To elect. To vote. To choose.
Medicine in Australia is largely about choice. Patient autonomy sits as one of our highest values. We pride ourselves on ensuring our patients are able to give informed consent, that they have the right to choose what treatment is appropriate for them. In a system that is well resourced, it is easy to become complacent about the choices we have. During my elective, I learnt about the harsh and unforgiving realities of choice in the developing world. Ethiopia is a country of great beauty and diversity. In choosing it for my elective, I hoped to experience what it means to practise medicine in a ‘resource-poor’ setting.
For a month, Bahar Dar, a regional town in north-western Ethiopia, became my home. It is situated on the banks of Lake Tana, a winding ten-hour journey from Addis Ababa. Felege Hiwot Referral Hospital services the region. It has four main wards: medical, surgical, paediatric and gynaecology. In addition to in-patient services, there are daily out-patient clinics, a HIV/AIDs treatment program, basic radiology (x-ray and ultrasound) and limited pathology services. It is difficult to tell exactly how many people use the hospital. There are frequently patients, and their families, camped out in the corridors or on the balcony awaiting treatment, or recovering post-op. It is quite common to see patients who have walked for three days to get to the hospital. Many are farmers, with limited education or access to transportation.
Next to Felege Hiwot Referral Hospital is the Bahar Dar Hamlin Fistula Centre. It was set up by Dr Andrew Browning in 2005, as a regional hospital affiliated with the Addis Ababa Fistula Hospital. Founded by Australian obstetrician/gynaecologists Catherine and Reg Hamlin, they provide surgery and rehabilitation services for women suffering from obstetric fistula. The two hospitals have a good working relationship, and I was fortunate to spend time at both.
At the Fistula Centre, I witnessed the devastating consequences of the lack of access to emergency obstetric services. For a woman in this part of the world, getting pregnant is probably the most dangerous thing she will do in her lifetime. In Ethiopia over 90% of women still deliver at home, the vast majority without a skilled birth attendant; the caesarean section rate is one percent (1). For every woman we see with a fistula, we know there are several who died of post-partum haemorrhage or sepsis, without ever receiving medical attention (2).
Amina is one of the survivors. She is 22 years old, and hails from a rural village near the Sudanese border. She married young, and soon fell pregnant. When the time came, she laboured alone in her village. The nearest health centre is hours away by foot and she had no means of transport. It was harvest season, so everyone was out in the fields. After several days of labour, the baby died, but she still was not able to deliver. Exhausted and delirious, her family brought her, by wheelbarrow, to hospital. Her uterus had ruptured. Miraculously there was a surgeon there and a theatre free. She awoke in a strange room, to find the world, as she knew it had changed forever. She had a large scar upon her abdomen, and was leaking urine. Now one year on, her fistula has been repaired.
As I listened to the stories of patients, time and again I was struck by the lack of control they had over the circumstances that led to their presentation. At times the barriers seem overwhelming. People speak of ‘the three delays’ – delays in recognizing problems, delays in transport and delays in receiving appropriate treatment (3). These are everyday realities for the people of rural Ethiopia. Each delay has multiple contributing factors, including lack of education, inadequate infrastructure and a critical health workforce shortage. What they add up to is drastically reduced life expectancy, maternal mortality rate of over 500 per 100,000 (close to 100 times my risk back home in Australia) and children dying of largely preventable illnesses.
In the paediatric out-patient clinic, a woman carries her young son, maybe three years old into the room. He is weak, with sunken eyes and a vague gaze. He has been unwell for some time, but their village is several days walk from hospital, and she could not leave her other children. His condition has deteriorated and she knows the prospects are not good. She cannot afford to pay for the tests to confirm the diagnosis or the treatment that he needs.
No words can describe that empty feeling; that sense that we, humanity, have failed. That feeling of impotence in the face of injustice – why is it like this? And why can’t we change it? How can a world with so much wealth put a mother in this position – to choose between feeding the rest of her family and treating her sick child? Nobody should have to make that choice.
Choice is a curious thing. It can constrain or liberate. It does not seem right, that I could potentially complete my entire medical training, and career if I so choose, without ever understanding the choices faced by majority of the world’s population when it comes to healthcare. In choosing Ethiopia for my elective, I was forced to deal with a confronting reality, but it also allowed me to connect with people, who have grown up in a world vastly different to that which I know. Time and again I witnessed patients and families show resilience and strength of character above and beyond anything I had previously imagined. The sense of purpose and feeling of community that drive the staff at the Fistula Hospital, and their compassion for the patients is truly remarkable. In spite of all the hardship, people in Ethiopia live joyous meaningful lives. They love their families, they go to work, celebrate festivals and birthdays, enjoy nature and drink great coffee! In Ethiopia I learnt not just about medicine, but also about humanity.
World Health Organisation, Country profile: Ethiopia, Department of Making Pregnancy Safer, World Health Organisation 2005 http://www.who.int/making_pregnancy_safer/countries/eth.pdf [accessed: 17th April 2011]
Elit L, Froese J, eds. Women's Health in the Majority World - Issues and Initiatives. New York: Nova Science Publishers Inc 2007
Lester F, Benfield N, Fathalla M. Global Women's Health in 2010: Facing the Challenges. Journal of Women's Health. 2010;19(11):2081-9. Sarah Gelbart (206406)