Barbers and stylists as health educators

 

Is this a creative option for Ethiopia?

We trained few barbers about hypertension and how to measure blood pressure in our project to address hypertension in East Cleveland. Each barber shop was provided with an automated blood pressure measuring machine. Any of their customers would have free access to these blood pressure machines to voluntarily take their own blood pressure. They were also provided with an easy access to a health care provider for advice if the customer’s blood pressure was elevated.

The barbers were fascinated when we reviewed the history of barbers in delivering health care that dates back to at least 1163 in Europe when Pope Alexander III issued a decree that prohibited members of religious orders from spilling blood. Because of their dexterity with scissors and razors, barbers began working as physicians or surgeons. In addition to shaving and hair cutting, barbers began performing bloodletting, which was a common form of treatment for many ailments, incision and draining of abscesses, and toot extractions (1) among other surgical procedures.

Imagine going to a dental place in January of 1164 in London and having your tooth out following a nice hair cut!

Henry the VIII in 1554 merged the fellowship of the surgeons with the company of barbers to form The United Company of Barbers and Surgeons restricting each to their own profession except tooth extraction which was practiced by both groups. That lasted until 1745 when King George II separated the two groups and then surgeons formed the Company of Surgeons which later became the Royal College of Surgeons in 1800 ( 1).

There are several studies that used barber shops and beauty salons to reach out particularly to minority communities in the United States for blood pressure and other health screening educations with rewarding results (2,3).

Hypertension and its complications such as stroke, heart disease, and kidney disease are a major health burden throughout the world including sub-Saharan Africa where the prevalence is increasing. In a recent community based screening in Ethiopia (4) involving over 9000 people aged 15-69, the prevalence of elevated blood pressure was 15.8%.  Low income countries don’t have adequate resources to address this and other emerging chronic illness such as diabetes and heart disease.

There is often a unique and trusting relationship that exists between the customer and a stylist or barber. Barber shops and beauty salons are located in almost all major cities in Ethiopia and can be a means of reaching large numbers of individuals in screening for hypertension and other health issues.

Imagine sitting in a barber shop or hair stylist in Addis Ababa just before the upcoming Ethiopian New Year and having to check your own blood pressure while awaiting your turn!

 

References:

 

  1. J Vasc Surg. 2018 Aug;68(2):646-649
  2. Am J Prev Med. 2014 Jul;47(1):77-85
  3. Arch Intern Med. 2011 Feb 28;171(4):342-50
  4. PLoS One. 2018 May 9;13(5):e0194819

 

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Electronic Health Records: Challenges for sub-Saharan Africa

I knock at the door, walk in, greet the patient, and sit next to a desk top with access to the electronic medical chart. The patient had already been seen by a nurse, medications updated and vital signs taken.

I only have 20 minutes allocated to see the patient, review and discuss findings such as labs and imaging, chart my exams and summary of my assessment of the patient’s conditions and outline treatment plans. Often times medications are send electronically to the patient’s preferred pharmacy. The patient is given a print out of the visit summary. It is all digital.

This is the status of medical practice in America which is changing rapidly; more patients in less time. It is all possible, however , due to the availability of advanced electronic health records.

Come to sub-Saharan Africa, there are enormous challenges in adopting electronic health records (EHR) despite significant benefits of improving quality of care and patient safety, decrease health care cost and greater efficiency. EHR systems increase accuracy, reduce mistakes through allergy alerts, access to laboratory data, immunization history, improve organizational and societal outcomes. Data can also be used for health care research. If implemented, it will have tremendous impact in a region that has about a quarter of the world’s disease burden but 1/8th of the world’s population.

In an excellent review (Int J Health Sci (Qassim). 2017 Sep-Oct; 11(4): 59–64), the authors pointed out 4 main barriers to adoption of EHR in sub-Saharan Africa: high implementation and maintenance costs; limited computer skills; poor electricity supply and lack of constant internet connectivity, and lack of prioritization of EHR. They suggested financial support, using low-cost technologies and phased implementation as potential solutions.

In another systematic review (JMIR Med Inform. 2017 Oct-Dec; 5(4): e44.) that was done in collaboration with the University of Gondar Hospital in Ethiopia, given that the main barrier to adopting EHR software in low- and middle-income countries is the cost of its purchase and maintenance, the open-source approach as a good solution for these underserved areas was suggested which has been used in low income countries in Asia and South America.

About a year ago this time, I accompanied my cousin to see a physician. I was pleasantly surprised that everything from the initial checking in to the actual physician’s visit was paperless. He had a chest x ray first before called in to see the physician. A senior lung specialist greeted us, logged in his desktop, pulled up my cousin’s electronic chart, listened to his lungs, and looked at the CXR films which was loaded by the time we got there, compared it to the previous one and outlined treatment plans. Only this time it was in one of the new private hospitals in Addis Ababa, Ethiopia.

Health information is an essential tool in modern health care delivery; the role of the private sector shouldn’t be underestimated in advancing the reach of electronic health records in sub-Saharan Africa.

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A dollar a day

There is a call by the PM of Ethiopia to Ethiopians and people of Ethiopian origin to contribute a dollar a day for supporting the development of the country.

The class of 1989 at the medical school in Jimma University (South West Ethiopia) which used to be called Jimma Institute of health Sciences started with a class of 55 and after a grueling 7 years, about half, 27 to be exact, graduated.

Include me in that list.

The list goes down to 24 if you count out our Eritrean friends. Tuition, food, housing were all paid for by Ethiopia’s meager resources.

Fast forward to 2018, about 12 of the 24 (50%) graduates in 1996 are now practicing outside of Ethiopia. Our class has produced US board certified internists, a cardiologist, surgeon, endocrinologist, nephrologist, public health experts, pediatricians who are involved in private practice, academic and in international institutions.

This trend is well described in a recent publication (Hum Resour Health. 2017 Jun 26;15(1):4). The migration of African -educated physicians to the US has grown substantially from 2005 to 2015. The number of African-educated physicians who graduated from medical schools in sub-Saharan countries increased by over 300% in the 10 years specified above. Ethiopian trained physicians practicing in the US increased from 355 in 2005 to 666 in 2015, which is an astonishing 87% increase. This is not limited to Ethiopia. In the same study, Egypt, Nigeria, South Africa, Ethiopia, and Ghana account for 76.0% of all African-educated physicians in the United States.

If you break down the number of Ethiopian –educated physicians practicing in the US in 2015 by medical school, 365 were graduates of Addis Ababa University School of Medicine, 152 were trained at Gondar College of Medicine and 149 were trained at Jimma University.

In a paper published in 2011 looking at the financial cost of doctors emigrating from sub-Saharan Africa that studied 7 countries including Ethiopia (BMJ. 2011; 343: d7031.), total educational cost per student was $29898 in Ethiopia, $28620 of which was spend in medical school per medical student. If you extrapolate that data and multiply it by the number of Ethiopian trained physicians practicing in the US in 2015, it comes close to 20 million US dollars which is a lost investment for Ethiopia due to immigration of doctors to the US alone in the 10 years up to 2015. For the 9 countries included in the study (Ethiopia, Kenya, Malawi, Nigeria, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe), the overall estimated loss of returns from investment was $2.17bn.

So when the new Prime Minister of Ethiopia called for the diaspora Ethiopians and people of Ethiopian origin to contribute a dollar a day, he is reminding us that more is expected from us.

We certainly can do more than a dollar a day!

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At the end of the morning report

 

Eritrean –Ethiopian war (1998-2000), a brief reflection.

I took brisk steps as I approached the main entrance of the hospital’s auditorium. I was the on call GP. It was a busy night call.

I barely had a moment’s sleep. I had to pull the charts to be there on time to present the admissions and main events that happened overnight in this hospital in the center of Addis Ababa.

It was not an ordinary hospital; being late was not tolerated.

It was not an ordinary time, in the middle of the Eritrean –Ethiopian war.  It was in 1998.

The senior internists and general surgeons had taken the first raw followed by the two pediatricians, gynecologists, radiologists. And almost all of the general practitioners had taken the back rows. The room was unusually full. I found a spot towards the back next to my good friend Dr T. We both were recent graduates but from two different medical schools.  The hospital’s ear, nose and throat surgeon walked in next followed by the medical director of the hospital.

A former colonel, the medical director of the hospital was respected when it comes to medical knowledge but was also feared.

“Good morning,” he paused and looked at us.

“I want you all to stay after finishing the morning report.”

The room remained quiet.

The medical director looked at me and indicated to start the report.

I did a summary of how many patients I had seen in the hospital’s urgent care, how many I had admitted and I recall telling them with excitement the delivery of twins, a boy and girl that I had assisted. Respiratory ailments like tuberculosis, bronchitis, asthma, heart failure were all presented in a precise summary.

It was unusual in that no one was interrupting me with questions or comments  like the other morning reports. Even the surgeons were quite.

Everyone looked tense and away.

Shortly the chief nurse walked in and took a sit next to the medical director. We knew than something was up.

 

“Well, I know that you all may not be aware but today we have to pick one of you to join the medial team that will go to the war.” He said firmly.

The war was raging at the border between Ethiopia and Eritrea including at the disputed Badme. It was a war that eventually would kill several thousands and by some estimates close to 100,000. Unfortunately it was a war between two countries of the same people but there was no time to reason out. Logic didn’t exist.

Every one knew it was coming but at least some of us had no idea that it would be that fast.

“It is going to be a rotating service for 3 or 6 months,” he followed.

“The first one goes to,” he looked towards where I was seated next to my good friend Dr T unrolling the piece of paper that he picked.

Dr T was the lucky one. When the chief nurse announced his name he was stone cold and was still sitting after everyone else had left the room, in a hurry ,to call their families. I stayed behind.

It was a sacrifice the country requested.

He packed up the following day and joined the team that was heading north to assist the war. Dr T came back safe but with many war stories about heroic deeds and near survivals. Until the end of the war in 2000, many of my colleagues and other health providers followed… some of us were spared because of sheer luck but put up the time to cover our colleagues . It was a war that touched many lives.

Today, 20 years later, partly because of the change sought by the likes of the twins that have come of age since the war, the leaders of Ethiopia and Eritrea have resolved their differences and made peace so that the same people in two different countries ,however late , can restart living together in peace.

And no more surprises at the end of the morning report.

 

 

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Prime Minister Dr Abiy Ahmed of Ethiopia

THE ABIY PHENOMENON

( by Dr Solomon Feyissa) Image result for dr abiy ahmed

I can imagine that many of us have talked about the Abiy phenomenon since he came to power a little over 100 days ago.

I have been mentally wrestling with myself what term to use to describe the Abiy phenomenon and finally convinced myself that “perfect timing” would be appropriate.

Had he come to the scene few years earlier or few years later I would argue that he wouldn’t have become the promising leader that we all are talking about but instead a regular nice technocrat of limited significance. I strongly think that things were ripe for him to shine at this point in time in Ethiopian politics.

He came at the right time in the history of Ethiopian political struggle for real democracy. I disagree with other people who give him too much credit for the changes and sometimes try to make him a messiah figure or a cult leader which seems to be a very wrong way to understand and describe the situation and could be dangerous and may encourage dictatorship.

His rise to power needs to be understood with the preceding political events and bigger context of political struggle in Ethiopia. No doubt that he is the best messenger for reconciliation, forgiveness, peace, change, democracy and rule of law. He is the right leader at this critical time which Ethiopia needs desperately.

Timing is everything, so this is his time and we should see his role as part of a bigger picture of ongoing political struggle but not as a one man show.   I would say it is important to understand and acknowledge the significant historical events of our politics of the last half century to explain his ascendance to power.

He is the outcome of the multigenerational struggle for genuine participatory democracy and rule of law. He is the off spring of a very protracted conception, pregnancy, labor and delivery of a bitter political struggle and process which costed thousands of lives.

The struggle for democracy and rule of law has been fought by different groups in different forms and shapes starting from the Neway brothers, Mengistu and Girmame   coup d’état.   Countless Ethiopians sacrificed their lives under the umbrella of different organizations and popular movements including EPRP, MEISON, ELF,EPLF,TLF,TPLF,OLF,EPRDF etc and the original Yoyane movement, the Bale upraising and the Mecha tulema association etc…

The first real opportunity was created when Haile Selassie‘s monarchy collapsed which was exploited by some junior army officers who eventually hijacked the revolution and became dictators and killed, arrested or exiled their opponents.

A second opportunity was created when Derg fell and ERRDF took over. This was also wasted because EPRDF ended up being a dictator and oppressive regime primary serving the ruling class by marginalizing, alienating and excluding significant parts of the society.

The 2004 semi free election brought some hope but was quickly decimated when the fetus of democracy was aborted by primarily EPRDF antidemocratic actions and partly by failed leadership of incompetent, weak and divided opposition.

As the repression intensified the struggle travelled through different phases.

The current success has the following hallmarks

  1. Death of former Prime Minister Meles Zenawi in 2012 decapitated EPRDF and caused significant leadership and succession crisis and snowballed the current political change
  2. Incorporation of information technology including internet, mobile devices and social media as a means of political discourse helped better communicate and organize citizens
  3. The critical role the diaspora played in helping lead and organize the public at home and abroad
  4. The relative success of the ethnic nationalist opposition movements and parties vis a vis the multinational/multiethnic parties in helping better organize and lead the struggle (the Wolkite identity issues and the Oromo protests were very good examples as the primary engines of change for the current events)
  5. Formal and informal leaders of the recent struggle were very sophisticated and employed very successful peaceful resistance guided by prior proven experiences elsewhere and scientific literatures on the subject which posed a huge challenge to the ERPDF government which is known for its heavy handedness and militarism and was poorly equipped to handle such struggle
  6. EPRDF’s own weaknesses including corruption, failed leadership especially after the death of Meles and division within and among member parties.

In early summer 2016, the popular protest and struggle seem to have peaked particularly in Oromia and Amhara regions where lawlessness, and socioeconomic unrest prevailed at which time ERPDF led government had to do something to avert the looming political and socioeconomic disaster threatening the integrity of the country.

EPRDF brought new faces to the OPDO leadership in the Summer 2016 in an attempt to ease the popular anger and protest. Shortly after that Irecha massacre happened in late September 2016 which exacerbated the ongoing strife and EPRDF had to declare a state of emergency which was extended and lasted for 10 months.

The new OPDO leadership was led by Lema Megersa who seems to be the main architect of the current political philosophy in the country. Lema was able to assemble and bring in young, educated group of people, aka TEAM LEMA, to the OPDO leadership and the region. Lema started by listening to the public’s grievances and spoke the language of the ordinary person and was able to convince many that he is on their side with his incredible oratory.

Most of his speeches were in Oromiffa and his power was limited to the Oromia region thus non Oromo speakers were unable to see his incredible political skills until recently. Lema introduced some reforms at the Oromia regional level including justice reform, land distribution, media reform, freedom of expression etc…which gave him popular support. He also did a lot to rein in corruption in OPDO and the region. Lema was able to recruit Dr Abiy Ahmed to the Oromia regional administration who was at the federal ministry of science and technology until summer of 2016. Abiy eventually became Lema’s deputy in the summer of 2017.

In early fall of 2017 Lema led a delegation to Bahirdar ( capital of the Amhara regional state) and broke the spell of artificially created and manufactured hate between Amhara and Oromo. He made a famous and impassionate speech at the event which gave him university admiration and put him on a national spot light and was also praised by the diaspora. He did the same with other regions including the South, Benishangul and Gambela. I belive this was a turning point in the country’s political dynamics proving that the different ethnic groups have nothing to fear of their differences and can live and coexist with tolerance no matter what.

As popular protest reached it’s peak causing subsequent strikes and siege of the capital, Prime minister Hailemariam Desalegn was forced to resign in an attempt by EPRDF to come up with some drastic measures/solution to solve the crisis. EPRDF also declared a second state of emergency. EPRDF government seems to have failed in bringing peace and stability despite using all tactics and putting all of its cards on the table so was forced to make some unconventional moves out of desperation.

The vacancy created by the resignation of the Prime Minister gave OPDO a chance to nominate the next EPRDF chairman and Prime Minister. Lema Megersa had the best chance to become EPRDF chairman and the next PM among the other leaders of EPRDF member parties but he was not a member of the federal parliament which essentially excluded him. He was a member of the regional parliament instead. OPDO as a party and Lema as its leader were very aggressive and publicly lobbied to get the position. OPDO made a very unusual move to give its candidate a better chance and remove even the perceived slightest hurdle it might face during the election process and to that effect OPDO decided to make Lema deputy and Dr Abiy chairman; essentially they swapped positions. Lema gets a huge credit for this maneuver which seems also selfless on his part to let his deputy take over his post and make himself a deputy.

This paved the way for Dr Abiy Ahmed to get a shot at the candidacy for the chairmanship of EPRDF and PM.    OPDO arm wrestled with TPLF during EPRDF meeting to get its nominee elected as chairman and was only successful after it got significant and tactical support from most ANDM and some SNNRP   members. Dr Abiy Ahmed became chairman of the EPRDF and elected by parliament to be the next PM in early April and after that the rest is history.

So far his performance is impressive and earned him majority support from all walks of lives even if he appears to have  some opponents from the old guard and hardcore EPRDFites.

I don’t intent to mention laundry list of his achievements in the first 100 days because they are public record and easy for anyone to see. Rather I will dwell in explaining his personal attributes, political advantages and political philosophy as mentioned below.

  1. His overarching theme seems to be reconciliation, peace, forgiveness, inclusiveness and love in an attempt to bring the country together and move towards democracy, the rule of law and prosperity and move away from vindictive politics of zero sum game and as an avid reader he might have gotten some inspirations from MLK, Gandi and Mandela
  2. Has exceptional work ethic and obsessed with not wasting any time and can be described as a 24/7 leader
  3. Cognizant of the fact that as leader he can set the tone of dialogue and political discourse through powerful rhetoric
  4. He seems to be using his literature and writing skills to give some life to his political speeches  and make it more palatable as opposed to a boring, dry cadre style political monologue.
  5. He is using his personal appeal and charisma to achieve his political objective and can be best described as the huger in chief
  6. Some of the overwhelming support he is getting from the public seems to make him more confident and bold by the day encouraging him to take more constructive steps
  7. Seems that he has some strong moral and faith background and very supportive of people of faith and religion behind and around him. Testament to that he was able to reconcile the divisions with the Ethiopian Orthodox Church, a remarkable fit in of itself.
  8. Seems to be using some evangelical skills in the content and delivery of his speech which MLK had used extensively
  9. Very savvy in using traditional media and information technology including social media
  10. Was able to connect to different sections of the community with his relative young age appeal and diverse back ground (his father is a Muslim from Agaro, his mother is a Christian from West shoa, married to a woman from Gonder)
  11. Has used his multilingual skills to the fullest (fluent in Tigrigna, Amharic, Oromoffa, English) to better communicate his political message, connect with people and achieve his political goals
  12. The fact that he came from the party operating in the region (OPDO)which was hit hard by the protest gives him some legitimacy, credibility and gets him the necessary constituency support
  13. Very ambitious man who is a thinker with big ideas which brings a good remedy for some of the small fights in our political discourse like tribalism
  14. Full of hope, aspirations with potential to influence not only socioeconomic and political landscape and dynamics of Ethiopia but also the horn and East Africa at large. Normalization of relations between Ethiopia and Eritrea is one such deed.
  15. Capable of writing new chapters in the political discourse and narratives and willing to take risks and to go to unchartered territory to explore new possibilities
  16. Seems committed to reading, willing to listen, learn and make corrections as needed
  17. His life journey seems to have made him ready for the job with the necessary academic and professional experiences required; he was a colonel in the military, director of INSA/cybersecurity agency, has a Ph. D. in peace and security, was head of OPDO secretariat, member of the federal parliament and had federal and regional ministerial posts.
  18. Seems to be willing to fight for his ideals and face the consequences of his actions and pay the necessary price to achieve his or his party’s goal.
  19. Seems to have the right temperament, personality and good will concerned for the wellbeing of his citizens
  20. Seem to create a good vibe and working environment for colleagues and create a positive atmosphere and encourage others change and improve for the better.

I believe we are just witnessing the beginning chapters of yet to be unraveled great life as a leader. Time will tell how far he can transform the struggle of the Ethiopian people in realizing real democracy, rule of law, peace, prosperity and stability.

We also shall see what kind of influence he will have on the horn and greater East Africa with regard to peace, stability and economic integration.

I also believe that the general public with well-informed active engagement and participation has significant leverage and can help him steer the wheel of change to bring the desired out comes benefiting all.

I have high hopes for him and believe that we will be talking and writing more about the remaining chapter of the Dr Abiy Ahmed’s phenomenon in the months and years to come. I can see more potential and greatness in his future.

I wish him, all Ethiopians, the citizens of the horn and east Africa good luck.

 

Dr Solomon Feyissa is a practicing physician based in the USA.

 

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Nancy Alonso

I found a surprise note on my desk after the morning clinic. It was a busy clinic with patients of various kidney and electrolyte problems including a challenging case of hypokalemia or low potassium.

At first it didn’t click. I read the note again,

Please call Nancy Alonso at———- she is in Miami waiting for your call.

It sure was her, her voice still strong.

We were a bunch of 18 year olds sitting in one of the new lecture halls awaiting to see the famous Cuban physiology professor. It was twenty six years ago in what then used to be called Jimma Institute of Health Sciences, one of the only three medical schools at the time, located in South West Ethiopia.

A sharp, intelligent and telegenic Cuban professor would walk in that morning and every morning for a year to lay the foundation for our education in medicine. There is no medicine without human physiology. There was no better professor than Nancy Alonso, in South West Ethiopia, where we had scarcity of educational materials.

She brought the complex human physiology in a way we could grasp and enjoy it. I still do.

It was a very volatile time in Ethiopia. The Cuban professors including Nancy had to leave after a change of government leaving a vacuum in the medical school which fortunately was temporary. With a strong foundation in physiology, most of the class of 89 went on to finish medical school. Some of us had the opportunity to pursue sub-specialty medical training in Ethiopia and beyond working now in private practice and academia, teaching the next generation of health providers. Among us are US board certified internists, cardiologists, endocrinologists, nephrologists, surgeons, to name a few.

I drove to Miami to pick her up. We were both thrilled to meet again.

She was dressed in an Ethiopian outfit and carrying a present for us, berbere, Ethiopian hot spice, and Teff, Ethiopian super grain, that she got in one of the Ethiopian stores.
After a cup of strong Cuban coffee, we drove to our house to spend the afternoon with my wife and daughter.

It was easy to see that Nancy Alonso’s two years in Ethiopia from 1989 to 1991 had left a lasting impression on her about the country, its people and culture. She told me that her experience in Ethiopia played a role in her becoming a writer. She also told me that she has an upcoming collection of short stories reflecting Africa. Most of her works are in Spanish but some are translated in to English.

We are testament that people like Nancy who travelled the world to teach did make a difference in the lives of many. Unfortunately some may not even know the impact they had on other’s lives.

This is a thank you note to Nancy Alonso, the Cuban biology professor and writer, for her contribution to our early education in physiology and medicine and for who we are today as a person.

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A life matters !

“Doctor, doctor, doctor,” she said, with a Spanish accent

“Look at me doctor,” she said again grinning

“Look at my face, I am happy now, I am happy now, my life is back”

Her eyes welled up with tears
This was a mother who had suffered from chronic illness
For too long
That many physicians in the Americas missed
Because they were looking for common things
Even after her vital organs, like the kidney and liver
Started to fail

I remember the day I saw her
I could tell her body was on fire
Of inflammation
That alluded many

Until we made a diagnosis of the rarest of rare diseases
Almost a decade after her initial symptoms

When I look back, it is not because we are genius
Or it is not because we had an eureka moment

It was because we opened our eyes, scratched our head
And looked for rare diseases

Because a life matters!

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