The Bone Setter

By Surafel K Gebreselassie

It wasn’t a surprise to see trauma cases every week. They varied from car accidents to simple falls. They were of all ages. The surgical outpatient clinic had just enough things to manage simple fractures and other minor traumas. The room had a desk, two chairs, an examination bed, few materials to make arm slings and simple casts. We also had analgesics and antibiotics.

I was finishing my coffee, one of Ethiopia’s gifts to the world when the nurse alerted me about a patient. It is not a coincidence that coffee originated where mankind did; that is if you believe in science. Many do.

So when Mosisa, a middle aged man from Keffa, was brought drenched in sweat, we were ready to help. He was cutting firewood when he fell. We used to be good at handling trauma. We quickly ticked off the main things; air way, breathing and circulation. He didn’t suffer major injury. His left forearm was swollen and had bruise marks. We send him for X-ray.

The day went buy quickly; a child with snake bite, a girl with a minor cut, a woman with a first degree burn, an elderly man with intestinal obstruction that we had to refer for emergency surgery.

It wasn’t until late in the day that I realized I didn’t see Mosisa back from X-ray. I called the radiology department. He had the X-ray and was sent back with the films but he was nowhere to be found.

Traditional bone setting is practiced in many developing countries. There are over 70,000 traditional bone setters in India, one of the largest groups practicing traditional medicine in the country. Although actual numbers are not available, traditional bone setters are commonly available in Ethiopia and are not limited to rural areas. They offer treatment for fractures and dislocation of bones. They often offer cheaper treatment and are believed to use faster healing methods. Fear of prolonged immobilization, perceived complications such as infections and amputations drives many patients to see traditional bone setters. Where there is lack of access and scarcity of resources, traditional bone setters may be the only readily available option for many patients in many developing countries. While many fractures heal properly with traditional treatment, bone setters often do not appreciate the dangers of tight splints that can, in some instances ,lead to gangrene by cutting out circulations. They often use splints made from split bamboo or strips of wood tightly bound around the limb, and in some cases including local joints. For example, in a study done in Arba Minch Hospital in Southern Ethiopia from 1999 to 2001, there were 49 amputations of which 25 (51%) had been required because of application of tight splints by a traditional bone setter.

It wasn’t just me. It wasn’t just Mosisa who disappeared with his own X-ray films. Many of my co-interns started to see the trend. Some patients would come back the following day or after a day or two with their X-ray films. Those tended to be complicated ones. We never saw the simple fractures again. The patients would walk in, go to the radiology department, pick up their X-ray films and disappear.

There are many smart people in every society although we may not appreciate them readily. One such person living not far from our clinic was a retired high school biology teacher who picked up bone setting. He would send the patients to the clinic where they get free X-rays. The loyal patients would take the films to him as instructed. He would look at the films. Where there is good alignment he placed bamboo splints, charged a few bucks and we no more saw those patients. When he thought it was a complicated fracture or couldn’t read the X-ray well he would send the patients back to the clinic, often the following day or a day after.

I never say Mosisa again. I suspected that he would have had a simple fracture, well aligned, probably had a bamboo splint, paid few buck to the retired biology teacher, went back to cutting his firewood reassured that he is in the safe hands of a clever bone setter in the neighborhood.

References used in the article
J Ayurveda Integr Med. 2011 Oct;2(4):174-8
J Bone Joint Surg Br. 2005 Jan;87(1):102-3.

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Albinos, what has lack of an enzyme got to do with a tragedy!

Ignorance and superstition fuel the persecution of albinos.

By Dr Solomon Feyissa

In this day and age many would assume that albinism is a fairly understood phenomenon. However the experience of albinos in some parts of the world doesn’t support this assumption. Rather albinism is misunderstood especially in some parts of Africa resulting in misconception and superstition, contributing to stigma, discrimination and persecution.

Albinism is a congenital disorder characterized by the complete or partial absence of pigment in the skin, hair and eyes due to absence or defect of tyrosinase (an enzyme which synthesizes melanin from the amino acid tyrosine). Albinism results from inheritance of a gene and is known to affect all vertebrates including humans. While an organism with complete absence of melanin is called an albino an organism with only a diminished amount of melanin is described as albinoid. Albinism affects people of all ethnic backgrounds; its frequency worldwide is estimated to be approximately one in 17,000. Prevalence of the different forms of albinism varies considerably by population, and is highest overall in people of sub-Saharan African descent. Albinism is associated with a number of vision defects, such as photophobia, nystagmus, and astigmatism. Some are legally blind. Lack of skin pigmentation makes for more susceptibility to sunburn and skin cancers.

It’s mind boggling to think that this simple truth about albinism didn’t reach some part of humanity in the 21st century. Given their predisposition to many diseases including skin cancers and visual disabilities, the public and society at large owes to albinos to provide them with extra protection and care they need. However in some part of the world they have to bear extra burden of stigma, discrimination and in some circumstances they are persecuted, mutilated and murdered. Persecution of people with albinism may occur for different reasons. One is based on the belief that certain body parts of albinistic people can transmit magical powers. Such superstition is present in some parts of the African Great Lakes region; it has been propagated and exploited by witch doctors and others who use such body parts as ingredients in rituals, magical or medicinal mixes, cocktails or drinks with the claim that their magic will bring prosperity to the user (“muti” or medicine murder). As a result, people with albinism have been persecuted, killed and dismembered, and graves of albinos dug up and desecrated. At the same time, people with albinism have also been ostracized (expelled from family or community) and even killed for exactly the opposite reason, because they are presumed to be cursed and bring bad luck. One such example is albino experience in Tanzania, the great lakes region and southeastern Africa. It is estimated that over 150,000 albinos live in Tanzania. A number of albinos have fled to the Dar es Salaam area as they feel safer in an urban setting. Tanzania is thought to have the largest population of albinos in Africa. Victims include children snatched or abducted from their parents. The killers and their accomplices use hair, arms, legs, skin, eyes, genitals, and blood in rituals or for witch medicinal or magical mixes or drinks. Fishermen incorporate albino hair into their nets in their hope to catch more fish from Lake Victoria or to find gold in the belly of the fish that they catch. Being an albino can be a death sentence in Tanzania. Since 2006, 71 people have been killed and another 29 have been attacked. 1 every 1,400 Tanzanians has it (the world average is 1 in 17,000). Most of the violence occur in the mining and fishing communities near Lake Victoria. By June 2008 killings had been reported in neighboring Kenya and possibly also the Democratic Republic of Congo. In October 2008 AFP reported on the further expansion of killings of albinos to the Ruyigi region of Burundi. Body parts of the victims are then smuggled to Tanzania where they are used for witch doctor rituals and potions. It looks like Albinos have become a commercial good. By 2010 cases had also been reported from Swaziland. Due to misinformation, ignorance and superstition, some locals believe albinos are ghosts that can’t die. Others think they were born into cursed families. And—most chillingly—witch doctors want to hack off their limbs to put in magic potions promising prosperity and healing. A complete albino “set”—ears, tongue, nose, genitals, all four limbs—can sell for several thousands. As a result, many of Tanzania’s 17,000 albinos have been hidden away by the government.Traders sell “cures” in the market of Mgusu. In Tanzania, where the annual per capita income in 2010 was $442, the limb of an albino may sell for up to $2,000. A miner will pour it in the ground where he wants to find minerals or a fisherman will pour it in his canoe. Since the police began protecting albinos, traders have complained that the price of the magic has become expensive. Albinism divides many families in Tanzania. Some albino children, are dropped at orphanages and never see their parents again. Others are raised solely by their mothers, abandoned by fathers who accuse their wives of having had affairs with white men. As a result, some albinos choose to marry those who understand them best: fellow albinos. Two parents with albinism, however, increases the probability that their children will be born with the condition. Despite the Tanzanian government’s efforts to educate the populace and end these killings, albinos are still seen as valuable commodities on the black market. The hunt for them has spread across the continent to Burundi, Kenya, and Swaziland. Many albino children face dim futures. Beyond primary school, little educational infrastructure exists for them. And in some communities, they’re considered mentally retarded and discouraged from attending school at all. Those who pursue an education often fall behind due to low vision, an affliction associated with albinism that makes reading difficult. Many grow up to be illiterate and work menial jobs. According to the Red Cross at least 10,000 albinos in East Africa have been displaced or have gone into hiding. Witch doctors have made tens of thousands of dollars from selling potions and other items made from their bones, hair, and skin. Rape is another horror faced by Tanzanian albinos. Girls, often in the remote northwest of the country, have been assaulted by men who believe that intercourse with an albino can cure AIDS. The exact number of victims is unknown, as social stigma prevents many girls from reporting rape. About 1.4 million Tanzanians have HIV.

There is some light at the end of the tunnel. A number of steps were taken by the government of Tanzania to protect the albino population. The president ordered a crackdown on witchdoctors. In addition, an albino woman, Al-Shymaa Kway-Geer, was named to become a member of the parliament, the first albino in such a position in the history of Tanzania. Police have also been advised to generate lists of albinos and provide special protection for them. To foil graverobbers, graves of the albinistic were to be sealed with concrete. However, by October 2008, killings had not abated, and while some suspects had been apprehended, no convictions had taken place. In January 2009, “Prime Minister Pinda had declared war on the albino hunters, and in an effort to stop the trade in albino body parts he had revoked the licenses of all the country’s witch doctors who use the body parts in their rituals. The first ever conviction for the killing of an albino in Tanzania occurred on 23 September 2009. The conviction came about following the murder and mutilation of a 14-year-old boy, Matatizo Dunia, who was attacked by three men in December 2008.The men carried the albino boy from his home late at night before chopping him into pieces. One of them was later found with the albino boy’s leg in his possession. The rest of the body parts were located concealed in a bush. The men confessed a desire to sell the body parts to a witch doctor. They were convicted and received death sentences. After events involving murders of albino humans by three Tanzanian men had been publicised by the BBC and others, the European Parliament strongly condemned the killing of albinos in Tanzania on 4 September 2008. The U.S. House of Representatives passed H. Resolution 1088, introduced by Rep Gerry Connolly (D, VA), by a vote of 418-1 on February 22, 2010. The resolution condemns the attacks and killings; categorizes them as human rights violations, and urges the governments of Tanzania and Burundi to vigorously prosecute such cases and to conduct educational campaigns to combat the superstitious beliefs that underlie the violent attacks.

References:
1. Wikipedia; persecution of people with albinism.
2. BBC news, 27 July 2008. “Tanzania Albinos Targeted Again”.
3. National Geographic article “As Tanzania’s Albino Killings Continue, Unanswered Questions Raise Fears” October 2013.
4. Superstition sparks violence against Tanzanian albinos, Jacob Kushner, NBC news/Global post, November 6th 2013

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The untimely death of the doctor

By Dr Kebede H Begna

I remember that long day and night at the intensive care unit of the ‘Tikur Anbessa” hospital, one of the largest and teaching hospitals at a metropolitan city, Addis Ababa, Ethiopia. It is the only major referral center of a city with 5 million people. I was the on call medical intensive care unit (ICU) resident. I was then given the privilege to take care of my own professor, who happened to come to the unit after a complicated surgery. He was a devoted teacher at the prime age of productivity. He had had blood in his stool but ignored it after he made a self-diagnosis of hemorrhoids. The bloody bowel movement worsened during a six weeks rural attachment service to Zewai, a small regional town, that he went with the final year medical students. His friends supported his suspicion and attributed the worsening of symptoms to the diet and dehydration due to the rift Valley desert hence did not seek medical attention soon enough. Finally he needed to be transported to Tikur Anbesaa hospital because of intestinal obstruction. The surgeon, a friend of the professor, had to make a difficult decision of closing the abdomen without doing any surgery. The fungating mass arising from his rectum not only closed the outlet passage but spread to the entire abdomen and liver. There was no precedent of survival to a disease of such degree, let alone at that time and that place, even in the age of molecular and targeted therapy.
They say, hindsight is always right, had he sought medical advice when he first saw blood in his stool, the young life would have not be lost. He was a loss to his wife, young children , the medical community , and to the whole country.
In the good old days, residents are expected to work like a robot. After a sleepless night taking care of my professor, and a rather long day, living far away from the hospital with my parents, I need to take a taxi drive through the busiest market in Africa, Merkato. I stopped by a barber shop to have a haircut. The moment I touched the whirling barber chair I fell asleep as if I had narcolepsy. The barber felt something wasn’t right about me. I did not tell him that I was on call and about to lose one of my mentors to cancer.

Colo-Rectal cancer is the second commonly diagnosed cancer after breast; and the third common in men after prostate and lung. It is though to be the second leading cause of cancer death in both sexes [Global cancer statistics. CA Cancer J Clin 2011;61(2):69 and 2014:64(1):9]. Approximately one in three people with colorectal cancer die of their disease.

My country folks say an ounce of prevention is better than a gallon of cure. Screening has been shown to decrease colorectal cancer mortality in number of studies; one module predicted that screening may account for the 53% of the observed decrease in colorectal mortality [Annual report to the nation on the status of cancer, 1975-2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer. 2010;116(3):544).
With age appropriate screening measure and proactive search for advice with first sign of blood with stool, life and misery can be avoided.
The take home message is do not consider blood with stool as benign with out proper evaluation. It is colon cancer unless proven otherwise, especially above the age of 40.

 

Dr Kebede H Begna is an accomplished oncologist currently practicing in the US.

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DAWN OF HOPE IN THE FIGHT AGAINST HIV/AIDS

The story of long acting Anti-retrovirals

By Dr Solomon A Feyissa

Very promising sign for future of pre exposure prophylaxis(PrEP) and potentially revolutionary step for antiretroviral therapy.

Advances in medical science have made HIV/AIDS a less lethal and chronically manageable medical problem. However we are still very far away from a cure or a vaccine. Antiretroviral medications have to be taken on a daily basis for life to manage the disease. Antiretroviral treatment requires adherence and compliance to be effective. It also causes significant side effects. In some parts of the world patients who are taking medications still face significant discrimination and stigma. Recent advances in long acting antiretroviral medications would address some of the current challenges of pre exposure prophylaxis and antiretroviral therapy including decreasing pill burden, side effects, stigma and discrimination and open the door for new opportunities and strategies of treatment and prophylaxis.

Recent studies shed light on the potentials of long acting antiretroviral:

Preexposure prophylaxis (PrEP) with oral tenofovir/emtricitabine, oral tenofovir, or tenofovir gel has protected some women and men from HIV in placebo-controlled trials. But all three strategies failed in two other trials involving African women, mainly because of poor adherence. A long-acting injected PrEP (post exposure prophylaxis) agent would obviate the need for daily adherence and could be a useful prophylactic for women and men who could get such a shot without fear of stigma.

Some antiretroviral have demonstrated that they have surprisingly very long half life after a single dose paving the way for possible monthly or quarterly administered therapy for pre exposure prophylaxis or chronic HIV/AIDS therapy. In one study,GSK1265744 (long acting Integrase Inhibitor) half-life ranged from 21 to 50 days after a single injection of various test doses in 56 HIV-negative volunteers .
Long-acting antiretrovirals could become preferred agents for HIV preexposure prophylaxis (PrEP) as well as for treatment of chronic HIV infection. GlaxoSmithKline and Janssen investigators conducted a trial (clinicaltrials.gov NCT01593046) to assess the safety, tolerability, and pharmacokinetics of GSK744 ( long-acting parenteral integrase inhibitor) with repeated intramuscular or subcutaneous doses in healthy adults, administered with TMC278 LA (long acting NNRTI) injected intramuscularly.There were no drug-related serious adverse events or significant laboratory abnormalities in this first repeat-dose 16-week study of these long-acting injected agents. Ongoing studies include evaluation of these two agents administered orally as a maintenance regimen for HIV-positive people. Pending results of this trial, injection of long-acting of these antiretrovirals may be tested in people with HIV.

In another study presented at the 20th Conference on Retroviruses and Opportunistic Infections, March 3-6, 2013, Atlanta, researchers were able to demonstrate the following results; the study was conducted on macaque monkeys. Two doses of GSK1265744-LAP (long acting integrase inhibitor) protected eight macaque monkeys from a challenge with simian HIV (SHIV), a simian immunodeficiency virus with an HIV coat. The investigational integrase inhibitor is already being studied in humans. GSK1265744 half-life ranged from 21 to 50 days after a single injection of various test doses in 56 HIV-negative volunteers.
In this study US researchers collaborating with GlaxoSmithKline, developer of GSK1265744, tested the protective potential of GSK744LAP in 16 macaque monkeys, 8 of them given an intramuscular injection of GSK744LAP at a dose of 50 mg/kg at two points 4 weeks apart and 1 week before SHIV exposure. Eight control macaques received no GSK744LAP. All macaques were exposed once a week for up to 8 weeks with SHIV. The researchers monitored macaque monkeys for SHIV infection with real-time polymerase chain reaction amplification of viral gag sequences in plasma samples collected weekly. All animals tolerated GSK744LAP. The macaque monkeys not injected with the integrase inhibitor all became infected after a median of two SHIV exposures (range 1 to 7 weeks). None of the 8 macaques treated with GSK744LAP a week before SHIV challenge became infected during the 8 SHIV challenges or 3 weeks after the last challenge (P < 0.0001 versus control). No proviral DNA could be detected in peripheral blood mononuclear cells and no anti-SHIV antibodies could be detected in plasma of treated macaque monkeys. Both signals of infection could be detected in untreated animals. Plasma concentrations of GSK1265744 throughout the study period remained comparable to exposures achieved in humans with an 800-mg loading dose and another 400 mg 4 weeks later. GSK1265744 trough concentrations were also similar in macaque monkeys and humans.The researchers plan to monitor all macaque monkeys for at least 10 weeks after the last SHIV challenge. The animals will then be sacrificed to permit extensive tissue analysis for SHIV. The investigators also plan to study GSK744LAP in female macaque monkeys.They conclude that "GSK744LAP appears to be a promising next-generation PrEP agent suitable for monthly to quarterly injections."

On going extraordinary achievements and discoveries in the field of HIV is making more likely than ever that the day when pre exposure prophylaxis and potentially HIV therapy could be accomplished with long acting injectables with a monthly or quarterly administration of medications is finally within our reach. We will stay tuned for more exciting news in the fight against one of the deadliest disease of our generation.

References:

1. Andrews C, Gettie A, Russell–Lodrigue K, et al. Long-acting parenteral formulation of GSK1265744 protects macaques against repeated intrarectal challenges with SHIV. 20th Conference on Retroviruses and Opportunistic Infections. March 3-6, 2013. Atlanta. Abstract 24LB.

2. Spreen W, Ford SL, Chen S, et al. Pharmacokinetics, safety and tolerability of the HIV integrase inhibitor S/GSK1265744 long acting parenteral nanosuspension following single dose administration to healthy adults. XIX International AIDS Conference. July 22-27, 2012. Washington, DC.

3. Spreen W, Williams P, Margolis D, et al. First study of repeat dose co-administration of GSK1265744 and TMC278 long-acting parenteral nanosuspensions: pharmacokinetics, safety and tolerability in healthy adults. 7th IAS Conference on HIV Pathogenesis, Treatment and Prevention, June 30-July 3, 2013, Kuala Lumpur. Abstract WEAB0103

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Battle of Adwa :March 1, 1896

Menilek destroys Italian army at the battle of Adwa on March 1st 1896

Chronology of events:

•1883 : Italian government buys Assab bay from Italian commercial firms
•1885 ( Feb 5): Italian landing to occupy Massawa
•1887 (Jan 27th) : Ras Alula defeats Italians at the battle of Dogali. Italians suffer 512 casualties.
•1889 ( March 9) : Emperor Yohaness IV fatally wounded in the battle of Metema against Mahdists, and names Ras Mengesha his heir. The death of Yohannes IV and the eruption of Great Famine (1888-1892) facilitated the expansion of the Italians as they met little resistance on their way.
•Menilek laid claim to the Ethiopian throne thanks to lineage reaching back to King Solomon and Queen Sheba. For Taytu Betul, marriage to Menilek ( who divorced princess Altash ,and had relationship with Bafena ) would fulfill a prophecy of royal destiny. Menilek and Taytu sealed their union on Easter Sunday in 1883. Taytu is of Oromo decent and was born in Semien, near Tigray with family contacts throughout the north bringing Menilek a local legitimacy.
•1889 ( March 26th): Menilek of Shewa declares himself emperor
•1889 ( May 2nd) :Treaty of Wuchale between Italians and Menilek. Antonelli signed on behalf of Italy. Article 17 stated in Italian version that Italy would control Ethiopia’s external affairs; the Amharic version said that Menilek could choose whether or not to ask the Italians to act on his behalf, but was not required to do so. Ethiopians said it was a trick; Italians blamed the Ethiopian translator (Geraz. Yosef Neguse who knew French but not Italian)
•October 1889, Italy declared a protectorate over Ethiopia on the basis of article 17.
•Queen Victoria expressed her happiness at learning of Menilek’s accession but advised him to send all subsequent messages to London through the king of Italy.
•A great Furor resulted at Menilek’s court. Count Augusto Salimbeni was called in and shown the Amharic version of the treaty. Menilek had been assailed by domestic critics for having “sold” the country. Empress Taytu came close to accusing her husband of treason.
•France never recognized the treaty of Wuchale despite Rome trying hard. The French government awarded Menilek the Grand Cordon of the Legion of Honor for his efforts to abolish slavery and bring “ civilization” to his country but refused arms.
•1890 ( Jan 1st): Italians formally establish colony of Eritrea
•1891 ( Nov 1st) MajGen Oreste Baratieri appointed commander of Italy’s African forces
•Menilek adhered to Article 16 of the treaty which provided for review after 5 years from date of signature.
•Feb 27, 1893 he declared to the governments of Italy, Germany, France and Great Britain that: The Treaty of Wuchale would be null and void as of 1May 1894 but that he is not nullifying friendship with Italy
•Feb 1894 : King Tekle Haimanot of Gojam and his army joins Menelik in Addis, was impressed by the palace; looking out he could see that the windows “ let in light, but not the wind”
•Isolated in Tigray, Ras Mengesha concluded that a sovereign Ethiopia was better than a colonial state.
•June 1894: he ( 32 yrs) and his army of 6000, Ras Alula and other chiefs arrived in Addis. Menilek pardoned them bringing Tigray back in to the empire. Menelik counseled Mengesha Yohannes not to make any rash moves against Italy. Highlands of Eritrea tried to rejoin the motherland; Italians quickly suppressed the insurrection.
•In 1894, Adwa was plundered by the native troops of Barattieri.
•Ras Mengesha marched to Koatit and Senafe in 1895 against the Italians.
•May 5 1894 , an Anglo-Italian protocol was issued which placed Harar within Italian sphere of influence. Paris objected but Treaty of Wuchale was mentioned as a reason.
•Pietro Antoneli was appointed the undersecretary of Foreign Affairs by Prime Minister Crispi ( who took power Dec 15,1893) send him to Menilek to resolve “their difficulties”. No one in Ethiopian believed any longer the intentions of Italy.
•1895 ( Sep 17th) Menilek calls for total mobilization of Ethiopian forces
•Estimated Ethiopian Army: 145, 0000 men of whom 57,000 mounted and 71000 with fire arms with 28000 having breech –loaders; 10,000 women lead by Empress Taytu. Ethiopia had 80,000 rifles, 8,600 horses and 42 guns
•1895 ( Dec 7th) Ethiopians wipe out Italian garrison at Amba Alagi
•1896 ( Jan 20th) Italian garrison at Mekele surrenders on terms
•1896 ( Feb 14): Menilek and Taytu arrive at Adwa
•1896 ( Feb 29th) : Baratieri decides to advance the night of the 29th.
•The Ethiopian guide (misdirection or sabotage) led the Italians astray.
•At 4 am on March 1st Menilek, Taytu and the Rases were at mass. A number of couriers and runners rushed in to report the enemy was approaching in force.
•The green, orange and red flag was unfurled and at 5:30 am Menilek’s 100 K strong army moved forward. The Ethiopian army was led by Menilek and Taitu (troops of Shewans, and south and south-western Oromos); Ras Mekonnen (troops of Harar); Ras Wolle (Yejju contingent-Amharans and Oromos); Ras Michael (Wallo Oromo army); Ras Mengesha (Tigrian troops); Ras Alula (Tigrian troops of northern frontier); Wagshum Gwangul (Wag and Lasta troops); Negus Teklehaimanot (Gojjam troops); and Ras Sebhat and Hagos Teferi (Agame troops).
•By 9 am Italian center crumbled.By noon retreat started.
•March 1st: Menilek destroys Italian army at the battle of Adwa. Italian loss: 6133 men killed ( 261 oficers,2918 while, 954 permanently missing, and about 2000 ascari). Another 1428 wounded ( 470 Italians including 31 officers, and 958 ascari). 3000-4000 taken prisoners. Italy lost 70% of its forces. Ethiopian losses: 4000 – 7000 killed, 10,000 wounded ( far smaller percent of strength)

Refereces
1.Jonas, R. (2011). The Battle of Adwa: African Victory In The Age of Empire,Cambridge:Harvard University Press
2.McLachlan, S. (2011). Armies of the Adwa Campaign 1896: The Italian Disaster in Ethiopia, Oxford: Osprey Pulishing Ltd.
3.Prouty, C. (1986). Empress Taytu and Menilek II: Ethiopia 1883-1910, New Jersey:The Red Sea Press.
4.Marcus, H.G. (2002). A History of EthiopiaLos Angeles: University of California Press.
5.Hansen, J.(2004).African Princess: The Amazing Lives of Africa’s Royal Women, NY: The Madison Press Ltd
6.Meredith, M. (2011) The fate of Africa: A history of the Continent Since Independence, NY: Public Affairs.
7.Harris , J.E. (1994). African –American Reactions To War In Ethiopia 1936-1941, Baton Rouge: Louisiana State University Press.

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End stage kidney disease in sub-Saharan Africa , is kidney transplantation the answer ?

Since the first successful kidney transplantation on Dec 23, 1954 at Brigham hospital in Boston, Massachusetts across identical twins, kidney transplantation has become the ultimate choice for patients with end stage kidney disease near or requiring dialysis conferring improved survival advantages, a better quality of life and decreased long term health care costs compared to dialysis.
While infection such as malaria , tuberculosis, HIV are still the leading causes of death in sub-Saharan Africa ( comprises of 47 countries with over 80% of the land mass of the African continent), non-communicable diseases such as diabetes mellitus and hypertension are becoming more prevalent contributing to the health care burden of these countries. Both diabetes and hypertension are leading cause of kidney failure. The prevalence of diabetic kidney disease is as high as 23.8% in Zambia, 14-16% in South Africa, 12.4% in Egypt, 9% in Sudan and about 6.1% in Ethiopia with overall estimate of 6-16% in sub-Saharan Africa.(1). Glomerular disease is also a common cause of end stage kidney disease with the nephrotic syndrome many fold higher in Africa (2). Chronic glomerulonephritis, diabetes and hypertension are also the leading causes of chronic kidney disease in Ethiopia as is true in the rest of sub-Saharan Africa (3). There is limited availability of dialysis and transplantation in sub-Saharan Africa, both cost and shortage of skilled personnel as main limitations. Many parts of sub-Saharan Africa lack nephrologists ranging from 0.5 per million populations in Kenya to 1.1 per million populations in South Africa. Funding for dialysis or transplantation in sub-Saharan Africa is mainly private and most patients can’t afford dialysis three times per week. For example only about 20% of patients in one Nigerian center can afford hemodialysis three times a week (1). Some countries such as Mali, Mauritius, South Africa and Sudan have government programs for some patients. For example South African covers for dialysis cost for patients who are eligible for transplantation. Peritoneal dialysis is limited in sub-Saharan Africa to few countries such South Africa because of the cost of the fluid and perceived risk of infection (peritonitis). Only a handful of countries such as South Africa and Kenya manufacture dialysis solutions. In Sub-Saharan Africa where 65% of the population lives in rural areas, although peritoneal dialysis seems a better option, there are other challenges such difficulty arranging transportation of dialysis supplies, lack of availability of space for storing dialysis supplies compounded by lack of access to clean water, electricity, etc. The average cost of hemodialysis in Africa is about $100 per session.

Transplantation is carried out in few countries in Sub-Saharan Africa such as South Africa, Nigeria, Mauritius, and Ghana. Most kidney transplantations are from living kidney donors although South Africa has deceased kidney donor program. Based on published reports, Sudan with a prevalence rate of end stage kidney disease about 106 patients per million populations has a dialysis population of about 2700 patients with kidney transplantation accounting for about 28% and with 26.4 % on active transplant list. Sudan has a program for organ transplantation that allows for 120 kidney transplants per year with full financial support. Between the period of 2000-2009, 588 transplant operations were performed through the government fund (4).

The treatment of end stage kidney disease in Ethiopia is limited to few dialysis centers in major cities such as Addis Ababa with about 180 patients getting some dialysis care. There were no patients on chronic peritoneal dialysis and no kidney transplant services exist in Ethiopia although a growing number of patients, about 150, had kidney transplants done in centers abroad (3) as outlined in a blog article on this page on Dec 18, 2013 by the head of the renal unit in Addis Ababa University, the main teaching hospital in Ethiopia.

As the second most populous country in sub-Saharan Africa, Ethiopia need a coordinated effort between the government ,the diaspora, the private sector and donor organizations to improve the care of patients with kidney disease that involves prevention and treatment of infections and chronic conditions such as diabetes and hypertension, investing on education and early awareness of chronic kidney disease, designing cost-effective strategies such as local production of dialysis fluid to initiate and expand peritoneal dialysis, and more importantly establishing a living donor kidney transplantation program after appropriate ethical issues such as organ trafficking and organ tourism are addressed. Kidney transplatation not only confers improved quality of life and long term survival but it is cost effective comparted to dialysis after the first few years.

References
1. Ethn Dis.2009 Spring; 19(1 Suppl 1):S1-13-5
2. Clinical Nephrology, Vol 74-Suppl.1/2010 (S13-S16)
3. Challenges of kidney disease in Ethiopia, a call for diaspora involvement ( http://tenayistilign.com)
4. Saudi J Kidney Dis Transpl 2013 :24(5):1044-1049
5. Peritoneal dialysis international,Vol.30,pp.23-28

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Chemotherapy: medicine, poison or both

By Dr Lemma

The Greek word for drugs, ‘Pharmakos’ has several meanings one of which means poison.  It is true that any drug if taken inappropriately and for the wrong reason can be a poison. This is particularly true for chemotherapy medications that are not usually selective in attacking cancer cells but also affect our healthy system.

There are some patients with cancer who refuse to take chemotherapy stating it is a poison. Indeed chemotherapy has serious side effects. However as the saying goes in my country, “sharp with a sharp” “Eshokin beshok”, it is also supposed to fight a serious illness. Technology is getting close to the point where we can selectively kill cancer cells with minimal side effect on the healthy body. There are several such medications collectively known as targeted therapeutic agents. However until that time comes fully, we still have to use conventional chemotherapy as long as the benefit outweighs the harm.

In general chemotherapeutic agents work by attacking rapidly dividing cancer cells. Thus the most aggressive cancers are the most responsive to chemotherapy. Unfortunately they also affect rapidly dividing cells in the body particularly the bone marrow (blood forming cells), the skin and the lining of the gut.

For ease of understanding we can classify chemotherapy related side effects in to two groups (this does not mean physicians are not concerned about their patients’ worries) :

I) Side effects most worrisome for the patient:

a)  Hair loss: hair loss is one of the most feared complications of chemotherapy for cancer patients. This is partly associated with the stigma of hair loss and cancer in the society as well as the self-image and cosmetic importance of hair particularly for women. Not all chemotherapy results in hair loss and when it happens it usually happens within 2-3 weeks of chemotherapy. The good news, it comes back when chemotherapy is completed! As some oncologists joke, it comes back in the color and style you want! Thanks to the cosmetic industry as well, wigs also called cranial prosthesis could make a big difference. Innovative ways are also being tried to prevent hair loss with chemotherapy.

b) Nausea vomiting: this used to be the most dreaded complication of chemotherapy in the old days. Fortunately with the advent of effective anti-nausea medications, the situation has changed dramatically. If used appropriately, nausea and vomiting can now be effectively prevented and or treated in most chemotherapy regimens. However there are times when it could still be a challenge for some patients affecting their ability to nourish themselves and resulting in dehydration as well as damage to the kidneys that may require hospitalization.

c)  Fatigue: fatigue is indeed a poorly understood but significant side effect that can adversely affect patient’s quality of life. It is difficult to measure, to find the exact cause as well as to treat fatigue. Several things can contribute to fatigue during chemotherapy including but not limited to the underlying cancer, the effect of chemotherapy, low blood counts particularly anemia, infections, anxiety/depression associated with cancer diagnosis as well as lack of sleep from pain, anxiety… A lot needs to be done to address the issue of fatigue not only in cancer but in other medical problems as well.    

II)  Side effects most worrisome for the treating physician:

a) Low blood counts: this usually happens within a week to 10 days following strong chemotherapy. The most feared complication from low blood counts is infection which can be serious and sometimes fatal.  Patients and health professionals should be in watch for any signs and symptoms of infection which can be subtle initially but can progress to serious illness within short period of time. Any fever in a patient on chemotherapy should not be taken lightly and patients need to either call their health care providers immediately or go the nearest emergency room. Personal hygiene is also important in minimizing the risk of infection.

The other complication of low blood count is anemia which can contribute to fatigue and other symptoms. Patients on chemotherapy will have frequent blood count checks and will be given blood transfusion as needed. Another possible complication of low blood count is bleeding but fortunately uncommon. This too can be prevented by transfusion when blood counts reach certain level. The good newssis blood counts will come back to normal in most patients once chemotherapy is completed and even in between chemotherapy cycles.

b) Side effects specific to specific chemotherapy medications: There are side effects which are specific to individual medications that treating physicians anticipate and follow up. Some chemotherapy medications can affect the function of the heart, others can affect the function of the kidneys, the lung or the liver. It is beyond the scope of this article to discuss all these.

c) Long term damages from chemotherapy: unusual but serious toxicity from chemotherapy and radiation therapy is the possibility of developing another cancer several years down the line. This is especially true in curable cancers where patients survive for several years after their initial treatment. Fortunately this complication is relatively unusual. However it is of real concern for the treating physician as well as the patient.

In summary chemotherapy needs careful consideration of its potential risks and benefit. It can indeed be harmful when used in conditions where the risk outweighs the expected benefit. This has to be thoroughly discussed between the patient and the treating physician.

Finally, with targeted agents (drugs that can selectively kill cancer cells with minimal side effect) coming to the armamentarium against cancer, time will come when we will look back and say how barbaric we were to use conventional chemotherapy….but for now we fight with what we have.  In my opinion, both those who treat cancer and the patients who fight the disease are brave enough to face an unrelenting enemy with whatever is available in their hands. It is also fair to say that significant achievements have been made and continue to be made just over the past few years, thanks to those who work day and night to bring about breakthrough!

 Dr. Lemma is a cancer specialist.

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A piece of my day: on being a patient

 A sharp abdominal pain woke me up shortly after I went to sleep. Soon I was throwing up everything I had for dinner, Injera ( Ethiopian bread made from teff, an ancient cereal) with red lentil ( misir wat) sauce, and some.  I thought it was  gastritis and would leave me alone but the pain got worse even as the vomiting subsided. I pulled myself up, opened my studio apartment and headed to the parking garage holding my belly. The hospital wasn’t far from where I used to live, a high rise apartment in Motown, Detroit. I parked my old Honda Civic and checked in the emergency department. The medical residents whom I worked with that morning would pass me by  without recognizing me.  I was just another patient in a white and blue gown with no name or profession or history. After exams, labs and scans I knew that it was not a simple gastritis.  My gall bladder was inflamed and I had stones. I needed surgery and it had to be done right away.

It was just another day until that night. I had a quick bowl of cereal with milk and a cup of instant coffee before I headed to the hospital. I was the resident in the team that consisted of two interns. The rounding physician was a much respected professor with mild demeanor and aware of the different cultures that we all hailed from, me from Africa and one each from China and Mexico. He would ask challenging questions and if I slowed down he would say,

 “I see that you are not related to the great track and field runner, you are not nearly as fast!” teasing me because of our similar last names with Haile Gebreselassie, one of the greatest distance runners of all time.

The interns would get to the hospital much earlier to see their patients and write notes. As a senior resident I supervised the interns. Bed side rounds would often start around 9 am after morning report where internal medicine interns and residents gather with rounding physicians including the Chief of Medicine to discuss admissions or challenging cases. That was one of the important venues for teaching. Rounds often end few minutes before noon. After a noon conference we get back to work to carry out the plans for the day, discharge the patients who were ready to go home, transfer the ones who need rehabilitation or nursing homes. Although most admissions happened during the night, on occasions we admitted new patients during the day and that alone would keep us busy. If we happened to be the on-call team, often once every four days, we had the responsibility to run code blues that can create a great deal of anxiety.

A senior surgeon with his team of residents and interns came over to the bed side. I was in severe pain after the medication had worn off.  He discussed the procedure in detail. I knew that the main complications were bile leakage, bleeding, and infections. He said he intends to do laparascopic surgery but if necessary he could convert it in to an open procedure. He said that was a routine surgery with 0.1% chance of dying from it. He said he would put me on antibiotics so not to worry about infections. Throughout my childhood I beat higher odds so I wasn’t worried about complications or death. I also felt that because I was a trainee in the same hospital, I would get extra attention. I ignored the idea of calling home in Addis. That would have panicked my parents, siblings and close friends. Any type of surgery is feared in Ethiopia. Some may not come out alive.

The operation was a relative success although it took longer than planned, but that was just the beginning. The second day I started to feel chills, developed high grade fevers, became uncomfortable.

The surgery resident stopped by and threw a tube in to my stomach through my nose to decompress my distended belly. I was worried.

The high grade fever continued in to the third day. I wasn’t getting any better. That was when I took it upon myself to check what was going on. Medical records were all electronic including medications and physician notes. I found a laptop computer in my room that was left by the nurse. I quickly logged in and opened my own chart. The first thing I did was to check my labs. My white cell count was elevated. I reviewed the medications I was supposed to get. I was shocked to see that I was not getting any antibiotics. I went through the operative note and the surgeon’s progress note. It was a complicated surgery. The surgeon had indicated in his notes that I needed antibiotics. I was puzzled. Before I logged off, the nurse walked back.

“What are you doing?’

“I am checking my labs.”

“You are not supposed to do that.” She was angry at me.

“I am a medical resident here; I am worried I am not getting better.”

“Still you are not supposed to look at your chart.”

“Do you know why I am not getting antibiotics?”

“I only carry out orders. Ask your doctor.” She slammed the door behind and left unable to hide her anger at me. I wasn’t trying to be a demanding patient.

She must have paged him. The surgeon came to see me immediately and apologized that he forgot to write the orders although he had it clearly written in his notes. My fear was another operation and who knows what could follow. Medical errors cost tens of thousands of lives in US hospitals each year. It can happen to any of us. It was not too late for me. I got better.

I left the hospital a week later with a lesson to pay attention to details and to be a better doctor.

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What happened to South Sudan?

I had several friends from southern Sudan while in medical school in Jimma, southwest Ethiopia. It was back in the early 90s during the second Sudanese civil war that lasted from 1983 up until the signing of the Comprehensive Peace Agreement in 2005 that paved the way for the creation of the newest nation in Africa, the outcome of which was threatened after the death rather unexpectedly on July 30, 2005, of Dr John Garang de Mabior, the charismatic leader of Sudan People’s Liberation Army/Movement (SPLA/M).

Those were trying times for many of my southern Sudanese friends who were the lucky few who got scholarships to attend 2 year pharmacology and related health science fields in what is now Jimma University after surviving extreme harsh conditions to escape to refugee camps in border towns in Ethiopia. I remember the heated debates about the civil war, its tragic cost on human life, the necessity of the struggle for justice and freedom. Almost every one of them had lost a brother, a sister, a parent, a close relative or a friend. Some perished in the wilderness trying to escape the brutality of the war. All had hope that one day there would be a better Sudan or if not, an independent South Sudan where its people will have the chance, if you will, of determining its fate. The war would continue long after I finished medical school but even then, back in the 90s, there was a feeling that it lasted far too long and had claimed far too many, over a million, lives. The southern Sudanese that I met in Jimma never identified themselves as Dinka or Nuer but as the oppressed people in Sudan. Whether Dr Garang wanted to see a fair but united Sudan where its entire people are all treated equally but not necessarily as an independent states is better left to scholars on Sudan politics for we will never know for sure what the outcome would have been had he lived to see the peace agreement. General Salva Kiir skillfully put together all the different interests and led to South Sudan’s independence, the newest country in Africa with riches such as oil but lacking even the very basic infrastructure. With its capital as Juba, the Republic of South Sudan became officially an independent country on July 9, 2011 following a referendum that passed with 98.83% of the vote. That was a day that put smiles on many faces such as mine, driven in many ways by an early exposure to the plight of its people through close friends in Jimma some of whom would advance in their studies to become doctors.

It will only take two years before the country would go up in flames in another civil war manufactured in South Sudan itself by the same leaders who spend their lifetime fighting for justice and independence yet with suppressed hunger for absolute power. The Kiir-Machar civil war started after the former, the president of the republic, fired the later, the vice president in what appears like a power struggle within the ruling party claiming tens of thousands of lives and displacing hundreds of thousands. The conflict had ethnic dimension pitting the Dinka and the Nuer, the largest and second largest tribes in the country belonging to the president and former vice president. I don’t know where my friends are today but I know some of them went back to South Sudan after independence but to think about the possibility that any of them, their families, relatives or friends may have died in this senseless war, drowned in the Nile trying to escape to safety, or making another trip to the all familiar refugee camps in neighboring countries pains me.

After all when Jon Garang said, “This peace agreement signals the beginning of one Sudan regardless of race, religion or tribe,” he may have foreseen the challenges of South Sudan as an independent country. In Sub-Saharan Africa, independence is not always a solution for injustice.

In a continent with no culture of resolving conflicts peacefully, how can one dream of one South Sudan regardless of tribe or different political opinion?

For God’s sake, leaders of South Sudan come to your senses and stop the misery of your people and put a smile on our faces.

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A piece of my day

Addis Ababa, 1998.

He looked much older than his 57 years. 

It was easy to note how emaciated he had become.  He was pale. His breathing was shallow. His belly was distended. His legs were thin, barely any muscle on his bones.

His daughters and his wife were standing by the bed side.

They had a resigned look with swollen eyes and dried tears.

 “Yimarih,” he said.

That was his last word.

His liver had failed from Hepatitis C virus and repeated doses of Hagenia Abyssinica or Kosso, the word used for the medicinal plant that many Ethiopians of my generation used for intestinal worms which is quite frequent as a result of consumption of raw beef or minced raw beef marinated in spiced chilli powder. The food tests so good most would risk having worms than cook it. The use of plants for medicinal purposes is very common place and wide spread in Ethiopia, a country endowed with diverse resources with different habitats and vegetation, knowledge often passed by word of mouth from generations to generations. Hagenia Abyssinica is one such plant commonly used for medicinal purposes especially in adult tapeworms but without much appreciation of its toxic effect on the liver particularly when used in large doses and multiple times.

Liver disease and liver cancer are very common in Ethiopia and other developing countries. Aside from the toxic effect of herbal medications, Hepatitis B and C viruses have high prevalence.

He suffered with many complications that required hospitalizations.  Treatment for Hepatitis C virus was not available. Not too long ago he survived a major bleeding episode.  During his last few months, he had to have 3-5 liters of fluid removed from his belly almost on a weekly base to ease his shallow breathing and distress.

“Yimarih (bless you),”he uttered after I sneezed; his voice was very faint.

It didn’t register in me until I sat down in the nursing station to write his death summary. It was overwhelming. I wasn’t feeling well myself with common cold but nothing compared to his ordeal.

He died of complications of liver disease; he was a good person, I wrote.

WHO Key facts

Hepatitis C is a liver disease caused by the hepatitis C virus.

The disease can range in severity from a mild illness lasting a few weeks to a serious, lifelong condition that can lead to cirrhosis of the liver or liver cancer.

The hepatitis C virus is transmitted through contact with the blood of an infected person which can occur through injections with contaminated syringes and needle-stick injuries, injection drug use, being born to a hepatitis C infected mother,  sex with an infected person, receipt of contaminated blood transfusions, blood products and organ transplants

About 150 million people are chronically infected with hepatitis C virus, and more than 350 000 people die every year from hepatitis C-related liver diseases.

Hepatitis C can be treated using antiviral medicines.

There is currently no vaccine for hepatitis C; however, research in this area is ongoing.

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