Language and culture.

A word about the language, Amharic is very very difficult. The script is uninterpretable if you don’t know it and is not a simple alphabet. Spoken Amharic – aside from the obvious problems of having a terrible accent has very subtle distinctions that are very revealing. For example, like a lot of languages there are gender distinctions. In this case the ending of the word or phrase changes depending on the gender of the person you are speaking to. To make it more complicated age also changes the words. Elders are very respected (so I may have to move here after this May), so honorific endings make the words different once again. These things I’ve mentioned are only one level of difficulty. Sentence structure is different as well. I’ve been trying hard to use words – thank you, please, hello – and to use phrases like lie down please or sit down please when seeing patients. I’m constantly getting them mixed up though. My accent – you can imagine. I say to each patient “Simae Dr. Michael naew” and usually have to repeat it and then have Muluken say the same words for them to understand – “My name is Dr. Michael”.

Non-verbal signals are also subtle. I really just started picking up on those today and so asked for a brief lesson in them from Muluken. I’ve noticed that people give and receive objects with one hand touching the other arm. When I gave my key to the cleaning woman at the hotel like that she laughed. I guess most Faranji (foreigners) don’t do that. Apparently it is considered very disrespectful to give anything with one hand alone. The head movements when saying hello to an elder should involve looking down not up. I do think this concept of respect and distinctions in the social order are interesting and different than the personal “tu” and impersonal “usted” for example in Spanish.

One man’s dilemma

This morning my last patient was a young man of 28. He has a wife and child who is Christian and so they cannot get permission to immigrate with him to Israel. The rest of his family including mother and siblings are already in Israel. He had to make the decision to stay or to leave his family. When we were done with the medical exam I asked his permission to discuss this decision. He said the life here is so terrible that he just cannot stay. There is a widespread belief in both the Jewish and Ethiopian Christian communities that Israel is the Promised Land and that everything will be better there. I’m sure that for him economically it will be better. I’m not really sure if it will be in other ways.  He hopes that one day his child will be able to come as the Israeli’s are discussing whether to allow the people here with patrilineal descent to come.

So are they refugees? It sounds like the current group are really economic refugees not refugees fleeing from persecution. I hope to be able to interview some of the Ethiopian workers in the Jewish Agency who made Aliyah with the first or second wave to get more insight.

Otherwise the morning was much of the same. Lots of screening, I’m getting the hang of the paperwork and realize how the triage function I’m performing will help the social workers organize their care on arrival in Israel.

The city

Last night in the downtown hotel I got my first full night’s sleep in a week. Glad I made the move. I wandered around the city streets for a long time in the late afternoon getting totally lost and needing to ask for directions back. There are lots of markets and cafes. When I got far enough from the center people seeming amused that a Faranji was that far from the tourist areas.

This morning I went outside around 5:00 to walk around. Just across the street from my hotel I saw in doorway 9 kids (maybe 10-14) all lying wrapped in blankets sound asleep on the sides – spooned with some of their heads on each other’s bodies. There were other homeless folks sleeping outside as well. The poverty really is remarkable here. Speaking of the poverty, it is remarkable how poor the hygiene is on some of my patients. Almost all have cavities. Some are caked in dirt and the body odor is, shall we say, noticeable. This is not true universally however.

Shabbat

I asked to be able to join the community for Kabbalat Shabbat. It was scheduled at 4:30. I arrived at the community center/synagogue at 4:15. The guards would not let me in until we got the head of security of the Jewish Agency on the phone to vouch for me. The community center was a large area consisting of corrugated metal attached to wooden posts for the walls and corrugated metal roof. The front area was without roof and the building was not enclosed as the roof and walls didn’t meet. You walk in and see a little open area with a tap with running water. Then behind a wall were the pews. As I walked in there were several rows of women all on one side all dressed in white and one man on the other. I joined the old man who jabbered away at me in Amharic asking all kinds of questions. He kept grabbing and holding my hand even once after clearing his nose onto the dirt floor of the synagogue then bringing his hand down to hold mine. I didn’t realize it until the service was almost over, but I had inadvertently sat down on the pew with the eldest men. All the younger adults and kids were farther back.

We were facing the bimah which had among other things cases of prayer books in Amharic script. (I later realized there were some in Hebrew script as well.) A young man set up a stand which people brought bags of bread and a bottle of wine on. There was a glass box on the floor of the bimah which was opaque on the side facing us; they put the candles in that box. Slowly but surely more people joined. By 5 there were lots of men and women on their respective sides and they pulled a curtain down the middle for a mechitza. A woman came up to the front and lit the candles in a quiet voice. Again, we could not see the candles or the flames because of the opaque side of the box. Sometime later quiet chanting started up behind me. There were three men on a raised platform towards the back of the men’s section. They chanted the whole service in a mix of auctioneering type speed talking and almost completely monotone chanting.   So I couldn’t read the Amharic, couldn’t hear most of the Hebrew, and had no melody to follow. There was a little bit of change in pitch and melody for lecha dodi. Otherwise it was really disappointingly boring. Since African music is usually so melodic and full of rhythmic energy and life this was really a letdown for me. Finally at the closing song the women started loudly ululating and musical life and energy came in to the room. Then, the prayer leader led Kiddush and motzi and a group of boys in the back started singing energetic songs and everyone was clapping. Still I didn’t leave until after 6. It was almost two hours that I was there.

Bima – Gondar Synagogue

Then I had a completely different Shabbat experience. I joined some people for dinner at a hotel with a lovely outside courtyard. Joshua, the head of security for the Jewish Agency in Gondar invited me. He was born in a small village in Gondar and made aliyah with his family at age 5 in the 1980s. So he has almost no memories of Ethiopia as a kid and is Israeli first in culture, language, and bearing. He shared with me some of his story. How hard it was as a kid in school. His white Israeli classmates all had pre-school, could read and write Hebrew and were way ahead in school. He, realizing that Hebrew was the key, said he dedicated himself only to Hebrew study ignoring his other classes until he got it. Then he did the same for each of his other subjects over the next few years till he caught up. He said, “I had no one at home who could help me” and so knew he had to work twice as hard as his classmates. He did his army service and went to college in Haifa and then into the security field. He was the head of security for the Israeli embassy in London for a few years and is completing his second year of his two year stint here in the next few months.  He said there is only one other Ethiopian Israeli like him who is here long term- Asher, the head of the program. Otherwise the Ethiopian Israelis like the white Israelis come for short term stints.

Joshua also told me a bit more about the community. There are no more of the original Beta Israel here in Ethiopia at all. The current crop are all people who – after it was determined that it would be possible to immigrate to Israel re-affiliated themselves with Judaism. (It had been a few generations ago for the most part that their families converted to Christianity).  The conversions to Christianity happened because of the great difficulties the Jewish community faced with job and land restrictions and other forms of discrimination. I certainly understand the decision to change in order to make life better (in both directions). But, Joshua tells me that the communities of Ethiopian Israelis do not support this at all. The attitude of his parents’ generation is “we didn’t convert when things got tough” but they did. Why should they be able to be considered part of our people and get services when they fled? It was very interesting to hear about that dynamic. I was reminded of the original Cuban community in Miami who looked down on the later refugees from the Mariel boat lift. Seems like part of a recurring theme in immigrant communities that immigrate in multiple waves for multiple reasons.

Also at dinner were two of the short termers, the religious leader and an older man who teaches Hebrew, he escaped in Operation Solomon via Addis in the 1990s. Also was a long term Israeli woman who is coordinating the teachers for the community and is much beloved by the community here.

Lalibela

Lalibela is a tourist destination with some amazing sites. In the 12th century the rulers of a new dynasty including King Lalibela took over from the older regime. They were Christian and wanted to establish emphatically that Christianity was the religion of the country. So in their capitol, now called Lalibela they constructed amazing churches carved into the mountains. The mountains have two layers of rock, a softer top layer and harder basalt underneath.  So they were able to carve away the softer rock and leave stronger structures beneath. Some of the churches are considered monolithic. This means that they are attached to the mountain only on the floor and other wise stand up like a monolith. Some are semi-monolithic, meaning they may have one or more walls still directly attached to the mountain or the roof still as part of the mountain. Outside of the city are cave churches as well but I didn’t have a chance to see them.

Each church is constructed with elaborate symbolism. For example blending architectural style of the preceding regime (the Axumites) with Latin crosses, there are Latin, Greek, and Maltese crosses blending together with the symbol of King Lalibela.

The very structure including number of windows, rooms, etc. is symbolic in each church of things such as the number of disciples, evangelists, etc.

Legend is that Kind Lalibela constructed them rapidly with the help of Angels. Scholars say there were 10s of thousands of workers brought in from Egypt and other countries to build them. My guide said that the problem with that is that it would have been impossible to get 10,000 people in those times (meaning that he found the angel story more plausible).

To get here I took a flight (could have driven 5-6 hours each way). It was well worth it. The town is a very busy tourist destination and the kids and young men on the street were quite annoying. The first time someone said “Hello, hello meester….where you from” I thought it was cute. After the hundredth time someone said that then followed by asking for money, pens, candy, or other things I didn’t find it so cute anymore.

Amazingly when I arrived in town I found out that it was Timkat in Lalibela, turns out that it was a special Timkat honoring St George. (Did you even know that you had a day George?) On a smaller level I saw the crowds, the replica of the ark, the priests, and the people joyously singing and dancing to be faithful to the ark. My guide wanted me to stay with the Timkat celebration for many hours until the churches opened in the afternoon. However, I think one Timkat is amazing. Two Timkats get a little old. So after a while I excused myself to go to a restaurant, sat on a shaded terrace overlooking the city, and peacefully read and eat. That was a good decision!

I wrote the above in Lalibela. After returning to Gondar my driver pointed out that they are decorating the streets for another Timkat on Wednesday. Yay! In the airport I met a couple originally from Addis who are Swedish and are not back here touring. Turns out they are staying in my hotel. We had a nice lunch together. Then toured the most impressive ruins here and had dinner together as well. They have a friend in Addis who lives near the airport and they will check to see if he can take my bag for my 10-12 hour layover there so I can tour without a suitcase. We are going to do some touring in town here together this afternoon too.  They also both have friends in Minneapolis. The wife spent 3 weeks there a few years ago with her cousins. The husband is good friend runs the Kilimanjaro restaurant. I’ve driven by it on Cedar near Riverside but never eaten there.

Gondar‘s Castels.

In the center of town (1 block from my hotel) is the “royal enclosure” of King Fasilidas. He moved the capitol to Gondar when he re-established it as a Christian country. He built a castle and other buildings then each subsequent king or queen in the dynasty built their own castle. Very interesting to see it with a guide who really knew the history. He presented them as some of the most important kings of Ethiopia. When I went back to the hotel and pulled out my history of Ethiopia book the scholar who wrote it calls them mostly powerless kings who did little but build castles while their Oromo (one of the ethnic tribes here who are mostly Muslim) advisors wielded the real power.

Jewish Village

Yesterday I went to see the remnant of the Jewish village near here. It is called Walleka. The community there was known for being excellent craftsmen. These were skills that developed at a time when the Jews were forbidden to hold agricultural land. (This is a country where the economy even today is nearly all agricultural).

Home meal.

Today I was invited after work to have lunch at my nurse’s home. They made one extra special dish – doro wat – chicken in a spicy red sauce. It is especially made for honored guests. I’ve had it in the US usually with one leg and one egg in restaurants. Here it must be made with a chicken that you take home live and slaughter at home. Men always do the slaughtering and Meluken did that this morning before starting work. Women always do the cooking. Bizhuan cooked the chicken for 6 hours. We also had a beef dish (tibs). She didn’t get the joke when I asked if she had to bring home a live cow in the morning too. (By the way the market always has live cows, sheep, and goats).

Coffee

After lunch they had a traditional coffee ceremony. I didn’t realize that it is not really only for ceremonial occasions but typically people have it three times daily in their homes. There is grass scattered on the floor. The raw beans are roasted in a pan over charcoal with constant stirring until they are perfectly done. Then the beans are ground by hand using a stick to pound them like in a mortar and pestle. Then the ground beans are put in a large pot with water and brewed. When the coffee is ready the incense which has been burning throughout is tossed on the coals creating huge clouds of scented smoke. This way anyone around – neighbors or other people nearby – know that coffee is happening and that they may come over to have some. A cup is poured for each person then brought around. The woman (and it is always always a woman) doing the ceremony adds water to the grounds and brews a second weaker pot again pouring all the glasses on a tray and handing them out one at a time. This is then repeated a third time. As you can imagine each coffee gets successively weaker. Still three cups of coffee three times a day is a lot.

Clinic.

Clinic remains interesting and fast moving. I should finish screening all the people who will be leaving on the first Feb flight before I leave. Today an Israeli medical student who just arrived for a week of volunteering teaching Hebrew here came into clinic and asked if he could work with me. He just finished the classroom part of his training but hasn’t seen patients yet. I enjoyed teaching him some basic physical exam techniques and he will come back tomorrow too.

One particularly interesting story was a man who fled to Sudan years ago. He had a family there. Everyone in his family died there except for him and his son (now in his 20s). So they returned to Ethiopia and now leave in 2 weeks for Israel. Another family just looked better off than the others and it turns out that they are from Addis and all speak English. One is actually a teacher of English and Math and spoke perfectly.

Lecturing.

I gave my first lecture at the medical school today, this one on HIV. It was very well received with lots of Q and A and engagement from residents and faculty. I’ll be talking about evidence based medicine on Thursday.

Dr. Stiffman giving a lecture at the medical school.

Soccer.

Ethiopia’s third game in the Africa cup is on as I’m writing this. Prior to this year they have not been good enough to qualify to participate in the cup for 31 years. So it is a big deal here. They tied the first game 1-1 (their first goal in 37 years in an Africa cup game) and lost the second 4-0. Even if they win today they may not go on to the next round of competition. I had planned to watch the game on the big screen in the central square with the crowds, but the atmosphere turned totally nasty this evening with dust and maybe pollution too making the air look opaque and your eyes and nose feel dusty. So, instead I’m watching in my hotel room and listening to the crowd through my window. Still lots of sun to see everyone so pumped up.

Watching football in the shadow of Gondar’s Castle.

Winding down.

I have two more days of clinic work and really am ready to come back at this point. We finish each day by 2. I’ve seen all the sights in town and eaten enough Ethiopian food for a year (although I really do still like it and usually get it rather than spaghetti).  90% of the time there is no internet. So – I read, write, and sit in the courtyard in my hotel. Not a bad way to spend time but after so many days of it I am ready to start real life again.

Food

I don’t know how, but somehow I don’t think I commented on the food yet. My favorite Ethiopian dish to order is “Fasting food” this is what we would call a veggie sampler. They have it everywhere on Wed and Fridays during lent but some restaurants have it all the time. Content varies. Typically there are several bean dishes, lentils and some garbanzo dishes. Generally my meals also included beets and potatoes and rice and collard greens. My favorites were “shiro” garbanzos or other beans – shiro tegabino in a thick paste, shiro feses an orange paste made of dried beans, or shiro bozena a liquid version served bubbling in a crock and with little pieces of meat in it.  All of this was served, of course, on injeera – the sourdough teff made flatbread of Ethiopia. The meat was not so good. Of course all of the livestock is “grass fed free range” or more accurately scrub and dirt fed and raised wandering the city. It tastes good but with rare exception was extremely tough. After trying beef and lamb a few times I tended to prefer the veggie dishes. (That said – at Ethiopian restaurants at home I like the meat just fine).

A rapid end to my stay in Gondar.

Wow. This happened fast on Wed afternoon. On Tuesday night a dust storm blew into town. Apparently it is a weather front from the Sahara next door in the Sudan. It has happened before but that was many years ago. The dust continued and all flights from Gondar on Wed and Thursday were cancelled with the airline saying flights on Friday would be iffy. I got an urgent call from Bizhuan on my cell phone asking me to meet her right away to problem solve this. I was unwilling to risk missing my flight home from Addis on Friday night. The only option was ground transport. So off to the bus station I went. Unfortunately all buses were sold out until Friday since I’m not the only one in this boat. What could I do? There were lots of “mini-vans” going. I got news that there was one outside my hotel and I needed to go pack immediately and they would wait for me. The ride was supposed to take about 11 hours.  The mini-van was a van with bench seats, they squeezed in 15 people, it was very very tight and there was no leg room. My seat was right behind the rear tire so the bump for the wheel took up half of my leg room. It was literally impossible for me to put my feet side by side at all during this whole trip. After I rushed to get there and was in the van by 4:15 PM they circled in town for about two hours dropping off and picking up other people ending up back in front of my hotel about an hour later and not really leaving until after 6. So before we even started I was hot, sweaty, and my legs were uncomfortable. With the dust there was no way that we could leave the windows open when driving – so soon we were all hot and sweaty. Next to me was a 12 year old Ethiopian girl. Just after we took off she said something in Amharic and everyone turned around and handed her a plastic bag. I was sure I was in for her vomiting but fortunately she didn’t. She did, however, sleep the whole way leaning on me – squeezing me against the side of the van- or putting her hand or arm behind me every time I leaned forward.

About two hours into the trip on a pitch dark highway under construction we got a flat tire. We had three scheduled stops- two of them just for pee breaks by the side of the road with all the men standing and the women squatting in their long dresses by the road side. These were really important for stretching the legs. The driver was listening to radio the whole way. Mostly it was Ethiopian pop music but there was a long stretch of a comedy monologue that my van mates thought was quite funny. All of it was loud and all of it was in Amharic. I had downloaded some podcasts on my iPad before leaving so listened to Fresh Air, This American Life, and Bill Moyers the whole way dozing when I could.

We arrived in Addis a little after 5:30 AM; the driver told me I would need to take a taxi to my hotel. By taxi he meant another minivan just like the one the long trip was in. These go on fixed routes like a bus. I’ve taken those before but had no idea where I was going. Fortunately another guy on the trip offered to come with me to help me get there. Turns out I needed to take three separate taxis to get where I needed to go. Fortunately the hotel let me check in even so early in the morning and I was able to shower and sleep. Best shower ever! The downside for my work was that I needed to cancel my last day of clinic and my second lecture at the medical school.

Addis

The upside was that I got to spend the day today touring Addis. It is a markedly bigger and more modern city than Gondar. Visited a church on a mountain outside of town with wonderful views, visited Lucy, boy is she short could be the original Stiffman. I did a lot of window shopping and like the stuff they have here.

I ate at what many consider the best restaurant in Addis. It is an Italian restaurant of venerable tradition started and run by Italians who live here. I had a three course meal with wine and sparkling water – House made fettuccini with gorgonzola sauce, grilled shrimp, and gelato. It was great. It came to 540 Birr or $30 US which is incredibly cheap for home. But for local perspective. My usual lunches cost 50 birr or 1/10th that. Even eating a full meal at an expensive hotel restaurant in Gondar cost only 1/2 that. Still – it was good and I may go back tomorrow for my last day.

Two days in Addis. What a great way to end the trip. I don’t think I would have appreciated Addis if I had just come from the states there. But after two weeks in the smaller cities and rural areas it really feels like coming back to a much more comfortable urbanized environment. The hotel was nice and modern. The internet was up all the time. The streets were all paved. It was easy to get around. On the other hand, there still are the very notably poor in most of the city. Beggars some of whom are crippled or deformed were ubiquitous.

I had an experience with a taxi driver that was frustrating. But, it’s not the first time I’ve been in this situation and I’m sure I’ll make the same mistake again. My first morning I was planning on going to a museum in town to start and the hotel concierge recommended that I get a taxi to a church on a mountain outside of town with a view of the whole city instead to start. So I did. This was a “contract” taxi or what we would think of as a taxi. There are no meters and so you have to negotiate a price ahead of time. The guy said 300 Birr/hour (about $15/hour). I specifically asked about going to this church and then the museum and he said – “you look, see, no argument”. I should have known better but went off with him. When we got to the museum at the end of the trip he wouldn’t accept 300 birr. I left it on the taxi and he ran to give it back. When I got out of the museum he was still there waiting demanding more. I asked to get the police but then decided just to give him more (500 Birr) to end the whole thing. I should know. Always always make sure you know the price first!

The national museum has a replica of Lucy. (The original is for scientists only I think). It was worth going to see her but the rest of the museum wasn’t really very well done.  I also went to a new private museum called the Red Terror Martyrs Museum and Monument. There were scenes and descriptions of the horrors of the Derg regime – the communist regime that ruled here from the mid-70s to the 80s. It was well done and powerful. It helped that I had read some accounts of the time and knew a little of what happened then. This museum is not in my lonely planet guidebook (which is a few years old). I hope when they re-issue it this is included.

I visited the Merkato today. They say it is the biggest market in Africa. Picture narrow streets with shop after shop open to the street or alley. I walked through blocks of carpet shops and virtual malls of clothing stores. Once I wandered in a particularly narrow dirt road alley and people started asking me where I was going. Turns out there were some homes (hovels really) behind the market. I saw families making their coffee and lunch and turned around to get back to the market. For shopping I went to Churchill St where there are lots of shops and it is less crowded and easier to navigate than the Merkato itself. I decided to go back to the excellent Italian place again for lunch, Castellis. Had a large plate of vegetables that I selected from a cold buffet – spinach, grilled eggplant, zucchini, roasted tomatoes, chicory. Then I had green cheese stuffed house made ravioli in a mushroom sauce. Wow it was great and the tiramisu hit the spot. Well worth it after two weeks of injeera.

I got pretty good at the “local taxis”. These are the packed minibuses. There are stops where they pull up and the guy in the back starts shouting the location. I would have to ask each time for my location. Usually I would hit 10 or more vans before finding the one to my destination. They usually cost 2-4 Birr or 10-20 cents for a long ride.

Shoe washing is a big thing here. It was in Gondar too. Kids will wash and polish the kids for a few birr. I didn’t use them until the very end and so was the only guy in town with constantly dirty shoes. Finally here I did use them and it was a trip. You sit on a folding chair on the sidewalk and they put on foot up then tap it for you to change feet. This happens back and forth first washing. Then rinsing. Then drying. Then putting polish on. Then rubbing the polish in with a rag, then buffing.  It worked. I even had my tennis shoes washed. They were filthy and now are respectable once again.

Got to the airport three hours early as suggested, long line outside to get into the building as you have to pass through security at the entrance (and then again when you go to your gate). Now all I have is two 9 1/2 hour fights – Here to Frankfurt, and Frankfurt to Chicago. Then customs and a short hop back home to Minnesota. Looking forward to seeing my kids, wife, shower, and bed – not necessarily in that order.

Fascinating on the first flight, flying on Lufthansa, the German airline, but still in Africa, Some of the other passengers were belligerent and demanding. We stopped in Khartoum to let some people off and my row of 4 seats was empty. So I lay down for 1/2 hour until they boarded the new people. I was supposed to share the row with a mom with two kids but some of the seat belts didn’t work. They moved them and I lay down again. Then a Sudanese woman who was pregnant and had booked 4 seats in a row started getting angry that she didn’t have 4 seats. I sat up so she could have the other three but she started yelling at the flight attendant. The attendant turned to me and said “I have a better idea. Follow me”. Next thing you know I was in first class. Dinner was lox canapé on bread and good cheeses, chicken kabob and excellent fruit. Had a nice wine with it too. The attendant came by to show me how to use the remote control seat which wound up going completely straight (with a slight upward angle.) Wow. Breakfast was excellent including grilled veggies and bread and jam and scrambled eggs.  After landing in Frankfort I was able to get another breakfast of Weiswurst. I told the waitress I only had 10 minutes and she got it to me.  Had a quick wash in the bathroom and changed my clothes to be a little fresher. Now I’m on board ready to take off on the next leg. That leg turned out to be pretty sweet too. I had paid an extra $100 to upgrade to economy plus on this leg. Turns out I wound up getting a row of three seats to myself.  Good sleep and decent movie watching after.

Chicago airport – got a Frontera Grill torta. Trying to stay awake while boarding this flight now.  One more flight delay, from the time I left the hotel in Addis to arriving home was 30 hours, what a trip. I feel very lucky to have been able to go and feel a real sense of satisfaction in stretching culturally and contributing what little I could.

Ethiopia Journal – day 1

The flight involved three legs – Minnesota – Chicago, Chicago-Frankfort, Frankfort-Addis Ababa. The flight schedule had only a forty minute layover in Chicago but they reassured me there would be time for the connection. All was well until I arrived at the gate. Flight delay of forty five minutes – the agents told me they still thought it would work out, but they booked me on a later flight from Chicago anyway. This one would leave two hours later – at six pm. The connection in Germany would be tight but still doable. But then… the flight became more and more delayed to the point where I needed to get on so as to ensure that I would not miss the later connection.  They got me on the standby list for the only other flight to Chicago that afternoon; I was number four on the list. Standing by the gate while the other flight was boarding was nerve wracking. They kept announcing it was full. Fate was kind to me though. Three people didn’t show up and neither did the first person on the standby list. So I got the last seat on the flight and made it to Chicago in plenty of time.

Being me, my priority was to get a good meal in Chicago before boarding. Unfortunately there wasn’t much in my terminal and I remembered some good restaurants from previous trips. I wandered to another terminal to sit down at a sushi place.  Shortly after sitting they told me that the computers were down and they couldn’t take my order. I wandered to the next terminal where there is a Frontera Grill – Mexican tortillas. I could not believe it, their computers were also out – they were out in every restaurant in the airport. They wouldn’t take my order even for cash. So after all that I hustled back to my original terminal and found a stand that sold me a fruit cup and a sandwich for cash.

On the first flight I slept most of the way. Watched some movies on the second flight:

In Bruges was an excellent movie, sort of thriller but really a psychological study. The two lead characters are hit men sent to Bruges by their boss. They struggle with the morality of their profession in a quirky and deep way. Highly recommend it. Ruby Sparks is one of my favorites. This is the second time I saw it. A very charming quirky love story about a writer who writes his dream girlfriend and she comes alive. Everyone should see this.

The plane stopped to let some passengers off and refuel in Khartoum, Sudan. We had a delay because one of the passengers who was supposed to get off didn’t have his immigration papers in order.  We had to just sit on the plane waiting. On Arrival immigration and customs were smooth and easy and my suitcase was there waiting for me.

One crazy uncertainty was that my domestic flight on from Addis to Gondar was supposed to be either Tomorrow (Sunday) 1st thing in the am or Monday.  The flight had been booked by someone in country and the only way to find out was to go to the Ethiopia Airlines counter – wait in line again – and have them check. Fortunately I did since the flight was early the next morn. The hotel near the airport was nice and a hot shower felt amazing after about 24 hours of either waiting in airports or sitting on planes.

I went for a walk in the neighborhood, it was about ten thirty pm on a Saturday night and the streets were packed with people. Unfortunately I got accosted right away by someone wanting to take me to find a girlfriend. I was pretty tired so just went back to the hotel and skyped home. Fell asleep around midnight, maybe two am there was a loud knock on the door and I jumped up thinking I was late for my am airport shuttle. It was just someone at the wrong room though.

Church started at about three am and lasted until five am. I know this because it was broadcast though a very loud-speaker that sounded like it was just outside my window.  At least that answered the question I needed to decide about whether to stay in a hotel outside Gondar that is quiet or one in the town center right next to a church with nightly services. Sleep wins over adventure this time.

I struggled to learn a few phrases of Amharic before arrival, but for the most part people seem indifferent to my efforts. It may be that it is just that my accent is so bad that they don’t know I’m saying good morning in Amharic. I haven’t met any people yet other than at the hotel so no real impressions yet.

Gondar

The flight to Gondar was about an hour. The countryside was mountainous agricultural land. Currently we are near the end of the dry season so although I could see the outlines of fields they were mostly dry and brown. I could see lots of dry creek and river beds as well.  Just as the plane started descending toward Gondar I could see Lake Tana. This famous lake is the source of the Blue Nile. The source of the White Nile is in Uganda and the two meet in Sudan forming the Nile before it enters Egypt.

I was met at the airport by Mulukan whose wife runs the clinic I’ll be working at. Today is one of the holiest holidays of the Ethiopian Orthodox church, Timkat. This is epiphany and celebrates the baptism of Jesus. They say in the guidebooks that Gondar is the most famous and best place to see this celebration so I’m lucky to be here. Mulukan tells me that the excessively long church service last night was because of the holiday. Timkat was amazing. I started at a pool made by one of the rulers of Ethiopia in the 1600s. Ethiopian tradition is that the Ark of the Covenant was there for two days, then moved to a church in Gondar and finally to a monastery at Aksum, another ancient and historical city. It is supposedly still there. To celebrate the baptism people start at the pool. Normally it is bone dry this time of year but they take 12 days to fill it just for the ceremony. Everyone turns out and many douse themselves in the pool. This is a common way that they renew their baptism and it is very spiritual. But also the kids go wild swimming like a busy day at the community pool. There are stands set up like bleachers outside the wall so that people can just sit and watch.

Children swimming in celebration of Timkat.

Then we went to see the street parade. Everyone in town goes. You can think about a cross between Simchat Torah and a G rated Mardi Gras.  The main focal point is a replica of the ark that is carried with elaborate ceremony. Young men carry green carpets that the unroll in front of it and then roll up after it passes so that they can run up to the front and unroll it for the next section.  Two deacons in white waving incense filled censors led the way. Another playing a stringed instrument followed. Then there were dozens of deacons accompanying the ark. Before and after this are dozens of floats depicting scenes from the bible. My favorite was of Mary carrying a baby Jesus who looked very Ethiopian.  One float was of Noah’s ark. All up and down the street are throngs of people. Some choirs were singing (in Ge’ez a language used only in religious ceremonies). Some groups of people were spontaneously singing and dancing. Thousands were just watching or taking pictures. I estimate that maybe a quarter were wearing white.  I was worried that taking photos might be considered rude but the locals were shooting away on phone and camera as well.

I was exhausted and ready to come back to my hotel anyway. But, I couldn’t have stayed out any longer anyway. Guess which doctor forgot to bring sunscreen or a hat to Africa. (Not to mention forgetting bug spray and my stethoscope).

Ethiopia journal day 2

I started work today.

Got picked up at eight thirty in the morning by Mulukan, Bizhuan, his wife, who is the nurse who runs the clinic, and our driver, we started with a visit to the Gondar University medical center. It is a teaching hospital with 500 beds that serves about 5 million people.  The clinical director, Dr. Yonas, showed us around. He gave us a little tour and introduced me to a few people in the Internal Medicine department to set up a schedule for my talks later in the trip. I got to spend a little time in the HIV clinic. This was a single office with two desks staffed by a medical student and an intern who saw patients in regular follow up. Protocols here include starting medications at a T cell count of 200 although it is getting changed to 350 soon. (In the US it changed from 350 to 500 in guidelines and many communities are starting the meds right away). Interestingly HIV care is the one aspect of medical care that gets funded. This is thanks to PEPFAR. Funding comes from the US government and a lot of help from the Gates foundation and Clinton foundation.  As a result getting HIV care is easier than getting care for other diseases that have expensive treatment.  Also – anytime they apply for a grant they try to tie HIV in to it somehow since no funding agencies have a lot of money for non-HIV projects here.

I saw two buildings that serve as the medicine wards. One that is the TB ward for multi-drug resistant TB, the other was a building especially for treatment and research on visceral leishmaniasis. This is caught from the sand fly bite and here it is a terrible wasting disease with enormous spenomegaly. They need to aspirate the spleen to confirm the diagnosis-a risky test.

Healthcare is entirely private pay and the doctors say patients don’t have much money so the charges are very low. The exception to this is HIV medication and a few other conditions.

The medical school lasts 6 years the last of which is internship. Then students can either practice or take a residency.  The government mandates admissions and they have increased the size to 250 students/class. The staff doctors struggle with not knowing the students personally and with trying to find clinical experiences for all of those students.

We then went to the Jewish Agency for Israel office. It is a walled compound with armed guards. (I guess all Israeli identified offices have to be.) There is a small separate building that serves as a clinic. I am performing screening exams to identify medical problems to be addressed immediately on arrival in Israel. The people I am screening leave in less than two weeks. I have sixty sit to screen during this time. I saw only ten people today, twenty-six scheduled for tomorrow. All three of us sat in one room. Muluken checked height weight and vision, then I did a brief physical exam, then Bizhuan checked vital signs and some basic lab tests. We filled out a page history form that will be entered on-line and sent to the absorption center in Israel before their arrival. It was a fast process and seemed to go well. After the first two patients were rushed in and put through the paces, I asked to have each one sit down so I could introduce myself and connect with them before we started. That seemed to go well. By the end of the morning they could almost understand my introduction the first time. “semae Dr. Michael”. How many ways could I mangle that simple phrase?

One patient had a simple ear infection but we cannot prescribe or treat and so had to send them down the road to the JDC clinic, another Jewish charitable organization that has a full clinic here. There were a few people with goiter, one with a murmur and several with straightforward skin conditions. Almost all had cavities.

Got back to the hotel for lunch at about two thirty pm in time to watch Messi and Barcelona lose a game. (I think it was a re-run.) The Ethiopian national team plays tonight and so everyone says I need to go to a cafe with a TV to watch with the masses.

Sleep is not going well. Jet lag is killing me. I got about 4 hours sleep last night before waking up at 1 AM. Just could not sleep. This makes 3 nights in a row with poor sleep. The newness and excitement here keep me from getting as cranky as I’m sure I would be at home.  As much as I hate the stuff I’ll take a sleeping pill tonight if I wake up again.

After my nap this afternoon I took a taxi to the center of town. The taxi was a van packed with people picking up more every few blocks. I started sitting on the hump behind the front seat facing backwards because there weren’t enough seats.

Downtown was awesome, packed with people. Markets with some people selling goods sitting on the street, others in small huts, others in shops.  Meanwhile people are hanging out talking to each other and cars, tuk tuks, and even some horse drawn carts are going by.

Ethiopia just played a soccer match in the Africa cup. The main town square which is right next to the historical castle had a large outdoor TV screen hung and thousands of people were in the square watching. When they scored their only goal (it was a tie game 1-1) the crowd went wild – singing, dancing and cheering. Some fun.

Ethiopia journal day 3

Gondar is a scenic city in a lot of ways. It is built-in the mountains which from here look more like hills but are at some elevation. In the center are the castles built-in the 1600s, they look like European castles. This is a city of about 200,000 so is definitely not a small village. A few words about the air: it is late in the dry season and so dust is everywhere. It’s not visible like smog but just anytime a car drives by you feel the dust. I’m sneezing a bit from it. That really got bad when I went by a market with spices and the pepper in the air really made me feel it.  It is pretty hot in the daytime and nice and cool in the evening.

Very busy day at work this morning, lots of screenings. One girl had a simple problem she was getting started with pierced ears; they had used little toothpicks which were left in with the idea that the holes would then be expanded.  One of the four spots became infected and developed an abscess that will have to be drained. I had to send her to the clinic down the road to get that done. There were two pregnant women both in the third trimester. Apparently the folks think it is good luck to give birth on arrival in Israel and so attempt pregnancy just prior to the trip.

Dr. Stiffman examines little girls ears.

After our screenings I had a referral from the Joint Distribution Committee’s (JDC) clinic down the road. It was a mom and one of her two children. She reported the child had excessive thirst and urination. These are hallmark symptoms of diabetes and they gave the diagnosis of type I diabetes to this child without any tests. The kid had no other symptoms and when I tested him had a normal glucose and normal urine. I told her he did not have diabetes. It turns out that she was trying to get medical recommendation to get on an earlier flight to Israel. Oh well.

It turns out that virtually the whole Jewish community has already moved to Israel. The people now awaiting immigration are people who were raised Christian but have proven that their descent is from Jewish families who were forcibly converted in the past. It is likely that most are now claiming a return to Judaism as a way to be able to move to Israel. It makes the decision of the Israeli government on who and how many to allow in challenging. Some Israelis staying in my hotel said that there is a real political dimension to that decision as well. The Ethiopians in Israel tend to vote for Shas – an ultra-orthodox political party. All the politicians in Israel with influence on the process know this. Some want to shut the program down now and others do not.

There is a very odd political rivalry among the various agencies here as well. The Jewish Agency for Israel is the main organization who helped from the beginning with the rescue of the Jewish population in the 1970s and since.  A separate organization is The Joint Distribution Committee. JDC runs many programs through the world helping Jewish communities in need. In Ethiopia they have a medical clinic in Addis Ababa and here in Gondar. It would seem logical that the JDC clinic would do the screenings for the Jewish agency but they refused to participate in a way that would allow health information to be sent to Israel. (Apparently the JDC and the Jewish Agency compete for funds and have battled with each other for 50 years. The long conflict is playing out locally here.) This is why my organization, Jewish Healthcare International (JHI) was asked by the Jewish Agency to do the screenings.  A lot of feathers were ruffled and JDC however didn’t want us invading their turf and so made JHI agree that they would only do screening and would not treat anything. Interesting how three organizations all trying to help people can let their own quirks cause unnecessary conflict. My two pregnant patients from earlier today both are getting prenatal care at the JDC clinic but I understand that the JDC clinic won’t send the records to Israel and won’t give them to us to send to Israel either. I don’t get it but that’s how it is.  To complicate it even a little more the Israeli Ministry of Health has an office in the Israeli embassy next door to our clinic. They do the vaccinations two weeks prior to departure and the TB screening as well. Divide and conquer!

Tomorrow I made plans to change hotels. The center of town is very exciting and it’s not so interesting here on the outskirts. I checked out a recommended hotel in the center and found it had comfortable beds, an inside courtyard for quiet sitting and a restaurant with a balcony that overlooks the center of the city. I think it will be worth the noise to move.