Black Lion Hospital

My last week flew by… I wish I had gotten to start at Black Lion Hospital a week earlier as planned. The volume of patients and specimens they see is so much greater than Dr. Y’s private practice. The biggest pathology department in Ethiopia, Black Lion is home to a total of 7 pathologists, 5 of whom serve as faculty for Addis Ababa University, the other 2 sticking strictly to signing out cases. The hospital processes 8,000 surgical specimens a year in the “Bits Room” (this must be a British term, but it sounds a thousand times cuter than the American term “Gross Room”). For comparison’s sake, Fletcher Allen in Burlington does at least 40,000 surgical cases a year and employs almost 30 pathologists full-time.
The Bits RoomSpecimens in the Bits Room (the right 1/3 of the photo are all specimens waiting to be processed).

One of Black Lion’s pathologists is an 82 year-old “retired” Swiss pathologist named Dr. Schneider. He moved to Addis 12 years ago to devote himself to improving Pathology in Ethiopia. His sole compensation for his work is his housing. From what I could see, he is always in motion, moving from one productive task to the next, so I didn’t get much of a chance to talk to him. He paid for much of the equipment in the Bits Room out of his own pocket. He sits on the board of the Ethiopian Medical Journal. He gives twice weekly lectures on relevant pathology topics to all the residents of Black Lion. The department head said that people started to respect and pay attention to pathology in a new way after he moved to town. I can see why. He has a passion and a gift for teaching. I attended one of his lectures (excellent) and I sat in on his slide sign-out with the residents one morning. His interest in me extended to whether or not I had the skills to help him figure out issues he’s been having with immunohistochemistry staining (surprise, surprise, I didn’t).

There are also 8 residents at Black Lion who were a joy to meet. Pathology training in Ethiopia consists of a 3-year AP-only program with time divided equally between four subjects: surgical pathology, hematology, cytology and autopsy. However, there are only around 20 hospital autopsy cases annually so autopsy months translate into study time for end-of-residency exams.

Before residency, folks complete 6 years of medical school straight out of high school (however, in an effort to train more physicians, the government keeps shortening this to 5.5 years currently). This training is completely government-funded and offered to those students who have the highest high school test scores. However, the entrance criteria are broadening to train more physicians. Nearly everyone I talked to was dismayed at the current push to train more physicians. Apparently the government wants 1,000 new doctors a year emerging from medical school. The infrastructure and resources are simply not there to train more students in shorter amounts of time. Quality will undoubtedly be sacrificed for quantity.

After medical school, doctors must complete an obligatory 2 years minimum of service as general practitioners, usually in rural areas. Once this commitment has been met, they can apply to go to residency in a given specialty (Black Lion is the only pathology training program in Ethiopia). During their post-graduate training, residents are “sponsored” by one of Ethiopia’s 7 medical schools or other government health organizations. They are paid average government doctor salaries (around $350 a month). In return, they commit to serve 2 years as physicians for their sponsors for every one year of sponsorship. Therefore most residents have 6 years of practice and teaching responsibilities in smaller cities ahead of them once they complete residency.

Residents at Black Lion
A couple of them admitted they were tempted to find ways abroad once done with residency. I can’t blame them. The working conditions and prospects for pathologists and other doctors seem pretty bleak. The halls of Black Lion are dimly lit and depressing. Despite daily cleaning by sanitation staff, things seems grungy and old. Even when more advanced technological automated equipment for processing and staining slides exists, that machinery often breaks down with no one to repair it. There are so many more professional opportunities and financial support abroad that you have to have a huge sense of dedication to stay.

The number of surgical specimens processed each day at Black Lion is limited by the number of plastic cassettes they have, which are reused from day to day. The resident on surgical pathology is supposed to gross in 20 specimens a day while the resident on cytology is supposed to take 20 FNA specimens in a day. There is a backlog of specimens waiting to be processed, with a delay of up to a week between receiving a specimen and grossing it in. One afternoon the resident ran out of cassettes after 17 specimens, so his work was done for the day.

Cassettes being reused

The FNA room

It seems like most people here have a good friend or family member living in the US or Europe. One of the residents told me that 20 people out of her graduating class of around 80 are currently training abroad, unlikely to come back to Ethiopia. Another resident said he disliked the term “brain drain,” preferring the more dramatic term “hemorrhage of physicians” to the west. Apparently, the government has advocated further shortening medical school to just 4 years post-high school. This would essentially make the Ethiopian MD degree useless overseas and prevent people from leaving the country for more lucrative practices abroad.

Some interesting cases I saw for FNAs in my last couple weeks included several spectacular goiters, an impressive case of cutaneous TB (see picture below), Burkitt’s lymphoma in a 9-year old girl, a fungating breast mass and many more. I also finally spent a morning with a dermatologist at ALERT and saw many leprosy patients in various stages of the disease. The most sad for me was a man in late middle age who had chronic untreated MB leprosy (lost the distal portions of all of his fingers) as well as elephantiasis of both lower extremities (perhaps mossy foot?) and scabies to boot. I felt a lot more shy about taking pictures toward the end of my stay, in part because I hadn’t yet formed a solid relationship with the doctors I was working with.

Here are a few more pictures I took at Bethzatha with Dr. Y, from Nico's 1st birthday party and some of the characters I enjoyed meeting:

A hospital bed at Bethzatha Higher Clinic. This is where we did bone marrow aspirations.Cutaneous TB
Dr. Y and his aging car.

We took Dr. Y and his wife to dinner at a fancy Italian restaurant to say thank you.

Me and Doche the day guard at my brother's house. Kayo's mom brought him the very sparkly shirt he is wearing from Japan.
Sahilu my taxi driver. I could called him on his cell phone and he came to shuttle me back and forth between hospital and home. He had Obama stickers prominently placed in his car.

Nico's birthday cake featuring Shimojiro, his favorite Japanese tiger.Nico's birthday party. A 1 year-old's birthday party is an event purely for the parents.

I wrote the above text on the plane ride home yesterday. I arrived safely back in the states late last night and am luxuriating in Josh's high-speed internet connection today! It's so good to see him and and my wondercats. I am hoping to keep in touch the residents I met and, of course, with Dr. Y. There is much to be done to support and improve pathology in Ethiopia. I have fallen in love with the country and hope to go back once I am trained as a pathologist and have some concrete skills to offer.

Thanks for reading this month! I have enjoyed the task of reflecting on and synthesizing some of the things I have learned. Next adventure: dove hunting in Argentina anyone?

I leave you with a little Nico video. His laugh is contagious.

Ethiopian Orthodox Christian Church

The Ethiopian orthodox christian church deserves mention in this blog because it plays a huge role in Ethiopian culture, dating back to at least the 4th century AD, and involving unique ritual and pageantry. The church celebrates the holy trinity as well as many saints and angels. One practical and unique aspect of this form of christianity is the fasting calendar. On 250 specified days each year (yes that’s 250… including every Monday and Wednesday, the entire periods of Lent and Advent, plus many other days in celebration of saints), observant orthodox christians are expected to fast until 3pm, and then eat only food that contains no meat, eggs or dairy products. This custom of fasting makes Ethiopia a fabulous place for vegetarians to travel, as requesting the “fasting menu” in any restaurant in Ethiopia guarantees meat-free fare.

Another unique aspect of this religion that has shaped my experience here is the music. I am woken up every morning at around 5am by chanting being blasted from the loudspeaker of a local church. It is haunting and peaceful, reminding me of the call to prayer that emanates from mosques except that it lasts for an hour or two at least. Apparently, on religious holidays like Christmas and Epiphany (January 7th and 19th respectively in Ethiopia), such chanting goes on all night. Below is a video I took at Saint Maryam church on Entotto Mountain which overlooks Addis. Despite my lackluster camera-skills, it gives a view of the city from above as well as a feeling for the sound of the chanting.

Mossy Foot and Travels

We had dinner last week with the US embassy’s medical officer Dr. T. He treats embassy employees over a large swath of Africa, from Nigeria in the west to Kenya in the south and up north to Egypt. He is constantly travelling either to do regular check-ups in various places or for any medical emergency that arises involving an embassy employee. I do not envy his job at all! He seems spread pretty thin. However, his stories are fascinating.

He says he is quick to medivac folks because he doesn’t trust the medical system here at all. In a little over a year here he has hospitalized someone locally only once, an acute appendicitis case in the middle of the night in need of urgent operation. He also says Dr. Y is the best and most thorough pathologist in Addis. From the sounds of things, it turns out I really did luck out having Dr. Y as a mentor here.

Dr. T introduced me to an intriguing Ethiopian pathological entity I had never heard of before. I haven’t actually gotten to see it with my own eyes, but I thought I would share it with you, my dear blog readers.

Although it may have the cutest name of any disease I’ve encountered, Mossy Foot is a serious problem here in Ethiopia. Its more scientific names are podoconiosis or nonfilarial elephantiasis. It occurs in a people who work barefoot in volcanic soil at high altitudes. Microscopic particles of volcanic silica penetrate the pores and clog the lymphatic system, causing swelling of the legs followed by development of sores and keloids (overzealous scar tissue). The feet often become infected with fungi and bacteria, eventually giving them a mossy look.

People with Mossy Foot are often treated like lepers and rejected from society. There are an estimated 1 million people suffering from Mossy Foot disease in Ethiopia. I got most of my info about Mossy Foot from the web site of an NGO working on the treatment and prevention of the disease in southern Ethiopia. Interesting photos and more details of their work can be found at mossyfoot.com.

It turns out I’m spending a 3rd week hanging out with Dr. Y at Bethzatha and ALERT. When we contacted the folks at Black Lion this week they said they weren’t ready for me. I’m not complaining because it’s so fun working with Dr. Y. Every day I am more impressed with his patient interactions and his ability to render a good diagnosis with limited resources.

Dr. Y drying bone marrow aspirate slides in the sun.

Yesterday we did an FNA on a patient with a "testicular mass" which turned to be TB involving the epididymis. Sorry folks, no pictures of that one! We also cut in a ruptured eptopic pregnancy specimen that was quite advanced.

Me grossing specimens and finally putting to good use the TB mask FAHC gave me at the beginning of the student pathology fellowship.
Ruptured ectopic pregnancy specimen.

On the personal front, last Friday was Nicolas’ 1st birthday. I was able to leave work early and partake in an Ethiopian coffee ceremony that the house staff put together for him (ok so he didn’t actually have any coffee, but we adults each enjoyed 3-4 cups of it). One of the compound guards gave Nico a gigantic zucchini from his garden.

Nico with birthday zucchini.

Coffee Ceremony

Nico's nanny Tewabich serving coffee, accompanied by sweet popcorn (in basket at right).

Over the weekend we flew 1100km north to Axum, capital of the ancient Axumite empire and only about 40km from the Eritrean border. It was nice to get away from the hustle and bustle of Addis. The landscape there is impressive: pale yellow-brown jagged, rocky hills intensively cultivated with terraces of tef, the grain used to make injera (Ethiopian sponge bread) and occasional scrubby trees. I would love to go back in the rainy season when everything must be lush and green. We saw ancient tombs, incredibly old churches and a newer building that supposedly houses the Ark of the Covenant. We also saw what is thought to be the ruins of the palace of the Queen of Sheba.
Field of obelisks.

Me and Kayo in front of fallen obelisk.

Landscape outside of Axum.

This northern region of the country was one the hardest hit by the severe drought in the mid-80s that turned Ethiopia into the posterchild for famine. That situation was worsened by Western govenments’ delay in sending aid (they were reluctant to help the socialist country) and then the Ethiopian government’s unwillingness to get donations to the far north when they finally came. About one million people died in total. An absolute tragedy. However, it is amazing to me how deeply that media campaign affected the image I had of Ethiopia before I came here. No subsequent images of the country ever replaced or modified the mental association I had that Ethiopia = starving children in a desolate landscape. I’ll bet the same is true for a lot of people in the States. Yet there is SO much more to Ethiopia! It is geographically and culturally extremely diverse and rich. I hope this blog is able to convey a tiny sliver of that. However, I realize that by showcasing the country's pathology here, I may be far from acomplishing that goal.

Because of the revolution in the 70s and the Derg regime through the mid 90s, Ethiopia got a late start at development. It now seems to be making up for lost time. There is HUGE amount of construction going on right now in Addis and elsewhere (there was plenty in Axum). In fact, I’ve never seen so much construction and road work in my life. The majority of the projects seem to be financed and managed by the Chinese… perhaps American investors are missing out! I think it will be fascinating to come back in 5 years and see how much has changed.

Typical construction site with ramp made of eucalyptus trunks.

As always, I'll leave you with a dose of cuteness:

Ishee

“Ishee” is a word you will hear hundreds of times a day here. It loosely means “OK” and is used as people start and end a conversation and shows active listening in between. This is the one Amharic word I have truly mastered… There are a lot of sounds in Amharic that are hard for a forenji (foreigner) like me to pronounce.

Last Sunday Andrew and Kayo hosted a lunch for the “gourmet club” they are a part of. It was quite an international crowd: Ethiopian, Egyptian, Swedish, Armenian, Italian, Chinese, British, Japanese, and American. They meet once a month at a member’s house and feast on fabulous food from the country of the host. Kayo prepared an amazing Japanese meal with bento box appetizers and then grilled tuna that Andrew had brought back from his recent trip to Djibouti (I am amazed he was able to check a cooler filled with 30lbs of fresh tuna).

Kayo's beautiful bento boxes

Elegant outside dining

There is a tortoise that lives in Andrew and Kayo’s compound. It usually seems to hang out in the flowers and shrubs, but occasionally strolls across the lawn. It decided to make an appearance during the party:

Tortoise

It has been good to get into a routine this week with Dr. Y. We arrive at Bethzatha Diagnostic Laboratory at around 9am each day and do a few lymph node and thyroid FNAs in the morning and look at slides that have come out. Then a little before midday we walk a few blocks over to the Bethzatha Clinic to do a couple bone marrow aspirates (we need a nurse to help with those). On Mondays, Wednesday and Fridays we then head to ALERT on the outskirts of town and eat lunch at the best (and only) restaurant I’ve ever been to that is housed in a shipping container (see picture below), run by a former ALERT patient. After we’ve had our fill of injera and wat, we do a few more FNAs and then sign out cases.

Shipping container/restaurant

Yesterday afternoon we saw a 6 year old boy whose left foot had swollen over the past year to a surprisingly big size. All his toes but his big one had auto-amputated. We did an FNA that was totally dry so we have no idea what is going on with him. I wasn’t able to get the full story and don’t know what kind of imaging or other tests he’s had.

Big Foot. I wish we knew why.

We see lots of lymph nodes containing caseous necrosis which in this neck of the woods is pretty much diagnostic for TB. No one wears masks in the health care settings here that I have seen to prevent the spread of TB. So many people have the infection that pretty much everyone has been exposed at some point or another. Dr. Y says they don’t use PPDs much here at all because everyone would be positive.

Pink Tuberculosis mycobacteria seen on acid fast stain

On Tuesday and Thursday afternoons we gross in surgical specimens back at Bethzatha which for all you non-pathology folks means looking at any tissue that is taken out of a patient in the OR or office, be it a big specimen like an entire uterus or colon resection or smaller pieces of tissue like GI or skin biopsies. I am impressed with the recycling that occurs to send specimens—jam jars, IV bags, syringes, even a Nutella container!

Specimen Containers

The description of each specimen is much more limited here than in the states… often it is just one or two measurements of whatever was submitted. I’ll be interested to see if things are different at Black Lion Hospital (the main teaching hospital of Addis Ababa University) when I start there next week. We usually take 1 or at the most 3 sections of any given specimen. Most of the time it’s only 1.

The formalin they use to fix tissue here is incredibly strong! Dr. Y had me try my hand at grossing in specimens and I didn’t last long before my eyes watered profusely and my lungs burned. I was relieved when he offered to take back over for me. I’m definitely used to a system with loads more personal protective gear, sharp knives, milder formalin, etc.

Dr. Y grossing specimens

This coming weekend we are heading out of Addis for some site-seeing and then next week I start at Black Lion Hospital, the main teaching hospital for Addis Ababa University. It will be interesting to see if they do things differently than Dr. Y who is nearing retirement and is a one-man show. I am also looking forward to meeting some Ethiopian residents and med students.

A couple fun facts about Ethiopian time:

Ethiopians use a different system for telling time: 12 hours of day starting at our 6am and 12 hours of night starting at our 12 pm.

Ethiopia uses its own calendar, the history of which I'm a little fuzzy about. In the Ethiopian year there are 13 months, 12 of which have 30 days and the 13th of which has just 5 days. They are ~7 years behind us.

Here’s a pic of me sampling the fabulous coffee here:

And I’ll leave you with a picture of me and my favorite nephew:

Week of Noma

So my first week of 4 has flown by and I haven't been able to post due to the extreme slowness of the internet connection at my brother's house... I can't even get the blogspot page to load much less think about creating a post. This morning I am at the cafe at the American embassy making the most of the high-speed connection to share some pictures and stories of my first week.

Typical Addis streetscape.

Andrew and Kayo's house: the lap of luxury!

I have split my time so far between the diagnostic labratory of a private hospital called Bethzatha and a place called the All-African Leprosy and Tuberculosis Education, Rehabilitation and Training Center (ALERT). Dr. Yohannes, the doctor with whom I am working and one of about 20 pathologists in all of Ethiopia, works at both places. I could not be luckier having him as my teacher this month. He has a great sense of humor and is passionate about what he does. He spent 20 years in France so we have been having fun communicating primarily in French. After 20 years of practicing in Ethiopia he is heading to Guadeloupe in 2 months for a more lucrative position with the French Government for a year or two. The car he drives is the same age as me... he wants to at least earn enough money to buy a car.

Dr. Y on the left and the long-time lab technician at ALERT

A pathologist's job in Ethiopia seems to consist mostly of doing cervical lymph node FNAs and bone marrow aspirations (Dr. Y does all sternal aspirations). This week we did about 6 a day. However, he is a jack of all trades. He also grosses in all his own surgical pathology specimens, which happens on Tuesday and Thursday afternoons. He stains his own slides. He writes his own reports. He does an amazing job of explaining the FNA/bone marrow aspiration procedures to anxious patients. Dr. Y at the microscope.

This week I also spent time with a plastic surgeon at ALERT. He was equally inspiring. He makes a total of $360 a month and does totally life-changing surgeries on leprosy and noma patients. I had never really heard of noma before coming here. It is a flesh-eating and disfiguring infection that can occur on the faces of malnourished children. There are currently 5 noma patients at ALERT that are undergoing reconstructive surgery to give them new lips, cheeks and noses. Most of them are in their 20s and have had their deformities since childhood.

Me and Dr. A the plastic surgeon.

Operating on a noma patient with Dr. A.

This is a noma patient's oral region before skin grafting.

The facial reconstruction happens in stages. The picture above shows an intermediate stage: a flap of skin and subcutaneous tissue from the clavicular and deltoid regions gets brought up to the cheek, attached with sutures and left there for 3 weeks so that it can form new vascular connections with its new environment. The flap is then cut and grafted tissue is revised to form new lips/cheek/nasal tissue for the patient as needed. One of the noma patients we operated on literally has no nose and no upper lip. It's absolutely devastating and I don't feel comfortable posting my pictures of him to this blog.

To end things on a positive and cute note, below is a picture of my nephew Nicholas, only one of the cutest babies ever to grace the earth.