Morning Rounds at Addis Ababa’s Black Lion Hospital

Posted on: 02-1-2012 Posted in: East Africa

By Dave Silvestri

JANUARY 24, 2012 – ADDIS ABABA, ETHIOPIA: My research was nearing completion at Addis Ababa University Faculty of Medicine, and having just spent nearly three weeks planning, administering, and collecting questionnaires in the classrooms and administrative offices of the school’s affiliated Black Lion Hospital (the largest public hospital and major referral center in Ethiopia), I decided to spend a morning in its patient wards. I had been invited to join my colleague and friend, Daniel, in his morning rounds as an intern on the internal medicine inpatient service. Although this was not my first exposure to health care in a developing setting—having volunteered in hospital and clinic settings in both Africa and Central America in the past (and having been a patient now twice during our travels)—my recent medical and business education now gave me a different perspective of the patients, their illnesses, and their stories.

Black Lion Hospital in Addis Ababa

As I had expected, the burden of disease was tragic, the facilities were basic, the stories were all heartbreaking. A teenage girl suffering from end-stage heart failure because of the severe valve disease she had acquired as a complication of untreated strep throat. It was clear to everyone in the room why she hadn’t sought antibiotic treatment in the first place for such a mild throat infection; for most Ethiopians, a visit to the doctor (if even an option at all) is costly, reserved only for refractory ailments for which time and a trial of traditional remedies prove ineffective. By the time she would have presented for antibiotic treatment, her throat symptoms had already resolved—but not before triggering the silent sequence that would ultimately irreversibly damage her heart.

Back in Nashville where I attend medical school, such a severe case of Rheumatic Heart Disease would be unusual—perhaps a handful of cases in the hospital at any given time. Here, they are routine. An older woman just down the hall was suffering from the same heart condition, from the same cause. With her heart unable to pump blood forward as effectively, she had developed a blood clot in the stagnant back chambers of her heart. It had gotten loose—as they frequently do—and become lodged in the vessels of her leg. Although the hospital team had succeeded in breaking this first clot before it had caused any damage by blocking circulation, she had in the meantime developed another clot in the stagnant blood just distant to the first one. When I met her, she was on intravenous blood thinners awaiting the next ultrasound assessment of her leg. The hospital team would no doubt get this one too, and perhaps then she would be free for discharge. But with her heart (the source of the first clot) still irreversibly dilated, she would need lifelong daily blood-thinning treatment, as well as the even more expensive routine blood tests needed to ensure that her medication did not creep to dangerously low or high levels. What might have been treated by a single self-limited course of inexpensive antibiotics had instead ballooned for this poor woman into an exorbitant hospital bill and a lifetime of costly medical management. With no insurance system available in Ethiopia to help offset out-of-pocket expenses, I imagined the ripples would be felt far and wide through her family.

In the room next door, another young girl lay emaciated with her family at bedside. All across her exposed extremities, the telltale maroon lesions of Kaposi’s sarcoma served as a scarlet letter of her advanced HIV infection. Her miliary tuberculosis would do the same. I wondered what her story was. Had she been one of the many young girls who spend their nights waiting in the shadows for a customer on the sidewalks of Piassa and Merkato? Had she like so many other disadvantaged and disempowered girls suffered rape? Or had she had her heart broken by false pretenses of love? I dared not ask. Nobody in the room was aware of her infected status—neither the patient, nor her family. I wondered—after they had somehow mustered up the funds to cover this growing hospital bill—how they would afford the treatment to give her a chance at life.

Next came a young boy recovering from leukemia. He was finishing up his second month at the hospital, and—lucky for him—he now had his own hospital room. It was not this way for every chemotherapy patient, I learned. Most other rooms in the hospital were at least double-occupied, with immunosuppressed patients frequently left exposed to the pathogens harbored by their roommates and unmasked visitors. It was the unfortunate reality, Daniel told me. Although the major public hospital and chief referral center in Ethiopia, the hospital revenues had put toward more pressing investments than best-practice isolation precautions. I shuttered to think of the tens of thousands of Ethiopian birr that a child’s family might spend on chemotherapy treatment only to lose the battle to a pathogen introduced by an expectorating roommate. Even the medical teams would walk freely without masks.

At last we came to a woman no older than my mother with terminal primary lymphoma of the brain. She had presented to medical attention with symptoms of a central nervous system lesion, but had delayed on obtaining a CT scan of her head due to its cost. Now, of course, the cancer was inoperably extensive, and she likely had only weeks to live.

*****

Amidst such tragic stories, I found it hard to believe that these patients were in fact the lucky ones: they had managed to make it to medical attention. The vast majority of Ethiopia’s largely-rural and rapidly growing population continues to reside in areas where traditional healers far outnumber formal health practitioners, where false healers masquerade as real ones, and where vulnerability to disease and premature death are an accepted and inescapable reality. In a nation of 84 million people—with nearly 40% living under the national poverty line and an average life expectancy of just 58 years—there remain just 2 physicians per 100,000 population (ranking 187^th worldwide) to help address such health needs. Most are concentrated in the urban areas like Addis Ababa, Gondar and Hawassa, and most spend the bulk of their time in private practices only accessible to individuals with sufficient means. In 2006, there were just 638 physicians in Ethiopia’s public sector—just 1 per 118,000 population: over a fourfold decline since nearly two decades earlier. The nation’s most populous regions continue to average just a handful of physicians per hospital (from 3.6 in Tigray to 6.1 in Oromia), with nearly half of all regional public hospitals lacking more than three general practitioners and over 80% with less than two specialists. In the two decades leading up to 2006, nearly three-quarters of all public sector physicians left the nation or found alternative full employment in the private sector/NGO’s. Today, the vast majority of Ethiopian public sector physicians work at just a handful of hospitals, and Addis Ababa University’s Black Lion Hospital is chief among them. Its facilities are lacking, capacity limited, but its minds are among the nation’s brightest. And yet, for every one patient I saw during those morning rounds, I imagined countless others without similar access to medical attention.

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Although the government is taking significant steps to expand the quantity of physicians being trained—establishing new medical schools and tripling class sizes in existing ones—it remains unclear how many of these new physicians will remain in the public sector, or in Ethiopia at all. International collaborations such as Addis Ababa University’s Medical Education Partnership Initiative take aim at retaining students, increasing their exposure to rural areas, and building capacity in medical education. Yet, here too, it is unclear whether the result will be benefit the nation’s populations in greatest need—the financially- and geographically disadvantaged.

And yet, one truth will continue to give reason for hope: physicians remain the most highly-respected job in society, nearly every secondary school student’s dream. If Ethiopia does succeed in adapting its medical education system to build capacity and enhance retention (and I believe there are significant additional avenues of opportunity, which I hope to explore in a future post), there will be no shortage of supply of individuals eager to enter this workforce. Although the present need can often seem overwhelming and the problem too vast, I believe this gives reason for encouragement—that the next decade will be an immensely exciting one in the transition of Ethiopia’s health care system. As collaborations bring new knowledge and resources, as research illuminates new opportunities, as national attention strengthens political will—and as Ethiopia’s economy, business climate, and foreign investment continue to grow—it may be possible for Ethiopia to emerge as a guiding light for sub-Saharan Africa, a paradigm for how a deeply impoverished, highly populous, and landlocked nation with a history of internal and international conflict can nevertheless rally through progressive leadership and effective partnerships to forge a new future for its deserving inhabitants.