Friday, January 29, 2010

SV11-12 -- LeAlem, St. Yared and OSSA

Site Visit Days 11-12 (Thursday-Friday) -- Relaxed Thursday. Highlight was morning move from Jupiter Hotel to La Source Guest House, an inexpensive ($25/day) pension off Gambia Street, in Meskal Flower district, a few kilometers from LeAlem. Several EHN beneficiary patients treated on Thursday, with illness ranging from ear infection (follow-up exam and irrigation), psychiatric treatment, to hypertension. Several Thursday-Friday case study pix below.

Arose early Friday. Productive, but mildly exhausting day. Pension breakfast, followed by macchiato at Kazanchez plaza, near LeAlem. 35 cent macchiatos are stunning, tasty. This trends from birth of coffee in Ethiopia and five-year Italian occupation during Mussolini reign. Fairly busy beneficiary intake Friday, about 15 total. Mid-morning travel with Dr. Aleymayehu to St. Yared Hospital near Bole to meet its director, Dr. Akeza Teame. We visited St. Yared in 2007, when it was a Higher Clinic.

I was interested to learn about St. Yared's evolution to hospital status, which entails an increase in facility size, patient volume, and broadening of departments. Expanding LeAlem to a hospital is a long-term option Alemayehu is considering. Our visit found St. Yared a very impressive facility, with 4-bay emergency department, CAT scan, ICU, NICU, two inpatient floors and much more, in a 6-story building. Unfortunately, St. Yared is underutilized and expensive. In its first year of operation, 2008, St. Yared treated 5,000 patients. By comparison, in 2008 LeAlem treated about 15,000 patients, although LeAlem is about 10% the size of St. Yared.

I reconnected with a doctor who I'd met at St. Yared HC in 2007 and Alemayehu connected with the director and doctors he knew on staff. While mixing EHN's beneficial care model with St. Yared's high-cost model may not make sense, we did establish that St. Yared could be a partner for rotation of medical students and residents from George Washington and other schools. The hospital currently has student rotation programs with New York's Albert Einstein Medical School and University of Kansas. My thought is, for the longer term, EHN/LeAlem might collaborate with St. Yared to provide an Africa community health internship or residency opportunity.

After St. Yared, I lunched with Organization for Social Services for AIDS (OSSA) Addis Ababa manager Paulos Kenea. I'm interested in partnering with OSSA. OSSA has HIV/AIDS operations in 11 of 12 Ethiopia regions, including multiple locations in the capital. Broadly stated, EHN's mission is to provide healthcare where there is none. Our program with LeAlem in Addis focuses on indigent women and children. As this is successful, we anticipate moving to establish needed healthcare in additional Addis locations and in rural areas, where there is no healthcare.

-- Almost all rural children are born without professional medical assistance, and there is not antenatal care. Many infants die. --

Partnering with OSSA, which reaches into rural areas through its HIV Voluntary Counseling and Testing (VCT) programs (mobile unit pictured above), may prove an efficient vector for EHN. Along these lines, after lunch, Paulos and I toured OSSA's VCT, palliative care and HIV/AIDS support facility inside Merkato, the sprawling marketplace (Africa's largest) at the heart of Addis. The facility is a fixed compound, a building with reception and about 12 patient rooms, and several outbuildings.

A concept is that LeAlem could rotate doctors through the OSSA Merkato facility, meeting indigent persons' healthcare needs, expanding EHN's program (without incurring huge overhead). This partnership and care delivery model might be replicated in rural areas.

HIV-positive twins, under OSSA care.  EHN/LeAlem referral partner.

Correspondingly, OSSA is interested in EHN support -- advocacy, at minimum -- for a nutrition program. OSSA patients, many of whom are on anti-retroviral therapy (ART), most often fail due to nutritional insufficiency. ART drugs need to be taken with food. Two OSSA ART children died last quarter due to poor nutrition; pediatrics on ART with good nutrition typically thrive. (HIV-positive twins, under OSSA care, are pictured above.) In response to a site visit interrogatory, Dr. Alemayehu identified nutrition as the most important collateral issue impacting the success of LeAlem beneficiary care.

On receiving a nutritional support grant (funding) request from Paulos, I told him that EHN's mission is focused on the current healthcare model, but that I would work to identify patrons and support to answer his request. I suspect that $100,000 per year is required to provide nutritional support for the 5,500+ households under OSSA care. Perhaps this is something to consider with the Clinton or another foundation.

Having dinner tonight with a referral partner from large Addis evangelical church. Partner is interested in EHN funding a dental clinic. Clearly this is an unmet need; dental hygiene is noticeably poor in the indigent population. My concern, however, is whether providing dental care is the best use for EHN resources and our intent to provide the highest-value, most beneficial healthcare for patients. I'll present our partner's suggestion to EHN's board for review.

While in Addis for two weeks, my (volunteer) job has been to conduct a formative review of LeAlem performance under EHN grant, develop case studies (including pictures) of beneficiary patients, and meet with current and prospective EHN partners. The subject matter is extraordinary, at times heart-rending. It is in situ -- and sometimes on-the-fly -- public policy and program development, made vital by the context, our proven results at LeAlem, and opportunities to make a bigger difference. As a going-in product, I developed a 29-page site visit plan, with introduction, conceputal framework, interrogatories, data collection tools, resources and such. My evolving product, which I hope to finalize by February 28, will be a report presenting findings, recommendations, anecdotal case studies, and additional material. EHN will use the report to shape program direction; produce material for media, fundraising and extramural support; report to donors, and for similar purposes.

Tomorrow, Saturday, I'll spend the morning at LeAlem in wrap-up mode, followed by a party at social worker Almaz's house. Sunday, I'll probably take a last long walk in central Addis, perhaps visit a museum and hit a few shops. Then, it's the airport at 7 PM, fly home, arriving at Dulles Monday mid-morning.

Thanks all. Very warmly, Jim

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Wednesday, January 27, 2010

SV10 -- LeAlem ER and Home Visits

Site Visit Day 10 (Wednesday) -- Big day today, from several perspectives. Walked five miles from hotel (Kazanches), up around Black Lion Hospital (picture 1) to Piazza, through Churchill Road shops, and back. Arrived at LeAlem about noon. While I was waiting outside Alemayehu's office, a 21 year-old beneficiary, Tewodros, was carried into the clinic by friends, screaming. He was lifted onto a gurney. Tewodros writhed and beat his stomach. Dr. Yilkal attended to the patient, auscultating, palpating abdomen, and providing chest x-ray. LeAlem laboratory provided white blood cell count and blood sugar tests. All were normal (and paid by EHN). Patient had taken meds without food, which may have caused abdominal pain leading to, diagnosed, severe anxiety episode. Dr. Yilkal put patient on placebo IV drip, which settled his condition. Tewodros slept (picture 2).

Met with church official who is a referral partner for EHN/LeAlem. Subsequently, traveled with Organization for Social Services for AIDS (OSSA) to mobile Voluntary Counseling and Testing (VCT) center, a truck with three counseling rooms in first segment, and test lab in second segment (pictures 3-5). Test lab produces results in 30 minutes. OSSA VCTs operate all over Ethiopia, serving tens of thousands, an integral component of the country's HIV/AIDS strategy.

Black Lion Hospital, Addis Ababa

Patient on IV, LeAlem Higher Clinic

Mobile Voluntary AIDS Counseling and Testing Center (VCT), operated by OSSA.

AIDS counseling, Organization for Social Services for AIDS.

Mobile AIDS testing lab, Organization for Social Services for AIDS.

After VCT visit, proceeded to home visits of OSSA HIV/AIDS patients and affected children (pictures 6-10), Aduare neighborhood, Addis Ababa. Met two young HIV-postive twins, AIDS orphans (picture 6), their aunt and two cousins, all living in one-room, one-bed home. Visited several other homes in destitute slum, photographed swarming children, patients and impacted community. Black and white, at bottom, is end-stage patient.

We are so lucky.

HIV-positive twins, under OSSA care.  EHN/LeAlem referral partner.

HIV/AIDS orphans and vulnerable children.

HIV/AIDS orphans and vulnerable children.

End-stage AIDS patient, under OSSA care.

Returned to LeAlem for report follow-up, discussion with colleagues (they met 'til 10 PM last night, working on report). Having lunch with OSSA director Friday (OSSA is a referral partner for EHN/LeAlem). Wrestled with logistical challenge of finding new hotel in town filled by African Union congress; ultimately successful, a $25/night guest house, but I think I'll have reduced Internet access. My Lonely Planet guidebook gives it a good mark.

Estimate that Thursday will be a long day, hotel move, patient case study work, and working late with partners to craft next report draft. Friday will be busy closing sprint, meetings (if possible) with US Embassy personnel and Addis hospital director, lunch with OSSA director, and dinner with referral partner.

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Tuesday, January 26, 2010

SV9 -- LeAlem

Site Visit Day 9 (Tuesday) -- Mellow day at the office, administrative/social worker and beneficiary intake area, pictured above ... desk in back is my temporary station. Today, shared draft site visit report with LeAlem partners, identifying areas for clarification, further research, questions, and concepts for discussion.

Followed a couple compelling cases, 7 year-old girl on follow-up for nausea and vomiting, pictured below with Dr. Alemayehu. And 49 year-old war widow with four children, presenting with stomach ache and retroperitoneal burning, complicated by asthma. She lives in one room house with her children, supported by pension income less than $100/year. At bottom, hugging social worker Almaz.

Click through photos for high-resolution.

Tomorrow, home visits for HIV/AIDS patients and orphans and vulnerable children, supported by Organization for Social Services for AIDS patients (OSSA), research postponed from Friday past.

Mid-term thoughts

While first week was rough, the second is proving smooth. (I had been overwhelmed, then a medical got me.) There seems to be a sweep of congruence. Collecting data, making observations, writing, reviewing with partners. Developing patient case studies and making photographs.

Even the hotel seems in rhythm. I initially planned one week in Addis, followed by a week in the Omo Valley (southwest Ethiopia, for ethnographic photography). The day I arrived I asked reception to extend my Addis stay to two weeks, so I could do more work. In a communication error, instead, they cut my reservation short. Last Friday, when I was bad sick, they knocked on my door and insisted I leave. The African Union Summit had filled all remaining bookings, including my mistaken vacancy. Most other hotels were full. I protested and showed my booking confirmation to gain a few day reprieve. Forces came to my rescue. Dr. Alemayehu appealed to the hotel manager, called the owner -- "Jim is helping the Ethiopian people, doing real work." Each day my reservation end date has crept forward. Fingers crossed. I board the plane next Sunday.

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Monday, January 25, 2010

SV7-8 -- Chill Sunday, LeAlem Monday, Learning

Site Visit Day 7-8 (Sunday-Monday) -- Took a restful Sunday, pretty well recovered from medical distress that made for sharp Friday. Walked about five miles around Addis, drinks with leader in Addis Ababa Cycling Federation, Dr. Telaye Wube. Did a good bit of writing and reading, picking-up Abraham Verghase's Cutting for Stone, recommended by EHN board member. Verghase's novel tells of romance and graphic detail of (some extraordinary) medical work at an Addis Ababa missionary hospital, during the early years of Emperor Haile Selassie. Gripping and apropos, intellectually large.

Similarly peaceful if routine Monday, with morning and afternoon case study work at LeAlem. A number of compelling stories captured, images below.

I'm increasingly impressed by the business model we've set for EHN/LeAlem. Here's a clip from my current draft: "LeAlem is performing work efficiently. Several notable factors and measures contribute to this finding, including: The clinic is an established, ongoing commercial operation that is not dependent upon charitable funding for successful performance; economic efficiencies that support successful commercial performance carryover to charitable activity supported by EHN; [and] costs for non-profit, charitable patient care is the same or less than costs for commercial activity. (E.g., some commercial patients request/demand additional tests that are not provided to charitable patients, where medical staff deem these tests non-essential.)" So, it seems we're on the right track.

On another interesting contextual note, the African Union 2010 Summit begins later this week, so the hotel is filled with an extraordinary range of diplomats and interest groups. Adds a definite class and mystique. It's pretty cool to sit in the hotel bar and absorb the culture, watching African soccer championships on big screen, sipping beer or such.

Also today, had a bit of a medical "Whoops!" I'm trained as an Emergency Medical Technician, and I've seen pretty much, from ER/ICU/brain surgery, to nasty bone, blood and shock trauma. I'm trained in scene safety and personal protection. But Africa is different. I probably need to assume many things are contagious, more than I'm used to. Today a very appealing child came in, and I lifted him high in my arms, offering comfort. Well, the little guy was recovering from Typhus, which is fatal (if untreated) 10-60% of the time. The translation was uneven, so I heard Typhoid, for which I'm inoculated. On return to hotel I read about Typhus. I quickly re-upped my Purell (alcohol gel) scrub and hopped in the tub for a thorough wash; I'm already on Cipro ... Well, it's to learn. This trip is definitely stretching my envelope.

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Saturday, January 23, 2010

SV6 -- Beneficiaries Home Visit

Site Visit Day 6 (Saturday) -- Visited impoverished homes of beneficiaries, followed by children's event at community center for orphaned and vulnerable children (OVC). Crawled through narrow alleyways, into 1-2 room mud and tin huts; swarms of beautiful children seeking contact and attention. (Glad I had extensive inoculations.) Compelling pictures. Area impacted by poor sanitation and hygiene, malnutrition, disease, economic destitution. First house visited had 2 rooms for 3 or 4 families, other houses similar. Admired craftsman weaving in front room of two room mud/tin house.

OVC event, organized by "Redeem the Generation," was extraordinary cultural dance show, followed by counseling discussion and distribution of free clothing. A licensed Ethiopian non-profit, Redeem the Generation focuses on psychosocial support for HIV/AIDS OVCs, educational support (e.g., tutoring, book clubs), micro-lending for small business start-up, HIV prevention education, and similar individual- and community-empowerment work. The association is led by a skilled staff with over 100 volunteers.

Click through pictures to see high resolution.

Day off tomorrow (Sunday), kicking back, attending local bike race, lunch with leader of Ethiopian Cycling Federation ... just like home!

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Friday, January 22, 2010

SV5 -- Sick Day

Site Visit Day 5 (Friday) -- Hit stomach problem, epigastric pain and bad bleed. Stayed in hotel room. Had a few email and telephone conferrals with wife, Carolyn, and Medical Duty Officer at US Embassy. MDO was great help, conferring on diagnosis and treatment. Started course of Ciprofloxacin, NSAID etc. Care, of course, was great, the greatest friend ever. Partners have planned ambitious Saturday site visits and events, so I need to steel myself.

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Thursday, January 21, 2010

SV4 -- LeAlem

Site Visit Day 4 (Thursday). Better day today, well-rested. Got over-tired Wednesday, stressed, both joy and sadness. LeAlem served 12 EHN beneficiary patients today. Dinner with 8 staff and children tonight; sumptuous Ethiopian meal -- $35 total (including beer). Pictured above is Gashaw, a LeAlem social worker. LeAlem maintains meticulous records.

Below are a few of today's case study pictures and abstracts. (Click through pictures for improved resolution.)

Pastoralist woman age 91, presenting with epigastric pain and disorder. No children; subsists by begging. Sleeps on ground in shed. LeAlem/EHN provided medication and vitamin B supplement.

Seven year-old girl, presenting with nausea and vomiting. 4th grade clever student, poised. Her name translates to "Work of God."

10 year-old boy and 36-year old mother. Boy presented with facial ulcers, and mother with flank pain. Mother previously treated for typhoid. Mother is blind; eight years without sight. Eye injury brought on by laundry work. Subsist by begging near church baptismal spring; live in one room house with 14-16 people.

38 year-old beneficiary with gynecological issues. Sells small merchandise on street. Two children, 10 year-old boy and 14 year-old girl. Children attend government school. Mother and children live together under plastic tarp by street. Treated by EHN/LeAlem (multiple visits).

35 year-old woman, previously cured from malaria. Presenting complaint, flank pain. Works in Addis as housemaid; earns less than $100 US per year. Helps support five children living in southern Ethiopia; her husband is farmer in Wolayta. Two children live in Arba Minch in order to attend better schools.

Tomorrow, home visits with HIV/AIDS social services agency caring for pediatrics with HIV/AIDS or impacted by AIDS (e.g., orphans). Similar work Saturday morning.

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Wednesday, January 20, 2010

SV3 -- LeAlem, Atetegeb and OSSA

Site visit Day 3 (Wednesday). "Symbol of Hope" (above), stamped on LeAlem patient processing forms. Three or four big events today. Quoted material from notes.

Atetegeb Partnership "I don't believe in an activist God, but sometimes you wonder: I was walking from Jupiter Hotel to LeAlem on busy Tito Street. I hadn’t slept well last night, so I was running late, about 9:30 AM. By Denver CafĂ© on Tito, waiting to get in a blue minibus, I saw a familiar face. It was Temesgen, Assistant Director from Atetegeb, who I had met Monday (notes). Of the millions of people in Addis, on the countless dusty corners, here was a man I knew, someone EHN could help. After surprise and greeting, I asked Temesgen if he wanted to come with me to see LeAlem Higher Clinic, about 150 meters down the road. We of course visited. I introduced Temesgen to staff partners, we toured the facilities, and Gashaw (social worker) got on the computer and prepared a referral agreement to enable Atetegeb to send children (and their nurses) to LeAlem for healthcare. A good days work! ... In my insomnia last night, cycling ‘What to do?’ concerns, I had thought through next steps. On waking I scribbled on my to-do notepad, '[Make sure to identify] specific next steps to set Atetegeb relationship.' Today’s encounter seemed Providential."

Patient Care We saw nine EHN-supported patients before I left clinic about 3:30 PM. Subject below is 16 year old boy without income (but in school), presented with dental pain (front teeth), swelling and bleeding. Treated by LeAlem dentist.

Memorial Plaque We installed a plaque in EHN/LeAlem patient reception office (where social workers obtain referral forms, develop patient background, record presenting diagnosis, and direct patients to course of care. The office is about 7x12 feet, with three or four desks, one of which I've taken over for site visit work. Depending on available translator, I interview patient and develop case study information. I may take patient picture.) The plaque honors the EHN-LeAlem relationship and major supporters, including "Joan Gibbons Wilson Memorial," for my mother who died cruelly from ALS.

OSSA Following a recommended line of inquiry, with social worker Gashaw, I visited OSSA -- Organization for Social Services for AIDS patients, not far from LeAlem. Compelling story, heart-breaking. "Had one-two hour meeting with Paulos Kenea, Addis Ababa region manager for OSSA, Organization for Social Services for AIDS. OSSA is supported by USAID, CDC, Catholic Relief Services and others.  Multi-path support for HIV/AIDS patients and impacted persons (e.g., AIDS orphans). Services include prevention counseling, psychosocial support, palliative care, orphan and vulnerable children program, and HIV testing. 120 trained community volunteers; home visit volunteers serve 10-12 households per day. Support for 5,500 children (285 HIV positive) and 1,220 patients on ART (anti-retroviral therapy) in Addis catchment.  Partners with EHN/LeAlem; economically disadvantaged OSSA pediatric clients receive non-ART medical care at LeAlem (up to 5 patient visits per day, no charge), under EHN program."

I'm going on site visits with OSSA Friday, where we will visit homes of indigent children in OSSA care.  OSSA manager Paulos made compelling argument for nutritional support (e.g, necessary for ART medicine intake, opportunistic disease defense). Children died last quarter due to nutritional insufficiency; children on ART with good nutrition often thrive.

Paulos provided me with several reports (which I'll read tonight), and case study of OSSA best practices, including testimonial about OSSA/LeAlem/EHN care model.

Friday will be very challenging.

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Tuesday, January 19, 2010

SV2 -- LeAlem and networking

Site Visit Day 2 (Tuesday) -- Short post today. Most of day spent at LeAlem, case study and report writing. Today is a national holiday, Timkat or Epiphany, celebrating Jesus' baptism. This kept clinic volume lower.

Did a lot of writing, conversation with LeAlem partners, coffee fete in courtyard (brewed over embers) with all staff. Case study subject today, imaged above, is pastoral woman presenting with acute gastritis. She lives in one room house, sleeps on ground with two children, sells candles near church. Her husband is deceased. She's proud of her children, her son having completed ninth grade (dropped out to support family) and her daughter continuing at tenth grade level.

A subject explored in today's writing and through email with EHN board is that nutrition is a critical co-factor to medical care success. Some medicine should not be taken without food, and poor nutrition, of course, fosters illness and deficiency. I'll look into network partners who may be available in Addis to help, or mark issue for future research.

Dinner tonight with US Embassy friend and LeAlem colleague (social worker).

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Monday, January 18, 2010

SV1 -- LeAlem and Atetegeb

Site Visit Day 1 (Monday). Walked to LeAlem for first site visit. Met key EHN staff -- Medical Director Dr. Alemayehu, additional doctor, laboratory director, and Gashaw, Abeje, and Almaz, social workers and program staff. Very impressive team. Observed patient intake for seven-year-old Desta (pictured below with mother) and documented case (e.g., income, living conditions, education, nutrition); learned about intake and referral structure; supporting HIV/ART and tuberculosis programs; network partners (churches, mosques, NGOs, local government healthcare organizations); obtained copies of partner relationship agreements and referral templates; learned LeAlem staff backgrounds and capability; toured LeAlem facilities, and more. Very busy day. Alemayehu saw c. 50 patients, clinic saw 100+ patients.

Very striking was afternoon visit to Atetegeb Worku Memorial Childcare Association facility in north Addis (assistant director Temesgen pictured at top, with child). Atetegeb, described by Melissa Faye Greene's There is No Me Without You, was remarkable. Joyous children, primarily AIDS orphans, age 11 months - 15 years. Most in good health, one (11 month old) suffering from failure to thrive (image below, with nurse).

Atetegeb is facing financial pressure due to completion of USAID grant for remote program in Bahir Dar and Debre Tabor (about 500 Km north of Addis, near Lake Tana) and pending completion of term with Hope for Children USA. Atetegeb facility fees are approximately $700 per month (not including salaries). Atetegeb pays for child medical care, including routine pediatric examination and advanced care (e.g., hospitalization, specialist visits). Due to strong mission alignment, EHN preliminarily agreed (subject to agreement by Alemayehu) to assume medical care for Atetegeb children, including pediatric exams, referrals and specialized care. This will reduce Atetegeb cost burden. Additional areas for prospective collaboration were discussed (e.g., Debre Tabor health program) for longer term, as EHN program matures.

Enjoyed traditional Ethiopian coffee with Atetegab Executive Director Sosina Tefarra, assistant director Temesgen, and staff. For me, a somewhat sedate Washingtonian, 30 minute drive from LeAlem to Atetegeb was notably exciting. Very fast driving, pedestrians, animals (donkeys, etc.), cars and buses zigging every-which-way, citizens marching in Epiphany parade ... apparent chaos, but no vehicular fatalities.

Site visit plan has proved very useful, established framework shared by team, and tools and interrogatories for data collection. Given productive day 1, much writing to do. Pictures look pretty good; only a few uploaded here b/c of hotel bandwidth constraints.

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Sunday, January 17, 2010

Abyssinian Casbah

That's a good way to describe this weekend, Abyssinian Casbah. I love Ethiopia, the Ethiopian People, the intricate and complicated capital. Many contrasts.

My 24-hour airport-to-airport, Dulles to Bole, excursion left me tapped, but I wanted to synch with East Africa Time, so I took a five-mile walk through central Addis Saturday afternoon. Hot dry dusty diesel fumes, the poor and desolate in every crevice. A man missing his legs. A beautiful infant, about ten months, in her mother's arms, raised to my face. A grandmother folded, parched on the sidewalk, moaning. My self-appointed tour guide, a very smart guy who started as a shoeshine boy by the UN compound and now works as a dishwasher at my hotel for $5 US per month. Ethiopian Birr notes and coins slip from my pockets, given as slim fodder. Billionaire Prime Minister Meles Zenawi’s palace, the opulent Sheraton, and fenced-off enclaves sit opposite tin hovels and open sewers.

Saturday night I reconnect with Mesay, a friend from my 2007 trip and his girlfriend, Ida. I give them photographs and Obama shirts. (East Africans are passionate Obama fans; several Addis restaurants are named “Obama Cafe” or “Obama Coffeehouse.”) We go to an old favorite for supper, Yod Abyssinia, spicy food, tibs and wat in a large pan of injera, live music and hyper-energetic tribal dancing. The crowd joins in, some jumping on stage. A wedding descends on the Yod, about forty people holding sparklers and flaming punks. Singers ululate. It’s wild. Many beautiful Africans, ferenge (tourists) jaws agape holding cameras.

Sunday I wake about 7 AM and meet Dr. Alemayehu, his wife Wolansa and eight-year-old son Eyasu (Joshua) at 9:30 AM. We have coffee and go to Gospel Light Ministries church for 11 AM service. Then we lunch into the afternoon.

Alemayehu and Wolansa met while graduate students in the Ukraine, Alemayehu studied medicine and Wolansa economics. Dr. A. worked for several clinics and hospitals, where he performed a range of practice, including internal medicine, pediatrics, and obstetrics. Among his most intensive education was serving as a military doctor near the front in Asmara, Eritrea, when the Ethiopians were at war. In 2006, he established LeAlem -- “Serving All” –- a private clinic in Addis. The Health Ministry designates LeAlem a “higher clinic,” a level below hospital.

Though our time was informal, our personal interests and EHN vision seemed congruent. Alemayehu described his grueling work schedule, as well as his success compared to other practitioners. Tonight we will have a more business-oriented supper meeting, reviewing the site visit plan, framing questions and anticipated interviews. Tomorrow, Monday, I begin observation and case study development at LeAlem.

Returning to the Casbah theme, Gospel Light service was stunning and joyous. The first hour was gospel music and dancing, with ululation and celebration among several thousand congregants. (Like a few other non-Ethiopians in attendance, I had simultaneous Amharic-to-English translation via radio earphone.) The music was followed by devotions and a sermon of about an hour. I saw and embraced several officers and parishioners I met during the 2007 trip. Remarkably, the young man stricken by juvenile onset polio whose picture I took in 2007 (below) stood in the pew immediately in front of me. The Casbah has almost become familiar.

“Mega churches” in the United States make me anxious, but those in Africa do not. The need for hope, spiritual relief and popular representation is severe in Africa. There, churches are transformative social and charitable engines, for example, helping end Apartheid and supporting AIDS orphans. Gospel Light is a partner with EHN, along with other churches, mosques and Addis Ababa social service organizations. They work together to qualify needful patients and provide treatments that result in improved health and ability to maintain families and attend school.

Details to come.

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Friday, January 15, 2010

Hopeful work in a sad place

Up early today. 2:00 AM Washington, DC, 10:00 AM Addis Ababa. Transitioning to East Africa Time. My plane leaves Dulles at 9:30 AM, arrives in Ethiopia 8:30 AM Saturday. I'm going to a sad place, with beautiful people, to do hopeful work. Received a bunch of nice phone calls and communications. My son at college in Boulder. Our cycling coach; she is going to throw a fundraiser at her shop in Herndon, perhaps, later, a benefit bike race. My mother-in-law. Dad. Friend at the U.S. Embassy in Addis. My driver Mesay, an old friend. Cyclists with material to donate. A gifted writer with Ethiopian children.

Yesterday morning, I spoke to Raj, my friend and Swings barista. He's going to Nepal, his home, Sunday. I mentioned Ethiopia. Alfeau, another barista at Swings, her father is very sick, in Addis; he lives behind the Hotel Concord. I said "Can I do anything?" Her English is not good. Her friend, an Ethiopian at the IMF, came over for an impromptu meeting. (Small world: He knew my good friend who headed IMF press and pubs, an EHN benefactor ...) Alfeau's father has Type 2 diabetes. Could I bring him medicine? But there is not time to fill a prescription. I asked medical questions. He has no money. His medicine costs $30 in Ethiopia, perhaps three month's income. I will take him to the EHN clinic and buy the medicine.

Wednesday at Men's Group, Western Presbyterian Church, we were unusually reverent. A friend spoke of the recent tragedy, the earthquake in Haiti that killed, likely, tens of thousands. How can there be any God? Such cruelty. I believe there is God, but his scale is different, in many ways imperceptible, a thin monolayer. In this ether we are given choice and opportunity to make things better. A reason we die is to make life meaningful, so we do important work. There is an apex where we get little pleasure in climbing higher, material gain, rank or whatnot; and we hopefully, necessarily turn and give back. Whether it is nurturing children, helping youth gain confidence cycling, or cleaning an invalid's spoils. In aggregate, the world becomes a better place. That's my gut.

Time for bath, final packing. Care is driving me to Dulles. Internet access in Addis is weak. I'll write, take pictures and post when I can.

John Wimberly wrote, "Vaya con Dios." We'll see.

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Monday, January 11, 2010

LeAlem Progress Report, December 2009

In the third month of Ethiopia Healthcare Network (EHN) grant performance, December 2009, LeAlem exceeded benchmarks, providing healthcare for 168 economically disadvantaged children and women in Addis Ababa, Ethiopia's capital. LeAlem strengthened networks and partnerships with churches, mosques, governmental organizations, non-governmental organizations, and others to recruit beneficiaries and best address needy people. LeAlem Medical Director Alemayheu Dinku Gebrehiwot reports: "All the systems of healthcare service delivery are functioning well and have been strengthened. The binocular microscope [funded by EHN] to enhance the healthcare service by performing different laboratory procedures was purchased."

Patients treated ranged in age from eight months to 80 years; 87.5% were women and 36% children or youth under 20 years of age. 99% of treated patients had income under $100 US per year; two patients (1%) had income between $100-$200 per year. Patient outcome level is based on the diagnosis and treatment given. During December, 29% of the patients were relieved from their pain, 24% were cured, 7% of the patients’ health status is improving, and 6% of the patients’ health status is improved. 3% of the patients are under follow-up, and 14% of the patients are under treatment. In addition, 15% of the patients were referred to hospital for services which are not available in LeAlem Higher Clinic.

Presenting symptoms included: Cough, night sweating, and loss of appetite; burning pain over the legs; dysuria, fever, chills, and back pain; undeveloped language skill; trauma to the right hand 5th finger and abdominal pain; irregular menses; flank pain and epigastric pain; joint pain and amenorrhoea; vomiting, ear pain, and eye pain; joint pain and on ART (anti-retroviral therapy); uterine prolapse; swelling over right foot; itching of the eyes and dysuria; poor vision and swelling over anterior neck; poor appetite and had hepatitis; general weakness and abdominal discomfort; epigastric pain and heart burn; abdominal pain and loss of appetite; fever, weight loss, cough, diarrhea, and vomiting; poor appetite, fever, yellowish eyes, and joint pain; decreased appetite, red urine, fever, and headache; cough, chest pain, fever, decreased appetite, dysuria, and flank pain; leg deformity; poor feeding; poor appetite and weight loss; fever, joint pain, headache, and sore-throat; supra pubic pain and itching over legs; tension, sleeplessness, and weight loss; pain over breast; backache and vaginal bleeding; flank pain, dysuria, and rashes over the loin; pin over operation site with discharge; scalp lesion, skin rashes, and abdominal pain; delayed development; poor vision after cataract operation; poor vision, headache, and scalp lesion; fever, cough, and weight loss; tension, headache, malaise, and sound in the head; diarrhea, vomiting, and grunting; back ache, pain over thighs, and vaginal discharge; vaginal bleeding; ear pain and discharge; pain over leg, headache, backache, and dysuria; joint pain, sweating, and hot flashes; swelling over jaw, epigastric pain and heart burn; cough, chest pain, and flank pain; fever, joint pain, and on ART; chest pain, epigastric pain, and completed anti-TB drugs; backache and trauma; tongue lesion and on ART; double vision and excessive sweating; eye discharge and itching of eyes; unable to walk; chest pain and scar over it; epigastric pain and decreased appetite; eye pain with redness and discharge; pain over leg, palpitation, and dysuria; back pain, flank pain, and swelling over vulva; trauma to the face; failure to thrive and skin rashes; headache, fever, and cough; unable to conceive; polyuria and polydypsia; pain over eyes and poor vision; and accidental falling.

As to lessons learned, LeAlem reports: "We have learnt that the provision of the healthcare service with your kind support has enabled patients to continue their bread winning activities and schooling in the case of students; we have continued enjoying the soul satisfying endeavour; and we have also learnt that the beneficiaries are thankful as usual for the healthcare service they got. The team work as we do it regularly enabled for coordinated effort and synergistic effect."

For further information on EHN and LeAlem, visit our web site or email

Sunday, January 10, 2010

To Addis

Been hectic here. Next Friday I go to Addis. Leave 9:30 AM, arrive 8:30 AM Saturday, refueling in Rome. It's a nice flight, time to sleep and read. I've vaccinated and medicined up -- yellow fever, typhoid, rabies, hepatitis A/B, DPT, anti-malarial, Cipro, lomotil and such. I lost part of my EMT kit this summer at a bike race, so I restocked -- new stethoscope, CPR mask, airways, saline, wound care, PPE, glucose, splints, occlusives, etc. I'm not sure, but I may have some EMT work during the site visit. We will be looking at some unsupported locations, folks who need care. It will be sad in some ways, hopeful in others.

I'm traveling as a volunteer for a 501(c)3 non-profit I helped start in December 2008, Ethiopia Healthcare Network (EHN). When my mother died cruelly from ALS in 2005, my father reflected that while he had personal monuments -- books, stories, a play about his work, -- there was not a memorial that represented Joan, though she did wonderful things. We asked her pastor and he guided us to support a clinic construction project in Dukem, about an hour south of Addis Ababa. Impressed with the mission and church, I signed on, helping to raise and contributing a goodly sum. Fortunately, in a way, before we sank funds into construction, we lost title to the rural land (due to a reportedly corrupt act). I helped refactor the program as a non-profit corporation focused not on real estate construction but on efficiently providing care to needful patients, disadvantaged women and children. In November 2007, we conducted a survey in Addis, including visits to several clinics. I was very impressed by one facility and its medical director, LeAlem Higher Clinic and Dr. Alemayehu Gebrehiwot. After the land problem, we reached out to LeAlem and requested a proposal.

With EHN support, starting in October 2009, LeAlem hired a part-time doctor, social worker and nurse to provide healthcare to disadvantaged women and children. Results have been promising. Here's a summary from November 2009: "LeAlem exceeded numerical benchmarks set by the grant, caring for 103 patients. Ninety-two percent (92%) of the patients had annual income below $100 US per year; the balance had annual income of $100-200 per year. Ninety-seven percent (97%) of post-school age patients were female. Without EHN support, all patients would not have had access to professional healthcare. Patient outcomes were largely positive, alleviating suffering, treating disease, and supporting improved pre-natal and infant health. Patients were treated for a diverse range of diagnoses, including pneumonia, head injury, reproductive complications, pregnancy, diarrhea/intestinal disorder, gangrene, hemiparesis, urinary tract infection, seizure, candidiasis, asthma, metastatic cancer, adverse reaction to anti-retroviral therapy (ART), and Parkinson's disease."

We cared for 168 patients in December and my sense is that patients and service capability will continue to increase, partly owing to this month's trip. Interest and activity is burgeoning. I've several letters and resumes from medical school students who want to work in Addis as summer volunteers. Individuals with high net worth are looking into the program, we're organizing a fundraiser at the Ethiopian Embassy in DC, and more.

The purpose of my trip this month is to review grant progress, develop case study material, understand how we can best help, and develop relationships and ideas for future work. With EHN's Board, I wrote a 30-page site visit plan, providing background, articulating survey questions, and identifying contacts, from US embassy staff, to NGOs, social service providers and other clinics and doctors. The plan will help make the trip productive and facilitate writing an assessment and additional media.

The situation in Ethiopia is grim. Famine is projected by monitoring organizations. [USAID] Four million children are orphans, 500,000 from AIDS. Under-5 mortality rates are high. Less than 6% of women have medical care when they give birth. Average per capita income is $630 US. [WHO]

What EHN and LeAlem are doing is a small initial step. Our vision, though, is broad and resources sound. As noted by the plan, EHN is fortunate to be headquartered in Foggy Bottom, Washington, DC, blocks from the State Department, international development organizations, and a major university and medical school. EHN's Board is an exceptional team of medical doctors, individuals born in Ethiopia, well-connected professionals, and individuals with long-term experience with innovative charities. We envision drawing upon resources in Washington and helping them deliver value, and we envision EHN clinics and projects across Ethiopia networking together and with regional resources, NGOs, government and other organizations to provide care, alleviate suffering and improve outcomes.

The trip will be one positive step followed, I hope, by many.