This blog is being submitted from home.  I and trouble with internet access over the final week in Addis, and so did not manage to load the blog.  Most of what you see below was written before leaving for home.  I have added some final homecoming notes at the end

This will likely be the last instalment of my blog from Ethiopia.  We will be leaving for home on Friday.  I am not looking forward to the flight.  We leave at about 10.30 pm, stop in Rome about 6 hours later for about 2 hours, and then leave for Toronto, arriving at about 7.30 pm.  Since we are travelling in economy I will not be able to sleep.  I should be totally wiped by the time I arrive home.  

Since the last instalment of the blog we have continued to do our daily work, lecturing,  and seeing patients in consultation.    I was able to take a break.  I had a meeting in Frankfurt on Friday last week, so I flew out on Wednesday evening, arriving early in the am.  The meeting was in the Airport Hilton, so I did not see anything of the city.  Nonetheless, it was a good break.  Arrived back early on Saturday morning, and after a catch-up nap we sent sight seeing in Addis.  There is not much to see.  We had previously seen the Ethnographic Museum (a good display of various hominid remains found in Ethiopia, including Lucy, who is thought to be the first human ancestor ever identified) and the national Museum ( pretty poor exhibition), so we visited the St George Cathedral, not very old nor very impressive, but important in the life of Christians in Addis.  Thereafter we went to the Markatto, the local market.  We had a guide, who shepherded us around.  The Markatto is awful.  It very crowded, people, cars, donkeys, goats, all sharing the road,  There is garbage everywhere.  The stores have goods displayed in piles,  You can't really see anything unless you have the owner show you, by which time you are subject to high pressure sales pitch.  Crowded markets are not my thing.  However, we are able to get some souvenirs, so I was able to cross some people off my list.

Yesterday we treated ourselves, and had lunch at the Sheraton, which is within walking distance.  However, to get there we pass through a rather decrepit area, and wouldn't you know it, we were swarmed by a group of young men.  They did not hurt us, but grabbed us in an attempt to pick our pockets.  They were likely also after my camera.  However, we crossed the road and they left us alone.  No harm done, but not pleasant.

One last chore to do -  finish shopping for souvenirs.  Will try to get that done today or tomorrow.  

A few random thoughts:  Toyota must have made a killing here.  Four out of 5 vehicle smaller than a bus or truck were made by Toyota.  All the minibuses (and there are thousands) are Toyota's.  Most of the 4-wheel drive vehicles are Toyotas.  Most small cars are Toyotas.  American cars are rarities.  Even european cars are not common.  There is a Chinese brand that we see now and again, called Lifan, but apart from Toyota most other cars are also Japanese, Suzuki, Mitsubishi, Nissan, etc.  

Most cars truck and buses run on diesel.  Consequently, given the poor state of maintenance, a large number of vehicles spew black exhaust smoke.  Pollution is bad, mostly due to vehicle traffic.  There is little heavy industry to contribute to pollution.  

The taxi industry runs on ancient vehicles - Old Lada's old Toyotas of the vintage that I used to drive more than 30 years ago.  The blue and white cars in the photo's are all taxis.  They all have dents. The worn seats are covered by loose foam cushions. In one car the only working dashboard instrument was the radio.    The suspension probably gave up the ghost years ago.  There are impromptu car repair shops at the side of the road, cars up on blocks with the wheels missing, that are gone the next day.  Since there is no municipal program to remove these traffic obstructions I can only presume that the owner took the wheel off, had what needed repairing fixed, and put the wheel back and drove off.  

Private buses are classified as first line, second line and the rest.  These correspond to first and second class, but essentially this means that first class is only slightly less uncomfortable than second.  I hate to think what the rest are like.  People travel long distances in these buses.  This is how most people get around.  Our hospital receives patients from around the country, and some people travel days to get here, by these buses.  

 One more pick-pocket attempt on Tuesday last week.  I was on my own, walking to look for souvenirs.  Someone walked immediately in front of me and stopped, so that I would bump into him.  I was then bumped from behind.  My immediate thought was that this was a pickpocket attempt, and I whipped my hand over my back pocket, which was empty.  It and however, been empty all along.  I did not feel a hand in the pocket, but I think they did feel my pocket to see whether there was anything in it.  I have been carrying money in a pouch around my neck, tucked behind my shirt.  I studiously avoided carrying anything of value in my pockets, and if I did have something that I had to keep in my pocket I had my hand also in that pocket.  Not pleasant to have to be on guard like that all the time.  They don 't hassle locals, only whitey's.  

I have picked up a nasty cold on the last day or so in Addis.  now that I am home I am struggling with a blocked nose, worse than I have and in a long time.  Not exactly the homecoming I was wanting, but it will get better with time

That's all for now, until the next adventure.

Morris

PS, somehow the original pictures I and included disappeared.  Here they are again, with some more.  They are not in order.

M

 A general view of the landscape in Lalibela

 The local coffee shop outside our hotel.  The blue kiosk was constantly busy

 A street view outside the hotel in Addis

 Taxis lined up outside the hotel.  gthe one on front was non-function.  It sat there unattended the whole month.  

 The Markatto

 A spice shop in the Markatto

 Street scene near the hotel in Addis

View down one of the street flanking the hospital.  Traffic was usually horrendous.  There are only about a dozen traffic lights in the whole city.  Fortunately, the access to the hospital was controlled by two of these.

More Markatto

Markatto

 A bus stop in the Markatto

 View from our hotel when we went birding

 Lalibela market -  firewood section

 Small hitch on the way back from seeing yet another church, this one built inside a cave.

 Our guide in Lalibela invited us to his home for a "coffee ceremony".  This is common.  This is the dining room and living room.   Note the poinsettias strewn around the little stool.  Traditionally they put down some vegetation .  It's symbolic of something or other, not sure what.  THis is the kitchen, cum dining room cum living room.  Note the stove (that little stand with the kettle). This is a container with hot ashes to heat the water.  Note the kitchen sink (the wet spot in the corner).  

 View from the hotel when we went birding

 You try carrying this load!

 Charcoal for sale

 A view of the Lalibella Saturday market

.

 Another view 

 Lalibela market granary section

 Salt for sale

 The shoe store

 The haberdashery section

 Coffee beans

Spice alley

 The greengrocer

 The parking lot

 The goat exchange

 I had to put in at least one bird photo!

 A more distant view of the Lalibella market

 The Lalibella market again

 A traditional home.  the lower levee is for livestock.  the family lives in the upper section

Among all the Christian iconography, a Magendavid in a church in Lalibela

Oct 11

Today is the day for birding.  We had hired a guide.  He arrived promptly at 7.00 am and we were on our way.  Our destination was only 100 km from Addis, so we went slowly and stopped several times to look for birds.  Pretty country, but not spectacular.  However, we then arrived at our destination, a mountain lodge perched on the edge of a deep, wide gorge.  The river at the bottom of the gorge empties into the White Nile. , which is about 200 km from here.  Here the scenery is spectacular.  

Every possible inch of the country we have seen so far is under cultivation.  Fields reach high up the mountain sides.  The patchwork of different greens because of different crops adds to the beauty of the place.    

It's also impressive for some birds, vultures in particular, but also something called an Auger Buzzard.  This is an attractive bird, possibly a cousin of our red tailed hawk, judging by the buzzard's red tail.  It has the amazing capability of hovering at great height, almost motionless in the wind.  Other birds hover, but have to flap their wings to remain motionless.  Not this guy.  It's very impressive.

The place we are staying at is very rudimentary.  My room has a single bare bulb for illumination.  There is a bedside candle and matches.  Maybe that's for a possible power failure.  We'll find out.  As mentioned, the lodge on the edge of the cliff. looking down into the gorge.  It's cold now in the evening as I write this, but this afternoon when we arrived it was hot and it was very pleasant to eat outside.  

I had forgotten that we are close to the equator.  The sun is fierce.  I forgot my hat in Addis.  Bad move.  I got quite burned on the top of my scalp within a short period of time.  

Birding was quite good.  We totalled 57 different species, with about 20 that were new to me, including several that are found nowhere else, but Ethiopia and Somalia.  Since I am unlikely to ever travel to Somalia I was pleased to see those birds here.  I am getting to be really good at spotting birds in the bush and at a distance.  It's about time that I got this good.  I am still totally unable to bird by ear and I envy those who can.  Our guide found several birds by recognizing the call and going looking for the bird.  I can tell the difference between the call of a crow and a Blue Jay, but little else.  My next step, to get to know some of the calls! 

Oct 12.  We started out the day by driving to a nearby monastery and church which was the home base of one of the most important saints in the Ethiopian pantheon.  not tats e were going to see the church, but the birding nearby was good.  We found several specialties of the area.  The place is lousy with beggars, by the hundreds.  They rely on the fact that donating to the poor is supposed to ensure that your prayers will be answered.  (Despite probably substantial evidence to the contrary).  It really makes the place quite depressing.  Since the monastery is a destination for pilgrims and church-goers the approaches are crowed with people. One of the approaches was down a mountain path.  Like India, every bush was a toilet.  I had the misfortune to step in doodoo.  Human shit is a lot more unpleasant than either dog turds or cow pats on your shoe!!

Monday Oct 13

Back at the hospital today.  More impressions:  If you ever wanted to see the face of suffering humanity, come here.  Hundreds of patients are already lined up before 8.00 am.  They sit patiently, waiting for admission or for clinic.  I have seldom seem so many malnourished people, whether from illness or diet I don't know, but it's pitiful.  

Family members attend all inpatients, but they are not allowed onto the wards when doctors and nurses are doing the rounds or at night.  So they wait outside the wards.  There are few chairs or seating of other kind.  They sit on the floor and sleep on the floor.  It's difficult to grasp how poor these people are and this country is.  There are cockroaches (or a similar African variety) in the hospital.  Infection control is virtually non-existent.  Patients with TB are iafford even the low prices they ask here.  solated to the extent that they only share a room with one other person rather than the 7 bed ward.  The hospital's CT scan does not work.  So if patients are to get a CT they have to pay at a private facility.  Many cannot, so the CT does not get sone.  They also have to pay for some medicines, again the poor cannot afford this and so don't get treated.  

I have mixed feelings about what we are doing.  I initially refused to participate in this project because I reasoned that Ethiopia did not really need gastroenterologists, but needed the local equivalent of China's barefoot doctors, specially trained personnel who ensure that vaccinations are given, water is clean and sanitation is available, and that's where efforts should be directed.  This would mean that those who developed illnesses would not get specialist treatment, or at least not sub specialist treatment. However, the biggest gain in health for the healthcare dollar is going to come from preventative medicine, not specialist care.  More would die of diseases such stroke, heart disease, cancer, but fewer would die of TB, and other infectious diseases, particularly youngsters.  On the other hand, this is a rapidly developing country, and soon they will need specialists, so specialist training is also necessary.  I am not sure that we are contributing much to the country as a whole at present, although we are contributing to the education of a small number of physicians.  We saw a young women on rounds last week with acute leukaemia.  She had been given some chemotherapy (not the most up to date regimen) and had the expected reaction of failure of her bone marrow to produce enough cells to fight off infection.  This is a necessary part of the treatment.  In Canada however, they are able to treat any infections that arise (usually), but here they can't, and according to one of the doctors, all these patients die.  So I ask myself, why bother with chemotherapy.  This is an example of Western medicine gone wrong.  Even in the bad old days in Cape Town, we knew that this was a hopeless situation.  If someone came in with acute leukaemia and infection we did not treat.  So, I have reservations about our work here, in that it is not the what the country needs, but on the other hand I am probably doing some good.  

On a lighter note, I made acquaintance with an old African friend of the last few days, musca domestica, the common housefly, of which there are an abundance here.  I had forgotten how pesky they can be.

Love to all

Morris

Time for another update.  This time about the working conditions here.

 The hospital where we are teaching was built 60 years ago, and looks like it has not seen a coat of paint since.  To call it decrepit is to insult decrepitude.  It has not been maintained at all.  There are lights missing, toilets not working, elevators not working.  If this was Baragwanath in the days when I worked there it would be unacceptable.  But here they put up with it.  One of the faculty told us,with some despair, how he has watched the deterioration over the last 20 years.

However, the government priority is not in tertiary care, and they are reluctant to put money into teaching hospitals.  This is a bit short sighted, since Ethiopia is developing rapidly and they are going to need specialists and even internists, paediatricians and obstetricians in large numbers in the future.  They will not be able to meet the demand unless they start training people now.  As an example of how Ethiopia is developing they have opened up 13 new universities in the last 10 years or so.  The governments priority seems to be on education, perhaps rightly so, but it is disconcerting to see how poor the medical facilities are here.

In many ways practicing medicine here is an intellectual exercise. First, patients present at the late stages of their disease, with advanced cancers, untreatable bony deformities due to tuberculosis, advanced cirrhosis, advanced cardiac failure, etc.  Since there is little that can be done for these patients diagnosing the cause of the illness is irrelevant, but is only a mental exercise.  And even then diagnostic facilities are limited.  CT scans are done, but are of poor quality.  Interpretation is sometimes iffy.  Ditto for pathology.

Patients have to pay for these services, so the ability to manage patients is often constrained by what the patient can afford, which may be nothing.  It's all very discouraging, and I am glad that I do not have to practice in these circumstances.  I wonder what things would have been like if I had stayed in SA at
Baragwanath.

On a lighter side, I am slowly conquering those 8 flights of stairs that I ache to climb.  Today I had to climb them 3 times.  I am getting less and less breathless, but my leg muscles continue to protest that I am abusing them.

Food here is monotonous.  Most restaurants serve a variation on the same things -  spaghetti, macaroni, fried fish, fish prepared in other ways (similar from restaurant to restaurant).  I have not been brave enough to try any meat dishes except chicken.  Some of the dishes I have tried, e.g., soup, did have bits of meat in them.  All I can say is that the concept of tender meat is foreign here.  The chicken must have been long past its sell-by date.  The meat was similarly tough.  So, no meat for me.  However, food is cheap, so I should not complain, given that I have to eat out most nights and most lunches.

There is a very good Italian restaurant about a block from the hospital, where we will go once or twice a week.  They know us there by now.  Very good salad bar and well-prepared other items that one usually finds on an Italian restaurant menu.  We have agreed that we will eat in most nights, but perhaps eat out over the weekend.

I have so far given 5 presentations and have 6 to go over the next two weeks.  We also interact with the GI trainees every day, either clinics, case presentations, journal club presentations, etc.  We are getting to know them quite well.

Overall the week has so far been uneventful, except that the internet at the hotel has been out of commission for a few days.  It's working now, but who knows for how long.

I think I have briefly mentioned the conditions in the city.  This is a very poor country.  The older buildings are all somewhat dilapidated, although there is a lot of construction an a number of newer buildings that are privately owned and maintained.  The streets are in very poor repair.  Really, the potholes in Toronto are nothing by comparison.  The potholes here can break an axle.  In addition they are building a light rapid transit system, and they have left the roads in a terrible state.  You almost need a 4-wheel drive vehicle to negotiate city streets in places.  Traffic at rush hour is terrible, slowed down substantially by the poor state of the roads, and also by the fact that there do not seem to be many rules of the road, or at least people do not adhere to the rules of the road.  It's chaotic.  For those of you who have never been to Africa I don't think you can really imagine how things are.  Even for those of us born in South Africa, thing were much better regulated in SA than  they are here.

However, no more carping!  More next time after our birding weekend

Today we left Addis Ababa for a place called Lalibella, a small village where there are some famous churches carved out of rock.  It is supposed to be THE place to go in Ethiopia.  

The flight was OK, except that we were at the airport at about 5.00 am.  The plane flew over the largest lake in Ethiopia, Lake Tana, and stopped at a small town called Gondor and then on to Lalibella.  Lalibella is in the mountains, so the airport is 25 bone-jarring km away form the town.  The roads leave something to be desired.  We were met and taken to our hotel, which is attractive, clean but basic.  It costs the grand sum of $20/night, breakfast included.  Take that Sheraton!  And they throw in a mouse in the room for free (not a computer mouse!)

For the ex-South Africans reading this, this next bit is for you.  I can't say how uplifted I felt to be once again in rural Africa.  It was quite emotional.  I guess there is something left over from my youth that ties me to the place.  Although Ethiopia is far from South Africa the countryside is similar to Zululand and the Natal Drakensberg, areas where I spent a fair amount of time.  But it's more than geography.  There were aloes in bloom.  Little picanins (children) were herding cattle along the side of the road.  Some seemed as young as 6 years old.  There were women carrying wood on their heads.  Dry river beds were bordered by dongas (eroded ditches).  But enough!.  Suffice to say that I was pleased to be here.

The churches were quite something.  These were large edifices carved out of solid rock.  It must have taken hundreds, if not thousands or workers (?slaves) to create these "buildings".  They are still in use as churches today.  Ethiopia has a calendar or religious ceremonies like no other.  We are currently in a period of religious ceremony, and there are pilgrims by the hundreds at these churches.  There is not a lot of space, entrances to the churches are narrow, and there are narrow steps and ditches all around.  Two lanes of people, one in each direction, are not comfortably possible.  But, there is no such thing as "after you sir".  Rather it is "coming through, like it or not!"

One of the attractions of Ethiopia was that it has a large variety of birds and it has lived up to its reputation.  Without any effort I identified 20 species today.  There are some that I have seen before, but most are new to me.  

One additional point.  the weather has been favourable.  The rainy season was supposed to have ended last week, but it has rained every night, although not in the day.  it's a good thing though, because it keeps the dust down.  

Just a word about my travelling companion.  Cliff Ottaway is a retired gastroenterologist from St Michael's Hospital.  I could not have asked for a more congenial companion.  I hope he sees me that same way.  We are having fun together.  

Till next time

It is now day 5 of my Ethiopian adventure.  (so far not much adventurous has happened).  

I am staying in a hotel, that if it had fleas would be considered a fleabag hotel.  Fortunately, it does not have fleas (or bedbugs, or any other undesirable insects).  They achieve this by spraying insecticide around the room every day.  It would not pass as a one star in Toronto.  The bed is comfortable, the room is tiny, lighting is poor.  I will manage.  

The hospital is about 10 minutes walk away.  It is quite similar to the hospital I trained in in Johannesburg, old, in need of repair and a coat of paint.  The elevator does not work.  The GI offices and teaching rooms are on the 8th floor.  So each day I will have to climb the 8 flights of stairs twice.  There is a saying in Afrikaans that translated means "that which does not kill you makes you strong".  I hope that's true for the hospital stairs.  I should be able to kick an elephant to death by the time I am done here

I have not yet been in the wards, so I can't comment on those.  However, I have been in the clinic.  Many patients, some looking quite sick.  We were shown a patient who was a problem case.  If she was a Torontonian she would have been quite outraged and embarrassed by the goings on.  There were three Ethiopian trainees and three Canadians.  The poor woman had to bare her middle for us to examine.  We then had a "bedside" discussion"  while she sat, understanding nothing, waiting for us to finish.  I used to work like that back in the old days in Johannesburg, but women (or men) with any degree of sophistication would not put up with this behaviour.  

Of course, since people with any medical condition tend to present late in the course of their illness the presentation is often extreme, and there are signs and symptoms that we never see in Toronto.  

The residents here are quite knowledgable and clinically adept.  However, they lack sophistication, and for example, to day presented a case that can be characterized as "not seeing the woods for the trees".  They made the diagnosis with out biopsy, but did not offer the appropriate treatment because they did not have biopsy proof.  

The city is a typical poor African city, dusty, in a state of disrepair, but with some gleaming modern buildings.  Traffic is chaotic, but apparently as a pedestrian you are unlikely to be hit, since the driver would get an automatic jail term.  Most cars have scratches and dents, a function of trying to squeeze your way into traffic in a intersection without traffic lights.  The taxis are literally from the last century, Lada's old Datsuns, old Fiats, etc., held together with wire and a prayer.   

The city is full of birds.  In the short distance between the hotel and the hospital I have identified a dozen or so species, and there are more that I could not identify.  I am looking forward to going birding next weekend.  

This weekend I am off to Lalibella, one of the must-see  sights in Ethiopia.  The next instalment will be after I return form Lalibella