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.