by kids or asked for money.
  7. Putting manuals together – this covers an evening, the time shortened greatly by a helper (thanks Vicki), of placing all the handouts in order before heading back to the print shop for another afternoon of supervised binding.
  8. Confirm venue and confirm lunch provider – best to do at last minute (see point 10)
  9. Confirm names of staff to be trained – To date I have had 5 meetings with management to explain the staff I wished trained and request the list so I can prepare. I still don’t have it. Correction- I got it the day before.
  10. Double check 2 days before course on the list of names; only to find out that the weekend you booked 6 weeks ago has at the last minute been taken by another training session and so yours must be postponed. Worry that the meat you requested has already been prepared (a goat killed) and desperately try to contact the lunch provider to advise of postponement.
  11. Finally deliver the course 1 week late; and in spite of it all have a great time and successfully train 40 people how to safely manage obstetric emergencies (sadly the goat didn’t make it).
  12. Get on with the financial report, if it’s not finished within the week (before I leave) I won’t be allowed my exit visa…


Two months in – Ferenji anaesthetist in Axum

With my Zambian experience as a warm-up or ‘warning-shot’, I headed back to the African continent on Ethiopian Airlines with an open mind. Leaving home again has been hard, but I’m even more determined to ‘be the change’ – or some other similarly idealistic goal. Everything you aim to do in this context is a constant battle between idealism and realism. You adjust your expectations and ‘to do lists’ every day. But I feel at least this time prepared for that and that I will be in for a change of pace. I’ve been thinking about the contents of my first blog for some time and I think the best start is discussing the differences between life and work here and at home.

It’s fair to say Ethiopia is like no other country I’ve visited before; I feel very far from home. It’s almost difficult to describe what it’s like here and why it’s so different as I’ve been here long enough to feel like I’ve been here for years.
I live in Axum; far north in the Tigray region of Ethiopia, neighbouring the Eritrean border. Axum is a popular tourist destination in Ethiopia due to the rumoured presence of the Ark of the Covenant in the local St Mary’s church, and a number of archeological sites of interest, and the birthplace of Ethiopian Orthodox Christianity. Consequently there are frequently other ‘ferenji’ in town, and the local people are more used to seeing foreign faces around. Our house however is in a less developed part of town and the morning commute involves walking along dirt paths dodging donkeys and carts, goats and chickens whilst being stared at by people who seem less familiar with ferenji faces. I am lucky to be joined by Vicki (a paediatrician) and Romil (a paediatric nurse), both VSO volunteers and we all work at Axum St Mary’s hospital and stay in the same house 10 minutes from the hospital.
In terms of differences in day to day life; I have no problem getting up in the morning compared with hitting snooze numerous times at home, I am usually awoken by the pidgeons at my window or running along the metal roof. Not only that I’m usually asleep by 9pm as it’s fairly quiet in the evenings and there’s only so many boxset episodes in a row you can watch (I reserve that comment to exclude Grey’s Anatomy Season 9 which kept me up until 2am). Lunchtime is a dedicated event rather than the grabbed sandwich back home – usually 1 hour to 2 hours. We head home from the hospital via the local shops, which are essentially the front room of the stone houses, and pick up some banee (bread rolls) and eggs for less than 50p. Some version of scrambled egg mixed with tomato, onion and chilli is concocted on the electric stove and washed down with filtered boiled water, which is a continual household task that keeps you busy. Depending on the exact route back to work and the number of children, you quite often reply to a number of ‘hellos’ and invariably handshaking. Hilariously, and possibly a sign of the times in international development and demographics of international industry, instead of being shouted at as ‘ferenji’ (the standard term for foreigner’), we are sometimes called ‘China’.
Sometimes lunchtime is spent at work, where we have injera (Ethiopian staple made from the latest superfood teff) with shiro. This is typically provided by the hospital kitchen and shared out among staff whilst sitting in the changing area/note writing room/tearoom. The staff are always keen to include me and make sure I know the food is for me also. The staff I work with are incredibly kind and everyday ask me how I am enjoying Axum, ‘am I comfortable?’ is a common question. Coffee break in the morning comes after tea, which when I ask for only one sugar I am laughed at, I definitely don’t have a sweet enough tooth for their liking. Coffee is made as a typical ceremony, first roasting the beans, where the smell wafts through theatre and is brought to you to smell, then grinding, and boiling with water before serving. Serving is done in order of seniority and the surgeon always is served first. It’s a real pleasure to be part of the team and they are all very keen to make sure I’m included.
Another feature of life here is my new ‘family’ in Axum. Thanks to Vicky having been here for 6 months before me, she has introduced me to a network of wonderful people who are living and working in Axum in a variety of voluntary and professional capacities. Surviving separation from home is definitely softened by sharing hard drive content of up to date films and TV series, heading out for Sunday brunch of special full (curried beans, eggs, yoghurt), and post work beers at one of the local pubs. Another popular past time is visiting each other for dinner, and spending time with a lovely American family who kindly provide us with meat and dairy products and other such luxuries which are not easily available here in Axum. It’s always good to chat to other people here who are involved in different projects and hear of successes and difficulties in different avenues of development.

So back to work. The intensity of work here is definitely different from home, Axum St Mary’s is a district hospital serving 1.5 million population, but the throughput of inpatients is definitely less than I’m used to in hospitals in Scotland. That said, the intensity for staff due to low staff numbers is not reduced. There are only 3 senior (consultant level) doctors; one internist, one gynaecologist and one general surgeon. There are 5 SHO level doctors and 4 interns (final year medical students who work as junior doctors). The rest of the work is carried out by health officers who have further training in specialties; for example emergency surgery masters. In anaesthesia there are 2 such health officers and between them they perform all anaesthesia for the hospital covering a 24 hour on-call service. Daily elective lists occur and run until lunchtime or later, and emergency cases fill the afternoon and often through the night. As this is a district hospital and there is no ICU; complex surgery is referred to Mekele; the largest town in the region. Although I have just been amused to read the WHO 2003 publication “Surgery in the District hospital” which recommends that anywhere surgery and anaesthesia is practiced should have the ability to provide postoperative ventilation. I’m not particularly positive about the prospect of offering ventilation and an ICU environment however when there are only 2 people in the hospital who can intubate.
In terms of my own capabilities, it has taken probably until the last week that I’m not permanently terrified about providing general anaesthesia to patients who I can’t communicate with, using drugs I know have poor side effect profiles, with really the most basic monitoring you can expect to use. It takes a while to come to terms with being the only anaesthetist in the village, but the 2 officers who are here have fantastic practical skills. I really have relied on their abilities to manage paediatric airways and difficult spinals, their practical experience in terms of volume and variety definitely surpasses mine. And at times, I have found myself wondering what if anything I have to offer or improve here. And then a patient arrives for a laparotomy with no blood results, or I find out blood is available for a patient, but not until 9am when blood bank opens and its 7am and they’ve just lost a litre and a half, or my patient has a HR of 190 and I have no idea what it is as there is no cardiac monitoring; so I realize maybe there are small things I can hopefully do to help.
I am getting incredibly well acquainted with ketamine, it can get you out of many a tricky situation it would appear (including failed spinals in a room with no vaporizer or anaesthetic machine). Halothane is less of a friend than ketamine, and combined with ketamine and atropine I have developed insensitivity for any tachycardia unless it’s above 130. Getting really good at multi-tasking; never really understood the meaning until you need to give the drugs, open your own laryngoscope, lift your own tube off the trolley, intubate (plus or minus remove the stylet), inflate the balloon, confirm position and ventilate, oh and don’t forget the volatile, keep hand ventilating as there’s no ventilator, secure the tube with tape (major error if you’ve not already prepared it), and then if you’re lucky and the pulse ox is still working you’ve got time to take the BP as you can be sure there’s still a pulse because you can still hear the beep. I’m not sure my West of Scotland propensity for cardiac disease can withstand the pressure. I didn’t know how spoiled I was with anaesthetic nurses at home, I mean I thought I did, but I really didn’t.
Anyway hopefully that gives a bit of an idea of life as a ferenji anaesthetist in Axum! Starting some teaching this week with the surgical masters, and hopefully aim to set up an HDU, implement the surgical safety checklist, and deliver an obstetric emergencies course in the coming months. Delighted to have support from AAGBI and Lifebox for monitoring and books for the staff here which I will be picking up when I return home for a weeks holiday at the end of the month.
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Front Entrance to Axum St Marys Hospital
Front Entrance to Axum St Marys Hospital

Drug preparation

Preparing the coffee ceremony at work - a task for the circulating nurses.
Preparing the coffee ceremony at work – a task for the circulating nurses.