Fikir Eske Mekabir : medical analysis

Posted on November 16, 2013 by Tenayistilign

By Dr Surafel K Gebreselassie

Part I : Bezabih’s Illness

The late Haddis Alemayehu was arguably Ethiopia’s best novelist. He is primarily known for his classic work, Fikir Eske Mekabir (later translated to English as Love Unto Crypt by Sisay Ayenew) which is widely read in Ethiopia.  The characters in this classic work are house hold names. I took upon myself the challenge of analyzing the illnesses that the major characters had in Fikir Eske Mekabir in the hope to understand the diseases of the era in Ethiopian history covered in this master literary work. This is based on the original, Amharic version.

Bezabih is one of the lead characters in Haddis Alemayehu’s Fikir Eske Mekabir. Bezabih was the only child of Wudinesh Betamu and Bogale Mebratu. Bezabih’s illnesses during infancy and childhood defined the flow of the story.  The story depicts a loner Bogale who had lost his parents when he was very young and lived most of his life poor who would marry in his later years a woman of rich back ground, Wudinesh who had her own tragedy after all three of her previous husbands died. It took a lot of convincing by priest Tamiru to bring these two lonely souls together hence begin the story that becomes Fikir Eske Mekabir.

Two years later they were blessed with a boy and named him Bezabih ( means too much), to describe the many illnesses the boy faced until he reached his 5th birth day. At the end of his 3 months, he had a childhood disease named “Ankelis”, at age 6 month he suffered from a respiratory ailment called “Kuwakuat” and then at the end of the year he had measles. He was weak and fragile. These diseases almost killed him.

What did Bezabih actually have?

The stories tell us that when he had “Ankelis” the symptoms started with high grade fevers followed by short fast breaths. He would shake and move his hands and legs with his eyes rolling from his father to the roof then to the kitchen as if trying to escape from death.  His stunned father would scare away flies from his face and later would check his breath to see if he was still alive but his frightened mother would pray loud afraid that her only son was dying. His movements would slow down and he would go in to a deep sleep. After about two hours he would wake up, yawn and laugh as if nothing happened.

The above description of Bezabih’s initial illness “Ankelis” fits with the symptoms of a febrile seizure. The clue here is the onset of high grade fever followed by what appears like a convulsion. The deep sleep following the episode and the back to normal description clinches the diagnosis of febrile seizure.

Febrile seizures are convulsions induced by fever in infants and younger children. It often starts at 6 month of age, even earlier, and very unlikely to occur after age 5 years. A child would often have high fever, loses consciousness, and shakes, moving limbs on both sides.

 The child can also have twitching or rigidity in one portion of the body. It is very frightening to parents but is often brief and harmless. Febrile seizures are very common; as much as one every 25 children would have it. It doesn’t cause long term damage or progress to epilepsy.

 I was impressed by the detailed description of  what appears like a febrile seizure. One would have to witness one to describe it in such detail. So I suspect sometime before the book was written Haddis Alemayehu might have witnessed an infant, perhaps as old as 3 months, suffer from febrile seizure. It is also safe to assume that if indeed he had witnessed one he might have been frightened but what was he thinking ?

What Haddis Alemayehu described in Bezabih’s Ankelis is possibly his own encounter of a child near death…a child that will outgrow two more diseases including measles to become Bezabih, the lead character.

On my next blog I will look at the cause of death of Bezabih’s parents.

(To learn more about febrile seizures please refer to febrile seizure fact sheet / National Institute of Neurological Disorders and Stroke.)

Posted in Health, History | 3 Comments

STOP THE VIOLENCE AGAINST ETHIOPIANS

Posted on November 16, 2013 by Tenayistilign

                                                      

Our fellow Ethiopians  are currently facing cruel, inhumane abuses in Saudi Arabia. It’s very heartbreaking to watch the videos & to hear their stories. No human being deserves to be treated with such barbaric exploitation & humiliation; they deserve to be treated with dignity regardless of their immigration status.

We all need to come together to help our people.

Posted in Current events | 1 Comment

Basics on Diabetes Mellitus and Complications

Posted on November 15, 2013 by Tenayistilign

By Dr . Abay Taddesse

Diabetes mellitus (DM) is a chronic illness that results from absolute or relative deficiency of insulin ( hormone which controls blood glucose) that leads to excessive amounts of glucose in the blood which leads to acute ( short term ) and chronic ( long term ) complications which  cause most of the morbidity ( disease burden) and mortality ( death ) from the disease.

So far there are no cures for diabetes and all types of  treatments  (  pills, insulin injections ) are aimed at controlling blood glucose at a reasonable target so as to prevent short term and long term complications.

Classification of DM

* Type 1 DM
– Results from destruction of  pancreatic cells which produce insulin leading to absolute insulin deficiency
– Caused by genetic predisposition to the disease and autoimmune destruction of the insulin producing cells
– Needs treatment with insulin from the time of  diagnosis
– Insulin can be given in different forms- insulin vials with syringe and needle, prefilled insulin pens and continuous insulin delivery through insulin pumps
– Blood glucose runs in very wide ranges – at times very low
( hypoglycemia ) and most of the time running very high ( hyperglycemia)
– High risk for low blood glucose
( hypoglycemia) on treatment with insulin

*Type 2 DM
  – Results from progressive insulin secretion defect from the pancreas and inability of the body to use insulin which is called insulin resistance
  – Family history of DM in immediate family members commonly found
  – Can be treated with diet and weight loss ( which improves ability of the body to use insulin ) and / or pills or insulin alone or in combination
  – Life style change with diet and weight loss is the preferred first step of treatment

* Gestational DM
  – Diabetes diagnosed during pregnancy

* Other less common types of DM

Complications of DM

* Acute ( short term complications )
  – Dangerously low blood glucose
( hypoglycemia ) which can lead to coma and death
  – Diabetic coma due to excess acid production from fat
      ( Diabetic ketoacidosis)
  – Diabetic coma due to very high glucose in the blood which leads to dehydration

*Chronic ( long term complications)
  – Blockage of  coronary arteries
  ( blood supply to heart)
  – Blockage of  major arteries to organs and legs
  – Damage to eyes leading to loss of vision
  – Damage to kidneys leading to kidney failure
  – Damage to sensory  nerves of feet leading to diabetic feet ulcers and amputations.

Reference: American Diabetes Association Clinical Practice Recommendations published on Diabetes Care Jan 2013, vol 36 , supplement 1.

I will write more on prevention and treatment of common long term complications on future posts.

Dr . Abay Taddesse is a graduate of Jimma university, trained on Endocrinology , Diabetes and Metabolism at Wayne State University in Detroit and currently is practicing Endocrinology and Diabetes care in Southern Ohio, USA.

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Another Way to Cure

Posted on November 12, 2013 by Tenayistilign

Bikat Sahle, PhD

 As morning came and gentle beams of sunshine flickered into her bedroom, Kidist slowly opened her eyes. She greeted the new day with her usual moans and groans that have become her daily reality of the last few years. As she has been doing for the good portion of the night, she continued to toss and turn in bed hoping to find a comfortable position to ease her pain and to rest a little more. Unfulfilled wish.

She jumped out of bed and walked to her medicine cabinet that was packed with pain medications. Herbal, over-the-counter, prescribed, name it. She knows drugs have long stopped working on her failing body. She randomly picked one up and took it compulsively. It seemed to defy her helplessness. As if to make a statement to herself once more that she is not giving up. She silently reiterated to herself, “Because I am a mother!”

She returned and lied in bed staring at her ceiling. The series of bad news that crumbled her life and hopes into nothingness in the past five years streamed in her mind’s eye. Anger and grief flooded her anew as she pitied the 29 years she spent on the planet. The first twenty four weren’t that bad, actually they were quite good. The last five, however, were so unbearable that she let them dash any good memories that preceded.  She lumped all the years together in her mind and rejected them with disgust. She refused to remember any good years, any good days. Not even one she allowed.

As she calmed down she pondered, “Who am I angry at? Kifle? The universe? My creator?” “Esti yihun”, she sighed.  As she lied there, there in her bed of suffering, watching in her mind’s eye the painful memories of losses and heartache, one bright thought lit up her mind and she smiled.  Her children’s adoption.

Kidist was diagnosed with HIV/AIDS five years ago and that was how her tragic ordeal began. Her husband, Kifle, first contracted the disease and died within one year. As she was hit by unending heart-rending news one after another since, she fights. Even after she learned that her body developed resistance to the medication, she fights. She continues to fight steadily for the sake of Dany (Daniel) and Elsie (Elsabeth), her four and five year old son and daughter.

She has no idea how Kifle got HIV. All she remembers is one night, the day after they celebrated Elsie’s fifth birthday, he came home looking so dark, disheveled, and devastated that she almost didn’t recognize him. He walked in like a zombie. A non-human.

Ever since, every time the topic came up, he sobs and turns mute that she eventually gave up asking him for explanation. She answered her own question, “Would it matter if I knew? Nothing will change how I feel or my circumstances. This is still the man I love. I choose not to torment him with guilt.”

In fact, without her share of tormenting him with guilt, she saw remorse, shame, and guilt eat him alive, more quickly than his fatal disease. She couldn’t save him.

The day her husband died, Kidist felt as though she needed a mental breakdown. But a breakdown seemed a luxury. “What about going into a comma?” She silently uttered as the thought felt so appealing to her. She wished to be in a coma for a few days to escape the emotions that were about to drown her. But even a coma wasn’t an option. She snapped herself out of the thought. She has to be there for Dany and Elsie. As it is, she is terrified that she soon will abandon them anyway.

She vividly remembers her first date with her husband. They worked as a teller at a local bank and they often went out for Machiato after work. The first day he asked her to go for coffee, he told her that he was attracted to her by her infectious laughter and charm. He said he agreed with the nick name colleagues gave her, “ende semua” which means “like her name”. The name Kidist is a female Amharic name for “holy”. She was well-loved, universally. And he was smitten.

On their first official date, Kifle asked her for marriage. Kidist welcomed it without hesitation as she is an only child who always longed for companionship. Her parents lived out in the country and she has been living alone.  

So on their first date, they talked about their wedding, playfully argued over the number of children they should have, and their children’s names. They laughed and giggled imagining themselves together in old age with gray hair and walking with a cane leaning forward.

In six months they got married and with each passing year their love grew and deepened that getting old as a couple seemed a sure dream. Today, Kidist stood numb at the reality that this cherished dream has just been stolen from her heart and shattered to pieces in front of her eyes. She gently patted her face with her two hands. “Come back. Be strong for Dany and Elsie” she reminded herself.

Kidist gathered all her strength and took Dany and Elsie in for HIV testing the next day. They seemed a little somber that day, but she made sure to protect them from their uncertain reality. They had no idea of the bleak future that was looming heavily over them like dark clouds. Only their mother could see and fear it on their behalf.  

The next day, as the goodnews of both her childrens’ negative test results were handed at the clinic’s waiting room, Kidist was surrounded by her aunt and nieces who hugged her and jumped up and down out of joy. To her surprise, instead Kidist shivered as she felt like she was hit in the head. The thought of leaving the apples of her eye as orphans suddenly toppled any good feelings of the news. She felt as though she was losing her mind as a kaleidoscope of emotions engulfed her. The flood gates of her feelings broke loose and she gasped and sobbed uncontrollably. Bystanders wiped away tears as they watched her with sympathy.

As she arrived home later that evening, she felt her dwindling energy was completely sapped for the day. She felt frail as a wilted vegetable. She recoiled into her bed to escape the palpable reality of her mortality. As she laid her head down on her pillow, she whispered a silent prayer that the next morning she would wake up from her nightmare, from the nightmare of her current life, to her idyllic former life.

As she became weaker and weaker and having realized that none of her extended family came forward to offer her children parental love and home, Kidist decided to try adoption. She was determined to do it as soon as possible while she was alive to help facilitate the process and prepare her little ones for the inevitable new chapter.

Out of the list the adoption agency offered her, Kidist said a prayer and picked Sisay and Roman.

Sisay and his wife Roman have one biological child. Sisay had a life changing conversation with his co-worker John who loved children and often talked about adoption. John’s passion was so contagious that it soon penetrated Sisay’s heart.

One evening after work, Sisay thought about orphaned children all the way home. He put himself in their shoes. He dreaded even the thought of his own child left in this cold and vulnerable world without parents. He felt it could happen to his child. “God forbid,” he muttered. “It can happen to anybody”. He was saddened by the thought of how difficult life without a parent must be for the millions of orphaned children in the country. That day he was determined to adopt a child.

As he was overcome by the daily grind of his busy life the next day, Sisay’s plan slipped away from his mind. What he also did not know was that his wife registered their names as potential adoptive parents.

Kidist woke up one morning remembering it was Saturday, the day for her weekly visit by her children and their adoptive parents. Soon after, she heard Danny and Elsie running and busting open her bedroom door yelling “Ema” as they endearingly call her. They were impatient to tell her all that has been happening in their new life in which she was strangely no longer a part of.  At first, she was startled by their unabated happiness and even entertained some jealousy and sadness that they didn’t seem like they missed her or that they weren’t concerned for her. She realized, “Wait, they are children. After all, this is exactly what I wished.” 

Following them were Sisay and Roman who walked in slowly with gentleness greeting her with a soft voice. There was a stark contrast in mood between the concerned and thoughtful adults and the energetic lively children.  As Kidist kissed Sisay and Roman shaking their hands so tightly, tears of bitter-sweet joy trickled down her cheeks. She felt her children were incredibly lucky.

Kidist was gladdened by the smooth adjustment of her children with their adoptive parents in the three weeks since the official adoption. She tells everyone, “Sisay and Roman are angels”.  Their extraordinary love not only to her children but to her in her deathbed overwhelms her. The love and bonding that have developed between Sisay and Roman and her felt no different from a family’s love. It was too good to be real.  

For every dark hole sorrow pierced in her heart, Sisay and Roman showed her a kindness act that mended and sealed each hole one by one. The cure she couldn’t find in medicine, she found it in the loving heart of these two human beings.

Kidist still worries. She worries that she has burdened the young couple with the adoption. She then remembers, “No, my children are a gift to them, not a burden”.  She wonders if Sisay and Roman would feel loved as parents by her children.  She asserts, “Well, true love is seldom unreturned. Even so, true love should not expect anything in return.” 

Kidist also worries whether Sisay and Roman will keep the pure love they have now or someday they would stop loving her children. She paused on the floor with a pensive stare and she remembered the unconditional love between her and her husband. “We were strangers. We were not related. There was no blood between us. But we became one because of our love and commitment. Family love is a decision, a commitment. To welcome another soul into one’s heart, one’s home.” Serenity came over her as she settled her thoughts. For now.

As she moves her body, she hurts. She quickly lets her mind drift back to the thought of Danny and Elsie in a warm home and safe hands. And she smiles.

 Bikat Sahle, PhD is a fellow at Cleveland Clinic. She completed her graduate training  at Fuller Graduate School of Psychology in Pasadena, CA. She also has an MA in Theology from Fuller Theological Seminary, Pasadena, CA, USA.

Posted in Short story | 5 Comments

Remembering Dr Assefa Taye

Posted on November 10, 2013 by Tenayistilign

the late Dr Assefa Taye

In that bright day in September of 1996, we were seated at the center of the university’s basket ball stadium which was packed with families and loved ones to attend our graduation after completion of seven agonizing years to be medical doctors. Our old t shirts and jeans were replaced by suits. We were dolled by black doctoral gowns with red hoods. It was a special occasion. We were particularly delighted to have had our choice key note speaker, Dr Tekletsion Woldemariam, a pediatrician who founded the medical school itself, Jimma Institute of Health Sciences.

“And now I present winners of the best research projects. These are going to be Ethiopia’s future leaders in science and technology,” the dean of admissions presented the research winners; the last of the prizes after the gold medalist was announced.

“And the winner is,” he paused gauging the pulse of the graduates. The stadium was quite. Families and loved ones were excited to find out if their daughters or sons were walking to the podium again to pick up a coveted prize. The faculty wearing their academic regalia, the dean of the medical school and deans of various schools such as the school of pharmacy, laboratory technology, environmental health sciences, nursing, invited guests were seated facing us in the first few rows. There was no overhanging cover so we all glowed in the blazing summer.

“And the best researcher of the class of 1996 is,”

The faculty were on their feet clapping knowing that this was the ultimate prize. There was not much in terms of research in science and technology in the country so producing high quality epidemiology based researchers was the ultimate goal of the school of medicine which was slightly different in its philosophy than the two other traditional medical schools, the one at Addis Ababa, the modern capital of Ethiopia, and Gondar, Ethiopia’s medieval royal city. It was different in its emphasis on community oriented philosophy allowing medical students to explore the medical needs of the surrounding communities through its mandatory yearly month long outreach programs.

As medical students, we were very close to each other.  Partly because most of us were not from Jimma, rather spread as far away as Asmara, Mekele, Gondar, Gojam, Wollo, Welega, Arsi, Harrar, Addis; Ethiopians of different shade came together for one cause, to succeed and have a better future changing the society for good in the process. Asmara was part of Ethiopia when we started medical school.  Our seven years were dotted with memories.

Assefa was seated in the raw next to me. I recall to these day how me and Assefa used to find ourselves in the campus cafe, very early in the morning, before anyone would wake up.

I remember knocking at the door and hearing the same voice day in and day out.

“Who is that? You are early for breakfast, push the door in and take a plate.”

The loud and thick voice always came from the same cook who was busy hurrying up the food and hot tea before the morning shift begins in earnest.  We would grab a plate of oatmeal or scrambled injera, Ethiopian staple diet, or a loaf of bread. We would grab it quickly before he had a chance to see our faces so that we could make it back again on the line for a second breakfast pushing and pulling with everybody else as if nothing happened. Some days he would stare at us just to scare us off but we were never caught.

I even thought for a moment that I might win this thing. The selection committee was tight lipped so it was not easy to guess as to who might win the research prize.  And finally the dean of admission finished those words,  

“Asefa Taye Zegeye, please come to the podium to take your prize.”

That was the last time I saw Assefa. He went on to practice medicine in Desse, Wollo. He even joined Addis Ababa University to do a master’s program in public health. I was shocked to learn that Assefa had passed away of medical illness.

Rest In Peace.

Posted in Obituary | 1 Comment

Cancer 101

Posted on November 9, 2013 by Tenayistilign

By Dr Lemma

Cancer is an expensive disease to treat. This is true anywhere in the world although most challenging when resources are limited. Although there are childhood cancers, most cancers are common in older ages. The commonest cancers worldwide are lung, breast and colon cancer. In men the commonest cancer is lung where as in women the commonest cancer is breast. However lung cancer is the commonest cause of cancer death in both men and women worldwide.
Although data is limited and based mainly on hospital reports, the commonest cancers reported for sub-Saharan African countries are breast and cervical cancer. This could be because:
-patients are more likely to seek care for more symptomatic cancers like advanced cervical cancer (bleeding, pain) or lump in the breast
-shorter life expectancy (cancers that present at older age may not be accounted for)
-other factors which are not well understood at this time

What causes cancer?
It is usually difficult to pin point a specific cause for cancer as it could be a result of multiple factors. Eventually everything comes to abnormal and uncontrolled cell division that will spread both locally and distant sites in the body.
Below are few conditions known to be associated with the development of cancer:
Smoking: associated with several types of cancers but most strongly with lung cancer. It is one of the commonest preventable causes of cancer death worldwide!

Excessive alcohol intake: strongly associated with liver cancer, cancer of the esophagus and stomach.
Infections: It could take several years from the time of infection to the development of cancer.
•Hepatitis B and C associated with liver cancer
•Human Pailloma Virus (HPV) is the initiating infection for almost all cases of cervical cancer. Also associated with head and neck cancers. It is important to note that HPV is sexually transmitted infection.
•HIV(particularly untreated HIV is associated with Kaposi sarcoma and some lymphomas)
•Helicobacter pylori (bacteria in the gut that also predisposes to peptic ulcer disease is associated with some forms of gastric/stomach cancer)
•Schistosomiasis(Bilharzia) in bladder cancer.

Hereditary: passing of genes in family that predispose to the development of cancer. This type of cancer tends to be seen at younger age and also in multiple family members/generations.
Familial cancers are responsible for minority of cancers.
•Familial Breast cancer: familial breast cancer is responsible only for minority of breast cancer cases. However, history of breast cancer in one’s immediate family also increases the risk of developing breast cancer.
•Ovarian cancer: the same gene abnormality that causes familial breast cancer also causes familial ovarian cancer. Again this is responsible for minority of ovarian cancers.
•Colon cancer: can be part of other familial cancers. Again only minority of colon cancer cases run in family.

Obesity (excessive weight):
Linked to several cancers (uterine,cancer,colon,breast…).Difficult to establish direct cause and effect relationship. Obesity is also a strong risk factor for diabetes, hypertension and heart disease.
Previous chemotherapy and radiation therapy or exposure to harmful radiation: could take few to several years before cancer development.

Symptoms of cancer:
Cancer can present in variety of ways depending on the location and extent of spread. Some of the ways cancer can present include swelling/lump in the body, pain, bleeding (especially for uterine and cervical cancer). Sometimes cancer can also be discovered on routine blood test or x-ray/CAT scan done for other reasons.
Advanced cancer is usually associated with significant and unintentional weight loss, decreased appetite, as well as decreased energy. As there are several other diseases that can present the same way, it will be wrong to assume that these symptoms are always from cancer. However one needs to be evaluated by a health professional before reaching into any conclusion.

Stages:
Early to locally advanced (in most cases stages I-III)
Advanced /spread (stage IV)

Treatment:
In general cancer treatment involves any of the following alone or in combination: surgery, chemotherapy, radiation therapy, hormonal and biologic therapy. Occasionally watchful waiting without initiating any treatment could be appropriate.

In most cases, the goal of treatment for early stage cancer is cure or long term cancer free status. However, most of the advanced stage cancers are incurable with current therapy and the goal of treatment is mainly to prolong life and to alleviate symptoms that cause pain and discomfort to patients. It is very important for the patient and health professional to have honest communication on the goals of treatment and expected outcome. This is very important as treatment can be associated with significant side effects.
An important component of care for advanced incurable cancer is to control symptoms particularly pain and help patients to be as comfortable as possible. In this situation, trying to treat the cancer will cause more harm than benefit and should be stopped.

What can I do?
This is a difficult question however the following are helpful to prevent some types of cancer or to diagnose it at early stages.
•Stop smoking
•Avoid excessive alcohol consumption
•Vaccines (Hepatitis B vaccine can help prevent liver cancer, HPV vaccine is relatively new vaccine and prevents the virus that causes cervical cancer)
•Undergo age appropriate screening that can detect early stage cancer or precancerous abnormalities that can be treated successfully:
oBreast: mammogram for women aged 50-74
oColon: colonoscopy starting at age 50
oCervix: Pap smear usually starting from age 21

Screening recommendations may vary depending on risk/family history. Screening services are not available in most low income countries making early diagnosis and treatment impossible. A recent study from India that showed successful cervical cancer screening using simple test with vinegar (the test reduced deaths related to cervical cancer in the community by around one third!). The test requires minimal expertise and is cheap to perform. This is encouraging news that could potentially be adopted in most developing countries. However, one needs to have the set up to evaluate and provide treatment for those who test positive. (http://www.medicalnewstoday.com/articles/261381.php)

Additionally healthy life styling including maintaining appropriate weight, exercise and healthy diet could help.

In conclusion, although infectious and communicable diseases still deserve priority in developing countries, the impact of cancer related illness and death is growing and should not be totally neglected.

Dr Lemma is a cancer specialist.

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Obesity in Ethiopian Immigrants ( a personal observation)

Posted on November 6, 2013 by Tenayistilign

by Surafel K Gebreselassie

We are four old classmates seated in a popular Ethiopian restaurant in the Washington DC metro area, home to the largest Ethiopian community outside of Ethiopia. The restaurant was packed. It was a Saturday evening. I was thrilled to find Bedele beer, the first beer I had, which started brewing just when I came of age. That was a pleasant change from Abba Jifar’s tej ( homemade honey wine), King of the Gibe Kingdom of Jimma.

We were four skinny boys then, in our early 20s. We are a different animal today.

Once the plate of kitfo (raw marinated beef), gored gored (raw beef cut up in to cubes), tibs (chopped up and roasted beef) arrived hot from the oven, we attacked it furiously.

“You have lost weight. Haven’t you?”

I was a bit surprised. I thought at first my friends didn’t recognize my weight loss.

Yes I did.

“That is impressive, how much did you lose? “

I would say about twenty two pounds but still have ways to go.

“Twenty two pounds!”

“Isn’t that like 10 kilograms? “

“How did you do it?”

I scanned the restaurant with my eyes. The chatty obese guys seated next to us had lowered their voices as if expecting to hear what I had to say. I stood up, stretched and walked to the toilet to wash my hands sneaking in between the tables.

It was rare to see plates of vegetables.

Almost everyone was eating some combination of beef, lamb or chicken.

Almost every table had one or two people who looked obese or overweight.

It wasn’t a surprise. By 2030 the global estimates of people with overweight reaches to a staggering 2.16 billion, and 1.12 billion will be obese (1) but this is not limited to developed countries. Overweight and obesity are becoming major health issues in low income countries with urbanization contributing to some degree although that pattern is changing with obesity increasingly seen in poor rural areas as well. In the developing world alone there are over 115 million people suffering from obesity related problems such as hypertension, type 2 diabetes, stroke, cancer, heart diseases. It is predicted that by 2030 the African region will see a doubling of heart disease related deaths (2). A recent systematic review also thought us that obesity was more prevalent in Africans who migrated to Western countries (2). For examples, there is a published report about increasing rate of obesity among Ethiopian women living in Israel (3). In this study, compared to
their arrival weight, after 14 years of average living time in Israel, 42% became overweight including 11% who became obese.

Ethiopian immigrants to the US, like ethnic Ethiopians in Israel, undergo several changes not the least of which is adapting to local dietary patterns and lifestyles. A diet rich in teff, whole grains and legumes is replaced by rich amounts of meat, sugar, dairy products and fats. Add to that high sugar soft drinks which are readily available; less calorie expenditure with the relative sedentary Western life. This is spiced up by the traditional Ethiopian foods in many ethnic restaurants particularly in cities with major Ethiopian population. The net effect is imbalance of calorie intake versus expenditure. The change in the Ethiopian immigrants in Israel who developed overweight and obesity that parallels that of the general Israel population (3) could hold true in the Ethiopian immigrant community in the US and Western Europe although that needs to be studied.

The server had brought Ethiopian coffee for each of us when I made it back to my seat.

“So how did you lose?”

It reminded me of my pot belly. Central obesity is even more dangerous. I learned that in medical school but never paid enough attention to myself until recently. I started by changing simple routines. I stopped adding sugar to my coffee and tea. I stopped extra calories from soft drinks and juices that I used to grab every time I opened the fridge. At least two to three times per week I tried to do some exercise be it walking or jogging. I tried to take stairs as much as I can in my work place. The individual changes I did at first didn’t seem much but the sum effect was a remarkable weight loss and feeling of well being. I still kept the visits to local Ethiopian restaurants because they are gateways to Ethiopia, but started mixing vegetables and fruits. It worked for me but not everything works for everyone. For example some people with arthritis may find it difficult to exercise so each individual has to tailor what works best.

Before I had a chance to listen what they had to say, we started the fight to pay the whole bill first, reminding me of how generous we are to each other and to others, something we still kept as immigrants even as we became fatter.

References:

1) Popkin DM, Adair LS, Ng SW. Global nutrition transition and the pandemic of obesity in developing countries. Nutr Rev 2012 Jan;70(1):3-21

2) Adeboye B, Bermano G, Rolland C. Obesity and its healthimpat in Africa: a systematic review. Cardiovascular J Afr. 2012 Oct; 23(9); 512-21.

3) Regev-Tobias H, Reifen R, Endevett R, et al. Dietary acculturation and increasing rates of obesity in Ethiopian women living in Israel. Nutrition. 2012 Jan ; 28(1):30-4.

Posted in Health, Memoir | 2 Comments

Summary of the AFFORDABLE CARE ACT ( OBAMACARE)

Posted on November 4, 2013 by Tenayistilign

Dr Solomon Alemu Feyissa

American Health Care System prior to the Affordable Care Act ( ACA) is primarily financed by a combination of private medical insurances ( mainly employer sponsored like blue cross blue shield, united, etc with employee contribution), government medical insurance like Medicare ( federal sponsored and for people >65), Medicaid ( state sponsored and for low income and poor), military sponsored ( veteran affairs health care system and military health care) and charity care through charitable organizations.

The pre ACA health care financing and coverages leave out about 20 % of the population who don’t fall in to one of the above categories . These include people who don’t meet criteria for Medicaid ( medical assistance) due to their income , self employed individuals and their families who are left on their own to provide their own insurance, people who don’t get employee sponsored insurance as the program is optional to the employers.

Pre ACA people with no insurance were forced to pay out of pocket or go to the emergency room to get routine/primary and non emergent health care. People with no insurance always had the option to go to emergency room for emergency and inpatient care and are always treated equally as per the ALMATA declaration ( hospitals can’t refuse emergency care including admissions regardless of patient’s ability to pay or not).

Thus ACA tried to address the coverage issue and aimed to make heath insurance reform in order to increase the coverage up to 95 to 100% of the population.

Core Aspects of the ACA: Primarily based on the Massachusetts health care reform ( Romney Care)

1. Medicaid ( medical assistance ) expansion by changing the income criteria so that many more million would be eligible.
2. Mandating employer sponsored insurance for employers with work force of 50 or more.
3. Allowing children to stay on their parents plan/insurance until age of 26.
4. Creating health exchanges as online one stop insurance comparison and shopping site/tool to encourage competition among insurance providers and help individuals get a better choice and deal. Think of it as priceline or expedia for travel and hotel bookings.
5. Provide subsidies for those who can’t afford insurance so that they will be able to buy one.
6. Individual mandate ( every one should buy insurance or pay penalty) to decrease risk pool by mandating young and healthy people to buy insurance in order to off set the cost for health care of older and sicker people.
7. Individuals will not be discriminated based on age, gender and pre-existing medical condition by insurance companies.

CHALLENGES
1. Supreme court decided that Medicaid expansion should be optional for individual states thus limiting implementation of the law.
2. Malfunction in initial roll out of federal sponsored health insurance exchanges.

CRITICS
1. The law mainly addressed health care financing /medical insurance reform.
2. Didn’t address major issues with regard to cost of care including cost and monopoly of medications and pharmaceuticals who charge many more times for similar drug/pharmaceutical/device/product in the US as compared to Europe and Canada due to lack of competition and monopoly and strict FDA policy ( only US manufactured drugs can be sold in the US)
3. Didn’t address the issue of defensive medicine which sky rocketed the cost of care and unnecessary care ( this could have been addressed by tort /malpractice reform and limiting law suits and liability compensation).
4. Law was passed only with support of democratic law makers which is making it difficult to implement specially with republican law makers who are trying to de fund it ( including recent government shut down) and republican governors who are refusing to cooperate in implementation of the law, for example most republican run states are not implementing the optional Medicaid expansion.

Dr Solomon A Feyissa is a practicing Internist / Hospitalist in the DC Metro/Baltimore area.

Posted in Current events, Health, Opinion | 3 Comments

Challenges of dialysis in Ethiopia

Posted on November 4, 2013 by Tenayistilign

By Dr Elias B

Managing chronic kidney disease in Africa is very challenging; Ethiopia is no exception.
Assume I am sitting in a clinic in Addis Ababa seeing patients with end stage kidney disease that require dialysis.

What do I tell them?

As you all know dialysis is a very expensive technique of cleaning our blood from the toxic substance that we all produce on a daily basis. Without dialysis eventually all patients with end stage kidney disease ( not acute kidney failure, that can recover) die unless they can get kidney transplant. It is a financial doomsday even in those who have access to dialysis.

The cost of one session of dialysis in the few places that is available in Ethiopia is as high as 1500-2000 Birr (about $100) which translates to about 4500-6000 Birr/week for the standard three sessions. That is a staggering sum of 18-24,000 Birr / month.
So would I tell them to sell their house, borrow money from families, and sell all their belongings to receive dialysis service specially knowing that it is not enough to sustain them for few months or even a year?

Now let us assume that you own a dialysis unit. Will you turn them down if they ask you to provide them with dialysis after they promised you with the money, knowing that they are going to sell their houses and perhaps use all family savings?

At the same time we see many affluent Ethiopians travelling abroad to get better health services. In fact health tourism is a huge source of income to many Asian countries. Thousands of Ethiopians do travel every year to these countries and spend significant amount of money to get all forms of cutting edge treatments.
For those people who can afford to travel abroad, availability of dialysis at home even if expensive is still cost effective. The challenge is these are the privileged few.

Who should then get dialysis?

Is it fair to draw the line between the few rich and poor majority?

Ethiopia is one of the fastest growing countries in Africa. The health services, particularly in areas of prevention, have showed improvement. I would like to bring the challenges of dialysis in Ethiopia to every one’s attention to draw upon international experiences and tailor it to national, epidemiological, social, cultural and economic realities, and provides guidance on identifying what actions need to be taken to address the challenges of caring for patients with end stage kidney disease in Ethiopia

Dr Elias is an Interventional Nephrologist currently practicing in Pittsburgh, PA ( USA).

Posted in Health, Opinion | 16 Comments

Bed wetting (nocturnal enuresis)

Posted on November 3, 2013 by Tenayistilign

By Dr Lemma

I would like to disclose that I am not an expert in the field but I thought it would be worthwhile to post a short summary. 

Bed wetting: also called nocturnal enuresis is defined as incontinence episodes while asleep. Most children acquire full continence by the age of 3-4 years. A child has to be at least 5 years old before one can make the diagnosis of bed wetting. Although variable, bed wetting is seen in around 5-10 % of school age children. It is more common in boys than girls. Fortunately most children grow out of it with out requiring any therapy.

Bed wetting that happens with out day time urinary symptoms is called monosymptomatic and is usually difficult to find the exact cause. However when it is accompanied by day time urinary symptoms like an urge to void, frequent urination and dribbling, it is usually related to bladder dysfunction. Most of the information below applies to the form of bedwetting with out day time urinary symptoms (monosymptomatic)

Studies have showed that up to 20-40% of children with urinary incontinence present with behavioral disorders which can precede or follow the onset of bed wetting.

Possible causes of bed wetting:

-impaired perception of bladder fullness during sleep

-imbalance between bladder capacity and urine production at night

-impaired antidiuretic hormone secretion at night (anti-diuretic hormone helps the kidney to reabsorb water)

-possible underlying psychological problems (could contribute to return of symptoms) (could also be a result of bed wetting)

-abnormal bladder function especially in those with day time urinary symptoms

Treatment options in bed wetting: main method of therapy is behavioral and not medication.

  • Behavioral treatment: needs motivated parent and child.

-Drinking, sleeping and urinating habit:

-learn to urinate when there is the urge to do so

-scheduling urination before bed and in the morning

-limiting fluid intake within 2 hours before going to bed (make sure the child gets enough fluids during the day)

-Alarm therapy: the child will sleep with alarm that has sensor which is turned off(rings) with moisture/bed wetting. This will wake up the child and eventually train the child to wake up before bedwetting. It takes several nights before it works but is usually successful in half to 2/3 of cases.

  • Medications:

-usually temporary solution

-problem comes back when the medication is stopped

-useful in situation where short term control is needed

  • It is important to look for and treat any co-existing psychosocial/behavioural problem.

References:

1. Ertan et al. Relationship of sleep quality and quality of life in children with monosymptomatic enuresis: 2009 Blackwell Publishing Ltd, Child: care, health and development, 35, 4, 469–474. 

2. Naseri M, Hiradfar M; Monosymptomatic and Non–monosymptomatic Nocturnal Enuresis: A Clinical Evaluation. Archives of Iranian Medicine, Volume 15, Number 11, November 2012. 

3. Lampel et al. Urinary incontinence in children: Dtsch Arztebl Int 2011; 108(37): 613–20. 

4. Gontard, Does Psychological Stress Affect LUT Function in Children? Neurourology and Urodynamics 31:344–348 (2012).

Dr Lemma went to medical school in Jimma. He studied Hematology and Oncology at the Karmnos Cancer Center/ Wayne State University in Detroit, MI.

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