Tenayistilign

By Surafel K Gebreselassie 

I drove faster than I normally would. It was in January, in the middle of a snow storm. My car skidded and stopped at the edge of Superior Avenue. I normally wouldn’t take Superior to go to work. The speed limit on Superior was only 25 miles per hour. I paid a fine once for just being 5 miles over. It’s true; two hundred American dollars. My old Honda was clear on the photo. I wanted to grab a small cup of coffee. Otherwise I would have taken Carnegie, the first road I learned after I moved to Cleveland. 

I was pleasantly surprised to find Ethiopian Sidamo coffee. I paid for a large cup instead.  

It was more than a decade ago, fresh out of medical school. We had to do mandatory medical service in government hospitals for 2-4 years but the location was decided based on a lottery. I was assigned to Awassa, the capital of the Southern States including Sidamo. Short of getting a job in Addis, the capital, Awassa was one of the few coveted spots. After about a 6 hour bus drive I arrived to this beautiful lake side city.

The conference room had filled up half way when I arrived. Most were late because of the snow. The fellows were seated on the left corner, all but one. I saw some new faces, a mix of medical students and residents. The staff physicians trickled in, some yawning. Every Wednesday morning there was a case conference except the third Wednesday which was allocated for kidney biopsy reviews. 

‘I am presenting this case today to see what you guys think about it? Do you all have the case summary?’ 

 The master clinician asked scanning everyone as quickly as possible pointing to the pack of papers. 

A 68 years old patient was described as having been treated for kidney failure. He read the summary loud with a melody that looked like an entry to a good novel. 

“He has renal failure,” he quipped. 

Then drilling the fellows started as usual reminding me of my training days. The differential diagnosis was discussed in good detail. 

‘So what do you think about the elevated potassium? What are the symptoms of kidney failure? How would you use the blood and urine data? How would that help you at all?” 

In the ensuing silence, I drifted back to Awassa and then to Turmi, a small city in the Omo Valley. The drive was rather dramatic. I made it to Arbamich the following day but I missed the weekly bus service to Jinka, just by a day, it turned out. I didn’t have enough money to wait for a full week so I paid what I had to ride on the roof of a heavy truck, a 12 wheeler. It would take us 24 hours to reach the city of Jinka,  about 200 miles. The road was bad. The drive was challenging. To my astonishment, the driver decided to take a break around mid night. 

“We are stopping here,” he said in the middle of nowhere. I was still sitting on the roof of the truck hungry and tired. Through the front light I could see some families from distance all lying on the dirt circling big trees with their cushioned two legged stools giving them neck support. I couldn’t see very well but suspected they might be families of the Omotic community such as the Hamar people.

“Get off the truck and take some sleep,” shouted the assistant driver his voice echoing in that barren land. 

“We have to take a break until down. There are ghosts and wild animals,” he followed. 

 I got off and stretched myself. I thought I could fall if I tried to sleep on the roof. I pulled out a towel and lay on the side road resting my back on the roots of a eucalyptus tree. They left the truck’s light on to scare away wild animals. I was too tired to be afraid of Hyenas or Lions or Tigers. 

When we finally made it to Jinka it was mid-day and I wasn’t alone on the roof.  A Konso family joined me later. They are known for irrigation and terracing of mountain slopes and erecting carvings of loved ones or important persons. A brief stop in the health office in Jinka, the main city in the Omo region of Ethiopia, brought another surprise. I had yet to make another trip, this time to Turmi, a market town home to many of the Hamar people. Word was out that I was coming to Turmi, what could have been the first doctor to run a health center. I was welcomed.

I still remember the light honey wine (birz) that I enjoyed surrounded by the beautiful Hamar people. My first patient was a middle aged man who came with his two beautiful daughters, 19 and 20, with elaborate hair dressings of red clay.

He had nausea, vomiting, swelling around his eyes and both legs. He wasn’t making much of urine.

I thought of getting married to a Hamar woman and settling down in front of the Burka Mountains and run the clinic but I had no chance unless I jumped  over a line of 10 to 30 bulls without falling, four times, completely nude.

The medical students were quite. They even look confused. He scanned them with his eyes.  He cleaned the blackboard with his clinched fist and started drawing the collecting duct of the patient’s kidneys, a scratch and sort of two parallel lines.

One is facing the urine, the other the blood. 

“What are the symptoms of kidney failure?” he asked them again. 

Nausea, vomiting, body swelling, decreased urination, fluid buildup around the lungs and the heart, confusion, even coma. 

The discussion was getting hot. 

Everyone was chipping in but me. 

I drifted back to the Omo Valley.

By Dr Surafel K Gebreselassie

I don’t know how we did it. We did it anyway.

At least three of us had tuberculosis as far as I can remember. That would be 10% of the class of 1996. My symptoms were not as bad compared to my other two friends. It all started with four people, three medical students and a patient with open tuberculosis. There were no masks, if there was one we didn’t pay enough attention.

Cough, take a deep breath,

Cough, take a deep breath.

The patient didn’t disappoint us.

He coughed and coughed in front of us.

 We pressed and listened to his chest, anxious to report the fluid that we picked in his lung, to the uncompromising professor.

 If you couldn’t diagnose tuberculosis, you are no doctor.

That was for sure.

The professor would pull up the x ray later.

We were right on the spot; the left lung had fluid in it.

Mycobaterium tuberculosis was first discovered in 1882 by Robert Koch, the founder of modern bacteriology and winner of the Nobel Prize in Medicine in 1905, but the disease is perhaps as old as mankind bearing different names such as white plague, consumption.

It sure was consumption. It started to chip away my energy just when I needed it, right before the exam. I was tired and weak. Profuse sweating at night became a nuance. The loss of appetite followed. I was spared of the bad cough, at least initially so I wasn’t suspecting. The punishing schedule sure can make you sweat and lose appetite, so took the blame.

When I started to cough up phlegm, I knew that I was in deep trouble.

I picked up a sample and headed to the lab.

“Who are you?”

I am a medical student.

“What do you do here in this odd hour?”

I came here to do acid fast stain.

“Do you know how to do it?”

I had an A in Parasitology class.

 I answered the head of the lab with unease but I knew the follow up question would be difficult to answer. I didn’t want to tell him my lower grade in Microbiology. I had the staining steps memorized and knew what the bacteria looked under the microscope, red dots because it resists decolorization with acid rinse and takes up the initial red color of the dye, carbol-fuchsin.

He looked at me straight in the eye; an old man, perhaps in his 60s.

Sixty years of Ethiopian life at any time will easily make you old with no complaints because you have already made it beyond the life expectancy anyway.

He was head of the microbiology lab.  I was still standing by the door to get a permission to get in when he approached me.

“You look sick,” he said.

I broke down in tears.

He stopped what he was doing and took the sample from my hand. He stained it himself and summoned me to look at it with him.

“Look where the pointer is,” he said.

“You have it.”

Tuition, housing, basic food and medical care were free  in medical school. Pay back was mandatory service for few years in government hospitals after graduation.

I checked in Jimma hospital to be treated for tuberculosis. I joined the other two students who beat me by few days.  

History is full of stories of many who suffered from tuberculosis.

Such as author Edgar Allen Poe and poet John Keats

The bacterium was also found in ancient Egyptian mummies.

I was not afraid; we were in a different era.  Roentgen discovered X ray in 1895 and made it easier to diagnose.  Long before I fell for it, treatment was established starting with the discovery of streptomycine in 1944 and INH in the 1950s, followed by many more.

Soon every one found out that after all I was eligible for high protein diet, two boiled eggs added to the evening campus meal.

Two boiled eggs every day! That was a lot of protein but more importantly it helped me eat the rest of the plate, stew made of lentils, chickpeas on most days.  Classmates would take turns to share one of the eggs.

Two to four weeks in to my treatment,

I regained my appetite.

The fever slowly went away.

The cough eventually disappeared.

I passed the exams with flying colors.

I continued to get those boiled eggs way beyond the 6 month of the intensive treatment.

It is a bittersweet memory.

By Dr Lemma

Health is not just physical well being. Trust me I am not repeating the health definition by WHO which we recited several times in medical school. Nonetheless, it has a truth to it and I have a true story to tell.

I met Murshid on the famous street of Jimma town, Ferenj Arada. He was a young boy around 11 years old living on the streets. He looked short for his age, was a little chubby and full of smile. It did not take too long before we became friends and he was a regular visitor to our rented house where I used to live with my roommates.

One day he told me people used to call him crazy just because he carried his belongings, mainly clothing, in a plastic bag wherever he went. He was actually taken in by few families as a foster child but was kicked out because of his nocturnal urinary incontinence (bed wetting), a condition that can easily arise from the stress of street life and difficult childhood.

We did provide him a small mattress with a plastic covering underneath and he stayed with us. We eventually trained him and his urinary incontinence improved.

The grand plan started when I asked him more details about his family and where he grew up. He told me he was born in a small village called Aleyo located few hours from Toba. He left his village when his mother passed away from some unknown illness. Toba is a small rural town; around 2 hours drive from Jimma with a public telephone service and few shops here and there. I asked him if he wanted to go back to his family. After initial hesitation he said yes. I spoke with a social work department, an office that helped street children re-unite with their families, and they offered help to take Murshid back to his home.

That day came when we would take Murshid back to his village, to the place where he was born and raised, to meet his brother, his father and his step mother. He had been away now for few years and was not sure what to expect. He was not scared though, neither was he too excited. He knew he had to see them someday and was especially longing to see his father and his brother.

We headed from Jimma to Toba with a minibus. Once in Toba, we asked people where Aleyo was located. They told us it was few hours from Toba, behind the hills but the only way to get there was either on foot or ride a mule.

We found a mule for a fair price. I was a bit scared at first but thought that it would be a quick ride to Aleyo.  An hour passed by. There was no one we can spot. We zigzagged through the alleys and after another 2 hours including crossing a thick forest, Murshid spotted his neighborhood from distance.  Tears swelled up in his eyes. He pointed to the direction of the grave where his mother rested and immediately turned his face. It was against the custom in the village to keep on looking that way. So we turned around and continued to his father’s thatched house surrounded by many other similar houses. His neighbors immediately recognized Murshid. They placed their hands over their heads as a sign of surprise and immediately send for his father who showed up within few minutes. I still remember that moment when his father met Murshid for the first time after several years and kneeled under his boy’s knees and hugged him…we were all in tears.   

I was invited to go in and share a cup of Ethiopian coffee, sweetened with salt. I did not see his step mother though and was wondering how she will react.

It was getting late, I didn’t stay much longer, a three hour trip was waiting for me to get back to Toba where I can catch the last minibus on the way back to Jimma.

Murshid met his father, his brother and the rest his folks and felt at home. His face told it all. He was happy.

I still felt that being with his family, however poor, was better for him than the streets of Jimma and the unstable life in foster homes. I still remember the moment when he hugged his father; the palpable joy in his face. Weeks later, Murshid surprised me with a collect call from Toba.  It was at the end of a market day. He was with his father. He had picked up farming to help his father along with a crash course he had to take at the only elementary school for the entire surrounding community staffed with a lone teacher.  

Months would pass.  I was walking with my friends in Ferenj Arada.  It was early evening.

We stopped by a street vendor to buy some roasted corn.

 There was a young boy, rather skinny, walking alone carrying a plastic bag …I walked faster to get close…he started running…

Hey Murshid,

Murshid, It is me. Don’t be scared…

He run faster and disappeared  in the dark Jimma night.

I always ask myself if I ever did him a favor by taking him back to Aleyo but I will never forget the lesson  that it is not just enough to treat a symptom unless one deals with the root cause. 

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

By Dr Lemma

This is a story almost two decades old but is still fresh in my mind. I was a 4^th year medical student just starting to see patients, eager to appreciate abnormal physical signs which were common as most of the patients sought medical attention late.

An enlarged liver, a huge spleen that can even be seen under clothing, a racing heart and a crackling chest were few of the daily routines ,  and yet a cause of pain and suffering for those who had them.

It was a regular day in Jimma hospital but never regular for a young mother from rural Jimma, Feyate. She was admitted with body swelling and fatigue. There wasn’t much we could do to investigate her maladies; our laboratory was equipped to perform only basic tests such as measuring hemoglobin levels and white cell counts. Our imaging was the good old plain x- ray. It all came down to making sense of the patient’s stories and thorough examination for clues about different diseases. Thanks to our seasoned teachers who thought us such critical skills which I am afraid is getting lost from modern medical education.

Feyate was admitted in one of the medicine floors, a hall crowded with 20-30 beds. I could easily tell she was uncomfortable.

Later that day everybody was talking about an “interesting” physical finding in the medical ward and everyone was rushing to appreciate it.  It was a pericardial friction rub, a sound that is formed when there is irritation between the inner and outer coverings of the heart from conditions like renal failure. I picked up my stethoscope and ran to the medical floor. There were a couple of my colleagues by Feyate listening to the strange sound over her chest.

That is my patient!

I wasn’t happy that I didn’t pick the rub first.

It was pericarditis, an inflammation between the coverings of her heart, which was as a result of her advanced kidney failure. We couldn’t do anything about it.  Dialysis was unthinkable then and is still unthinkable in most of the cities outside the capital.

The senior physician suggested we discharge her home so she could spend the rest of her days with her family.  She knew we had nothing to offer.

 A bunch of young kids

Running around with stethoscopes

Chasing after murmurs and rubs

“I want to see my children,” she said, afraid that she will die far from home.

The dangers in renal failure include very high potassium that could result in sudden death, or accumulation of fluid between the coverings of the heart, or the accumulation of the waste products that the kidneys normally filter that can cause confusion and coma; or the uncontrolled blood pressure, and many others.

I still remember the poem I wrote her that day.

Lijochen salay endalmot (let me see my children before I die)                                       

Tolo awtugn kezih behiwot (send me home)

Eyalech baluan sitimatsen (was begging her husband to take her home)

Sitiwotewit let te ken (day and night)

Yerega tihut menfesua (her quiet and calm spirit)

Bibezabatim abesa (despite her sufferings)

Chirash atawkim maguremrem (she never complained)

“Feyate” bezaw silimlim…. (“I am ok” and back to slumber)

Feyate was discharged the next day and had to take a long horse trip home to be with her family and to be surrounded by her children, her neighbors and her community. Death is always a stranger one can hardly get used to …but when it is potentially preventable, the pain is much more difficult to handle.

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

 By Surafel K Gebreselassie

I woke up to a rare beautiful day in the winter of 1999. It had been raining for over a week. The dogs were out barking. The clear blue sky was hosting flocks of birds. It was a day for all the creatures. I decided to walk to the hospital. It was located about two miles from where I used to live. I was not alone. Everyone seemed to have waited for this day to walk to work creating a human traffic. It was no place other than the glamorous city of Addis Ababa, the capital of Africa.

I was a GP at one of the busy hospitals in Addis. Working in the pediatrics out-patient department, I had the opportunity to treat many of the city’s babies, admit those who needed inpatient care, and follow the chronically sick. On that beautiful day I was yet to have the most challenging case of my life. 

The hospital work began with the usual morning report followed by an infant with pneumonia, a 5 year old boy with seizure whose twin brother was healthy. I recall to this day his facial expression that posed the unanswerable question, why me? 

Then I saw a couple with their baby girl. They looked familiar.  Suddenly all the memories got loose. Yes I sure did see them before; two HIV-positive patients on treatment for pulmonary tuberculosis. I was doing HIV counseling when I first met the couple. That had to be 2 years back. I remember the shock during the first encounter. 

In most places in Africa, even at present time, being HIV-positive is like receiving a death sentence. And the most gruesome fact for the physician was to break this deadly news, which is probably true even today. 

 Certainly the first day was tough. I counseled them subsequently for weeks. In a matter of months they went beyond finger pointing to accepting their medical problem and started working towards optimal health but things would get from bad to worse in a matter of few months. He had a bad viral infection of the eyes (bilateral CMV retinitis) and would lose both visions. He was a long distance truck driver and had to stay home. She became the sole bread winner washing clothes for well- to-do families. In a place with no anti-retroviral treatment options at the time, my advice was mainly  healthy diet, exercise , detecting early some of the common and treatable conditions that HIV patients faced, such as tuberculosis and diarrheal diseases. But the most satisfying part was to give them emotional support in a society where the stigmas of such diseases were sometimes graver than the disease itself. One of the topics discussed was how to avoid pregnancy through effective contraception methods. In the pre-retroviral treatment era, pregnancy carried about a 20-30% chance of infection for the newborn and another 10-20% coming from breast milk. Those 50% of kids who may not acquire the disease would have lost their parents by the time they reach adolescence and would be subjected to homelessness and all the fallbacks that come with it. So we strongly advised them against having a baby. 

I looked at them again; they are the same couple I sure counseled for a while. Suddenly they were full of tears. Their cute baby girl seemed to sense the tension of the room and started crying.   

She wasn’t afraid of me.

She crawled in to my arms. 

What is her name?   

Mimi.

 Mimi is often a name used for baby girls before actual names are given but some do end up taking it as a permanent name. I was curious why they named her Mimi but they hesitated to say more. 

Mimi was within her expected range for weight. She can walk unsupported. She was a little older than a year. Her chart revealed no major illness in her 12 months on earth. 

I picked up my stethoscope and listened to her lungs and her heart. She had calmed by then and her heart rate wasn’t fast. 

Started bouncing back and forth, myself, confused, I guess. 

But why this little girl ? I asked, like the boy with the seizure.

I looked straight in their eyes, which were swollen like a person with nephrosis but with no answers. 

Why did they bring about this innocent life knowing the risks after so many weeks of counseling? 

It was about continuity. It was about living full, and leaving the rest to God. After all it was not a world governed by their will. Ultimately it was about hope. In their mind they never doubted she would be fine. They lived for a year with denial. They were getting weak from the opportunistic infections and they wanted to know the truth.

 Would this cute baby be free of the virus and face the uncertainties of the future on her own? 

AIDS killed many people and left many children orphans. Her parents were still waiting to name her and hoping that grandparents would see her through childhood and adolescent years like so many children in sub-Saharan Africa. I wish there was anti-retroviral treatment then. 

I wish I was able to do more than give them the good news. 

Yes, Mimi indeed had no HIV!

Yes, the test came negative!

Yes she can have a proper name!

 Mimi lived to face the other childhood killers like measles.