Arrival and Work in Gondar

Posted by Rebekah Maldonado-Nofziger, SCOPE fellow, May 7, 2018

I have been in Gondar, Ethiopia now more than one month. And is well!

I arrived around the time of Easter, so Gondar was hustling and bustling getting ready for Easter holiday and celebration. For Easter Sunday, Adino invited me to his home to celebrate Easter with him and his family. Adino’s mother in-law prepared the traditional coffee and had delicious food. Friends and relatives of Adino’s came to spend the afternoon together. It was great getting to know Adino’s friends and what they are doing at the University of Gondar or in other places of work.  I ate engera with lentils until I was full (more than full!). The Ethiopian culture is so welcoming and giving.

Since my arrival, I have lived in four separate locations. Even with all the moving, it has been good to understand the various sections of town and meet the people in the different areas of Gondar. I am often pulling out my Amharic English book trying to find the words to communicate! Currently, I am living at University Guesthouse where previous fellows have lived. I have also been meeting and making friends from all over the world, United Kingdom, Germany, Switzerland and fellow Americans. Together we create a supportive network checking in with one another and seeing how things are going.

From the University Guesthouse, every morning and afternoon Monday through Friday I either walk to the University of Gondar or take the minibus (picture a minivan in the USA) into the University of Gondar. The minibuses have a route that they follow. The difference from the United States is that you can stop the minibus on route at any point to get on or off the bus. In many ways, I like this. In the Seattle, you can only get on or off at the exact bus stops, but here in Gondar if you are walking and feel tired, you could stop the minibus and get on. The only down fall I have experienced, is if the minibus is full then it is not possible to board. In which case, I keep walking. Either way, one way or another I get to the University of Gondar!

On a side note: I was walking to the University of Gondar beginning of this week and I have learned stay focused; I am on a mission to get to the University. I was so concentrated that I did not hear one of the Ethiopian doctors who was calling to me from his car (he lives at the guesthouse too). I finally looked up and he said, “I have been calling for you and you did not respond.” I applogized profusely and said I was so concentrated that I did not hear him. He forgave me, and said come on! I got into his car and he gave me a ride to the university where he too works. It was a nice break from walking and from being in the minibus!

Upon my arrival I have been working very hard on updating the training manual and having meetings with Dr. Getahun, Adino, and Simegnew to talk about how we can make improvements on the training manual. One document that I have been using immensely to update the training manual is the Ethiopia Demographic and Health Survey (EDHS) 2016. One thing that has stood out to me when reading the EDHS survey is the importance of education especially among women. Women suffer from many disparities in Ethiopia and in part, I believe it is because of the lack of education. Education and health are very intertwined. Reading the EDHS survey has continued to make me passionate about the work that is being done through the SCOPE FLAME project partnering with priests (usually men) and the Health Development Army (usually female and comparable to community health workers) to empower and educate women on the importance of receiving antenatal and delivery services. This ultimately assists in reducing maternal and neonatal deaths around pregnancy. Through my work here, I am finding that increasing the health and wellbeing of women is important. In addition to this, education is also very important to increase their health and economic status of women. After doing this work, I find myself talking to women at the restaurants or little shops, asking them about what they are studying and what they are passionate about. I encourage them to keep studying!

This week (4.25.2018) there has been a training being organized by Kendelam, Ethiopia SCOPE Fellow, with the Holy Water Project sites at the University of Gondar. I was able to sit in for half day training and observe Adino provide education on adherence to HIV medication and the important role that priests can play in this work. To start off the training one of the priests would pray. Although I could not understand the language, I could tell they were very engaged. The priests would ask Adino many questions. During break, I asked Adino how he felt the training was going, and he said that the priests were asking really good questions. Kendelam agreed! This is the time I wish I was fluent in Amharic. I need to continue to work on my Amharic!

It has been great working with the SCOPE Gondar team. One area I have been working to understand is the health system of Ethiopia. Although it is not super complex, because I am not from Ethiopia the health system does not come natural to me. Dr. Getahun is always telling me to ask questions and ask the same question again if need be. And I do! This kind of learning environment provides me confidence to ask questions and an environment where I can easily learn. This is just one example of how I have felt support from the Gondar team! I am so delighted and honored to be working in partnership with the team.  One of these days my plan is to invite the whole SCOPE Gondar crew over to my house for a meal

Adino’s Journey

An Ethiopian SCOPE fellow travels to the U.S. and learns valuable strategies to support the work he is doing toward effecting change, and improving the health of his country. 

Adino’s warm smile was the first thing I saw when we spoke over SKYPE at 6:30 a.m. my time. He graciously forgave me for forgetting that we had gone through daylight savings here in the U.S. and I was an hour behind our agreed upon time. Time is different in Ethiopia, as it is in many places in the world.  This is one of the many things I miss about the place. There is fluidity to time in Ethiopia, which is lacking the rigidity I have become so accustomed to in the U.S. So Adino and I began chatting and catching up as I sipped my coffee and he sat by a darkening window as the sun set at the end of his day.

I first met Adino in the summer of 2014 during my time as a SCOPE fellow in Ethiopia. In Amharic Adino’s name means “healer, “ which as you will see is quite appropriate. When we met I quickly caught onto the fact that he was committed to bettering the health of his fellow Ethiopians, and that he had deep, rich Ethiopian Orthodox faith.

Adino grew up in Debark, a sizable town of around 25,000 people located 100 kilometers north of Gondar, where the University of Gondar, and SCOPE’s main hub is located. Debark is the closest town to the Simien Mountains National Park, and is the location of the park headquarters. That is to say it’s stunningly beautiful. Adino shared his childhood with 3 brothers and 2 sisters. He is the third born child in his family. Growing up consisted of a lot of  “Playing in the mud, playing soccer, playing with friends and family” as well as helping the family out in a number of ways. Let me just say that Debark’s mud almost stole the shoes off my feet when I visited Adino’s hometown during my time as a SCOPE fellow. I also enjoyed the single best cup of coffee I have ever sipped at the hands of Adino’s brother and sister-in-law who hosted us for a coffee ceremony when we visited. Adino attended school in Debark and graduated with a 12th grade education.  Then he set his sights on Gondar.

The Simien Mountains just north of Debark

Adino’s sister in law performing the coffee ceremony

Before joining the University of Gondar, Adino wanted to study medicine, but landed in public health due to his budding interest in the research side of medicine. After completing his bachelors in public health, Adino was sent to a rural health center 150 km from Bahir Dar to work as a public health professional and try to impact the health of the community there. When I asked Adino how he felt about going to the health center, he responded honestly that at the time he was disappointed. He had not expected to be sent to this rural place, and he was the first health officer to ever set foot in the area. Adino’s face then began to light up as he began to speak about how his experience there surprised him:

“The hospitality was very nice, and they appreciated me more than I expected. They had many, many problems, but they had no access to get medicine. I took that as an opportunity. I saw everything from gynecology clinic, to delivery, to the kids, and everything. The respect from the people when you are there is amazing, because normally they would be referred. I felt a huge sense of helping the community, and the rural farmers. It was a good opportunity for me to serve my people and I still have warm feelings about my time there. It helped me really understand the public health system and the problems in rural areas.”

After his time as a public health officer, Adino returned to Gondar where he continued seeing patients. He followed patients with multi drug resistant tuberculosis (MDRTB), which again had him travelling to the farthest reaches of the region. He visited all the health centers in the region and learned a lot about public health outreach.  I can only imagine the ways this work has served as an asset as Adino works with SCOPE to reach out to some of those same areas and deliver much needed services today.

Adino completed his Masters in Public Health at the University of Gondar in 2015.  One of his esteemed professors at the university was a former SCOPE fellow, Kefyalew. Adino was one of the best students, and Kefyalew brought him along for some of SCOPE’s work, which eventually led to Adino applying to become a SCOPE fellow himself. When I asked Adino what it was about SCOPE that piqued his interest, it became clear that his experience in the rural areas was informing the way forward for him:

“I am a deacon in my church, so the religious part of SCOPE caught my eye. I have been in the rural areas and seen their suffering. I know what the rural communities are facing, and working with SCOPE would be a good opportunity to continue helping. The religious fathers are very influential. We are using their influence for positive activity. For me, I believe SCOPE makes a difference, and that it is a good strategy.”

Through SCOPE, Adino recently left his beloved Ethiopia for the first time in his life, and travelled to Seattle for three weeks to participate in a short course on Implementation Science. When I asked about his time, his warm smile spread across his face, and he simply responded “wow.” He went on to talk about how cared for he felt. When I asked what surprised him most, he shared that he had not expected much hospitality. He explained by saying the perception of the U.S. in Ethiopia is that people are “very busy, and not very hospitable.” He went on to talk about the meals he enjoyed, and his visits to Mt. Ranier, Boeing Museum of Flight, and Bainbridge Island. It was obvious that the warmth of those involved with SCOPE in the U.S. stunned him.

Adino and Kate (SCOPE’s program coordinator) at Mt. Ranier

I asked Adino to share about the importance of the training he received.  He talked specifically about how he now understands the methodology behind the FLAME project, which is one of SCOPE’s big projects currently, saying that it became “extremely clear.” More generally he spoke about identifying the “know-do gaps” in Ethiopia. He talked about all of the observational research conducted in Ethiopia, which gathers interesting information, but often never effects change. It sits in published journals never influencing the realities on the ground. Adino talked about learning how to identify a problem, then identify the know-do gap and conduct implementation research to effect change, and then sharing the findings with those in power with the goal of effecting change at the policy level: “My attitude is totally changed. We have many problems, and using implementation science can work.”

In ten years Adino hopes to have earned his PhD and “be well engaged in problem solving in public health research in Ethiopia.” He never plans to leave Ethiopia for more than enough time to complete necessary studies. Adino always plans to return home where he will spend his life living into the name he was given, and creating opportunities for health and healing in Ethiopia.

It is an incredible privilege to have Adino working with SCOPE. As a former fellow I can say that one of the most meaningful parts of the fellowship is the chance to collaborate with, and learn from our Ethiopian counterparts like Adino. He wanted to be sure I thanked all those who supported his trip to the U.S. in a myriad of ways, and all those who support and believe in the work SCOPE is doing. He is happy to be back home with his wife, and his beloved injera, but has nothing but warm memories and gratitude when he remembers his time in the U.S.

GOODBYE TO GONDAR

The information we collected from all those visits to rural health centers around Gondar is now revealing insights! After thirty visits and seemingly endless questions, we now have a fuller picture of the current health care services available to pregnant women.

We learned that although midwifery services are readily available and free at all of the places we visited, most women don’t use them. And many women don’t come to the prenatal visits that are designed to detect complications before they turn into emergencies. Sadly, we learned that many health centers have very limited ability to rush pregnant women to hospitals if they show up late, with unforeseen complications or life-threatening problems.

The health center spaces where women give birth here are basic, and continuous improvement is necessary. Many delivery rooms don’t have clean water or soap readily available, and few have the full spectrum of basic emergency delivery supplies recommended by groups like the World Health Organization. Some maternity centers are so remote that cell phone signals don’t work, and patients often must hike for miles on dusty or muddy paths to reach health care.

But all of the health centers have staff that care; that is what I will remember most from the assessment visits. Health center staff were always eager to show us how they were trying to provide the best care they could. Some health workers, like the head nurse atAbawuram, asked us to share their frustrations and needs with the world. Others were excited to hear what SCOPE is doing, and hoped that their site would be selected for the next round of Priest training work. All were clearly dedicated to making sure babies were delivered in the safest way, in one of the world’s most challenging locations.

With my work now finished, I handed off my data, maps, and analysis into the capable hands of the SCOPE/ FLAME team members at the University of Gondar. Over the coming weeks and months, they will go on to collect more individual and focus group data, and will begin the Priest and health worker training which is the hallmark of the SCOPE maternal health intervention. It is our hope that this work will encourage more pregnant women to give birth in the safest way possible, so that their babies can have the healthiest start in life.

As I return to the University of Washington, I am diving back into my studies in maternal and child health with a renewed appreciation for the complexity of delivering care in places like Gondar. So many factors must come together to make maternal care safe and effective; staff must be well trained and supplied, women must value the care enough to seek it out, and emergency resources, including transportation, must be available. Overlaid on all of these issues are the cultural and religious factors that influence families’ decision making. Addressing such a complex yet vitally important need requires innovation and understanding. SCOPE is on the front lines of testing novel ways to save lives, and I am proud to have been a part of this work.

Last week, Sheldon and I said heartfelt goodbyes to the colleagues who have become our friends on the SCOPE team in Gondar. We walked around the bustling streets one last time, and were marauded for one last time by the neighborhood children whose hugs and greetings have become a highlight of our morning routine.  Now, as I get settled back here at home in Seattle, I find I cannot describe my experience in Gondar with SCOPE in just a few sentences. The immersion into front-line global health triggered more questions in me than it answered. But some things I know for sure- I will never forget the new friends and experiences that I gained while working with SCOPE, and I will keep working to improve the health of women and children in areas like Gondar. For now, I want to send heartfelt thanks to SCOPE’s supporters and donors for enabling Sheldon and me, and the entire SCOPE team, to do the hard work of learning, understanding, and hopefully, changing the world.

THOUGHTS FROM THE PLANE, PART II

It’s hard to believe my time in Ethiopia has come to an end – time really does fly! I am currently sitting at my gate in Addis Ababa airport waiting to board my 20-hour flight to Los Angeles. I have a mixture of emotions leaving Ethiopia – I’m sad to say goodbye to this beautiful country and the friends I made, I’m grateful for the experience and memories, I’m excited to reconnect with family and friends over the holidays, and I’m anxious to return to graduate school.

While sitting here at my gate reflecting on the past 6 months, what consistently comes to mind is my appreciation for the SCOPE team. They played a vital role in both my personal and professional life, and I will dearly miss them. Our family of managers, data collectors, and qualitative facilitators were a true joy to work with. Whether in the office or out in the field, they took on every task, or challenge, with a smile on their face. Each and every one of them is caring, hard working and dedicated to improving the health of their communities.

In fact, in my first blog post (also named Thoughts from the Plane) I said, “Above all else, I cannot wait to meet the study team and work together. I know they are a group of talented, smart individuals and I can only hope I will offer the team half as much as they will inevitably teach me.” As I suspected, this SCOPE team taught me more than they will ever know. They opened my eyes to an entirely different culture. They shared with me their personal experiences, providing me with context and the ability to understand and appreciate their perspectives. I am beyond thankful for their friendship and the many memories together.

From a professional standpoint, I am truly grateful for my SCOPE fellowship. In the future I hope to pursue a career in program implementation, and working on the FLAME study provided me with the invaluable experience of implementing global health interventions in rural settings. I gained a deeper understanding of the barriers and challenges to working in rural communities, and know this experience will serve me well in my future endeavors as a public health professional.

As I board my flight, I am ending this life chapter and beginning a new one. I have grown as a person and professional throughout the past 6 months, and will surely take this experience with me on my next journey. I will hold the memories close to my heart and will ensure the lessons I learned inform my future work. Thank you to everyone who supported me throughout my fellowship. And special thanks to our blog readers – it has been wonderful sharing this experience with you!

FLAME QUALITATIVE DATA COLLECTION

Qualitative Research Preparation

This is my final workweek in Ethiopia and I would like to share with you our progress on qualitative data collection for the FLAME study. As many of you know, the FLAME intervention will pair priests with health workers and train them to conduct community outreach to encourage pregnant women to receive safe antenatal and delivery care. Prior to implementing the intervention, we are conducting focus group discussions (with pregnant women, male partners, and priests) and key informant interviews (with health center heads and health extension workers) to gather information that will help us optimize the design of the FLAME intervention. For example, we hope to better understand pregnant women’s healthcare seeking behavior, their preferences for childbirth, and how priests can be involved in community outreach.

These data will be invaluable in improving the FLAME model to hopefully ensure successful outcomes during intervention implementation. The table below details the primary discussion topics for the focus group discussions and key informant interviews.

Since my arrival in June we have been developing tools and preparing for qualitative data collection. With limited practical experience in qualitative work, it was difficult for me to anticipate the amount of planning and preparation needed. I’m grateful for the opportunity to gain experience in this field and learn firsthand what is required to ensure quality qualitative data collection. To provide a bit context, here are some of the preparation activities we completed throughout my time in Ethiopia:

We developed five discussion guides, one for each of the participant groups – pregnant women, male partners, priests, health center heads, and health extension workers. We applied for ethical approval from the University of Gondar and the University of Washington. We created a participant recruitment plan for each of the five participant groups. We developed standard operating procedures that provide step-by-step instructions for how interviews and focus groups should be conducted. We crafted an analysis plan for how these data will be analyzed to inform the FLAME trial. We recruited qualitative facilitators from the University of Gondar and trained them on our protocol. We developed log sheets to gather demographic information from participants. We negotiated with the University transport office to ensure transportation to rural communities for the interview conduction. And the list goes on…

After many months of preparation (and a few logistical set backs), we are finally in the data collection phase and very eager to learn from our discussions with participants. In the past two weeks we have conducted 2 focus groups with pregnant women, 1 focus group with male partners, 2 interviews with health extension workers, and 1 interview with a health center head. Data collection is moving along nicely and we hope to complete all qualitative research by mid-January.

Qualitative Research Preliminary Findings

Our tools are working – operating procedures, discussion guides, log sheets, etc. – and the discussions have been insightful! I asked Adino, FLAME program manager and qualitative facilitator, about his reactions to his first focus group with pregnant womenlast week and he said, “I am very pleased with our visit. Although the pregnant women arrived over an hour late, we had a fruitful discussion with them. Our most interesting finding was the influence of mothers and mother-in-laws in pregnant women’s healthcare seeking behavior.” To elaborate, the pregnant women highlighted that mothers are a primary barrier to seeking healthcare during pregnancy and delivery. Mothers will often say ‘I have eight children and delivered all of you at home- you should do the same.’ As a powerful influence in their lives, women struggle to refute their mother’s advice.

Adino also highlighted the challenges women face in disclosing their pregnancy. Women often feel uncomfortable or embarrassed sharing their pregnancy status with the community. Rather than disclosing, they often wait until they are ‘showing’ and community members notice the pregnancy. These feelings of discomfort are exacerbated for unmarried women, who are shunned from the community. Pregnancy out of wedlock is strongly discouraged and the community, including family and friends, often rejects unmarried pregnant women. Sadly, some unmarried pregnant women will attempt suicide or seek abortion to save them from having to disclose their pregnancy status.

I also asked Simegnew, SCOPE fellow and qualitative facilitator, his thoughts on his most recent focus group discussion with male partners. He highlighted a few key findings from the discussion that were particularly interesting. First, he said, “Male partners are very voluntary for their wives to have communication with priests. There is no topic they would not want their wife to discuss with a priest. They believe soul fathers are their ‘fathers’ – they know everything about their lives and women are free to share with them.” This speaks to the integral role priests play in parishioner’s lives and their comfort in discussing personal topics with priests.

Additionally, in regard to delivery, the male partners noted a significant difference between women who live near the health center and village, and women who live in more remote settings. In the village, nearly all women come to the health center for delivery. Conversely, in the remote areas, women often deliver at home because of cultural and distance barriers. Culturally, many rural residents believe that a woman’s first delivery should take place in her mother’s home. Regarding distance, it is challenging for pregnant women to travel numerous kilometers to the health center without access to roads or vehicles; and women do not feel comfortable, or have the resources, to leave behind their children and household responsibilities for multiple days.

Adino, Simegnew, and health extension worker walking through Mussie Banb village after conducting focus group and interview.

Although I will not be in Ethiopia to oversee the remaining focus groups and interviews, I am confident in our qualitative team and eager to hear their results. I am already intrigued by our findings and curious to learn more from the participants. There is no doubt these findings will not only improve implementation of the FLAME intervention, but also provide the SCOPE team with valuable context on maternal healthcare seeking behavior in the North Gondar Zone.

OuR FUL FAMILY

As you know, ful is one my favorite Ethiopian dishes – a delicious mixture of cooked fava beans, accompanied with a side of onions, tomatoes, garlic, and jalapenos. Ful is a breakfast dish and for nearly 4 months, I struggled to find a shop that would serve ful past mid-morning. However, about two months ago, I walked out of the SCOPE office and down the street in search of a midday snack. I perused the tuck shops and local merchants, and encountered a friendly woman making coffee and various Ethiopian dishes, including ful. I decided to sit in her little shop and asked for a cup of coffee.

Preparing ful on hot coals

While waiting for my cup of coffee, I was greeted by her adorable, happy children. The young boy, Alazar, had a fascination with my camera and kept posing for photos and giggling profusely when seeing his face on the screen. Her three daughters – Muwork, Fasika, and Marta – treated me like a princess. They washed my hands, cleaned the small table in front of me, and ensured I had plenty of sugar for my coffee. We tried to communicate, despite my limited Amharic and their limited English. After sipping my coffee, I returned to the office completely rejuvenated. Interacting with this wonderful family was the perfect ‘snack’! I remember sharing photos with Elizabeth and telling her we must return for ful one day.

Alazar

Fasika and Marta

I returned with Elizabeth a few days later, and the children greeted us with enthusiasm. Alazar ran up the street and jumped into my arms; I was flattered by his excitement to see me. The mother, Alemaddis, kissed my cheek as I introduced her to my friend, Elizabeth. We ordered ful and enjoyed watching Alemaddis cook, while playing with her son and interacting with her daughters. In our broken Amharic, we asked the girls about school, and they showed us their notebooks. Meanwhile Alazar bopped around making everyone laugh and asking for his picture to be taken.

Alemaddis’ ability to simultaneously cook multiple meals in her tiny shop is impressive, and fascinating to watch. Her hands move quickly, constantly stirring, chopping, and cleaning. She has a small charcoal cooker, one cutting board that rests on a bucket of vegetables, and no running water. However, despite the limited space and materials, she has developed an effective, resourceful system that allows her to continuously cook and serve clients all day. Thankfully her daughters are eager helpers, constantly washing dishes, peeling garlic, chopping vegetables, and cleaning tables. They are completely in tune with their mother’s needs, never needing to be asked to complete a task.

Alemaddis in her ‘kitchen’

This family’s energy is infectious, and Elizabeth and I both caught their ‘bug.’ Alemaddis’ shop has become one of our go-to lunch spots, and every interaction with them is equally enjoyable. As much as I would love to speak with them fluidly, there is beauty in our broken, cross-cultural communication. Spending time with Alemaddis and her children is therapeutic for me – guaranteed to laugh, eat good food, and feel welcome. I have fostered a bond with this family that I will dearly miss.

A SCOPE THANKSGIVING

As SCOPE takes on a major research study, the team working here in Gondar has expanded. While Getahun and Adino provide leadership, Sheldon and I also work closely with local Data Collectors and Gondar-based SCOPE Fellows to do the ‘legwork’ of the study (like visiting rural health centers). The Fellows and Data Collectors are our travelling partners, translators, and collaborators in the SCOPE work here. And as our time is beginning to wind down here in Gondar, we wanted to thank them.

What better way to say ‘thank you’ than with grand amounts of food? There was just one catch- our colleagues are all Ethiopian Orthodox Christians, and they ascribe to a detailed fasting schedule. Every Wednesday and Friday are fasting days, with extra periods of fasting prescribed for especially holy seasons. In total, the most devout members of the church fast for over 200 days per year! (For Ethiopian Orthodox adherents, fasting means nothing to eat or drink until about 3pm, and no animal products after that.)

A major fast recently ended, and we knew that an even bigger season of fasting was approaching with the Christmas season. So last week, we called the Fellows and Data Collectors together over a calendar to strategize. “When can we feast?”

There was only one day before our mid-December departure on which everyone agreed they could eat, and we were thrilled when we realized it fell only two days before American Thanksgiving! We would celebrate with an Ethiopian style meal to show our thanks for the Data Collectors’ and Fellows’ hard work.

Ethiopians love beef, and the streets in our neighborhood are filled with restaurants specializing in fresh meat. The beef is displayed prominently at the front, where it can be ordered by the kilogram. Then it is taken to a roaring fire in the back, cooked to perfection, and served on a sizzling brazier stuffed with red hot coals underneath. The slices of piping hot meat, called shekla tibs, can be eaten straight with one’s hands, or wrapped in bits of injera or bread and dipped in hot berbere sauce.

We knew that shekla tibs would be a special treat for our colleagues. So for lunch on Tuesday, we invited them to meet us at a local restaurant, where we ordered a feast of meat.

SCOPE Fellows and Data Collectors share a meal of thanks

There were smiles all around. I reminisced with the Data Collectors about our adventures visiting remote health centers.

“I remember when we had to hike through the mud,” Mehari told me, chuckling, “you slipped and fell in a puddle and I was sure you would be angry but instead you just laughed!”

Sheldon and I spoke about our plans- to finish grad school in June and continue working in global health. They updated us on their plans; most are either finished or almost finished with their Master’s degrees. Many spoke of their dreams of continuing school to obtain a PhD. Their eyes shone as they discussed future work on the FLAME study. After Sheldon and I leave in December, the study will continue into the intervention phase, building upon the work and training that we have all shared over the past five months.

SCOPE Fellow Kindalem with fresh Shekla Tibs

Sheldon and I said thank you. Thank you for teaching us so much about Ethiopian culture and for being patient with our learning. They asked us to remember them when we went home, and we said, “how could we forget?”

The next season of fasting begins this week. Many of the beef restaurants will simply close for the season. Once again, our colleagues will demonstrate with ease how they integrate their scientific work and their religious devotion. But before that begins, we got to share a Thanksgiving feast together.

After we returned from the Thanksgiving meal, I checked my phone for messages and found an especially touching one from our Data Manager, Malede.

“Wow. I feel proud to belong to this team.”

A LESSON IN HEALTH PROMOTION

When the SCOPE team visited from Seattle, they had an idea.

“Why don’t we create a poster to put up in the health centers SCOPE works with, to show people what we do?”

So in our office in Gondar, Sheldon and I played around with images and layouts, trying to express the “essence” of SCOPE. But it wasn’t until Rotary Fellow Simegnew (pronounced Sim-en-ya) got wind of what we were planning that things really got interesting.

Simegnew- SCOPE Rotary Fellow and Health Promotion expert

Simegnew has two degrees in health promotion, and is one of the newest faces around the SCOPE office in Gondar. He explained that there is a science behind posters and displays; that everything from the intended audience to the desired message can be planned so that the impact is precise and culturally effective.

“Let me make a creative brief,” he said.

The creative brief transformed what we had in our heads into specific directions. We wanted the staff and women at the health centers to see the poster and know that SCOPE pairs community health workers with Priests, and trains them to encourage women to have safer pregnancies. We wanted it to be in English and Amharic, with easy to understand pictures, so that people of any literacy level could understand it. Simegnew mapped this out perfectly.

Adino called our friend Gebeyanesh, along with a Priest based near the clinic in Ayemba, to ask if they would be willing to be our models in photos for the poster.

So this morning, camera in tow, we boarded an overcrowded minibus to Ayemba, returning to the clinic where SCOPE’s interventions have been so effective.

On the way, Sheldon and I peppered Simegnew with questions. He explained that ‘health promotion’ is a specialty within public health, and focuses on making sure effective, accurate health messages get to people when and where they need them. It involves everything from basic posters to high-end television and radio media. Simegnew literally teaches the class on health promotion at the University of Gondar, and perfecting the art of health promotion is his life’s work.

But like so many of our colleagues, Simegnew is also deeply religious. He explained that when he was in high school he decided to spend his weekends taking classes and studying texts at his local Orthodox Christian church. After years of work and study, he became a deacon. Today, while working at the University, he is still very involved with the Orthodox Church. He listed off the recent Saints’ days, and told us of his plans to spend a whole night praying at church this week.

While we were still deep in conversation, with the morning sun blazing, the minibus pulled into Ayemba.

The weather has been growing hotter here, and the absence of rain means the dust kicks up with the slightest breeze. Walking the short distance to the health center, we crossed a river. It was nearly dry, in contrast to the rollicking flow we saw a few months ago.

The health center was busy with the day’s patients, and Simegnew greeted the Head and explained our business. Soon, a Priest, easily recognizable with his white wrap and headdress, was visible walking up the dusty road leading to the clinic. As with many other Priests I have encountered here, he had a peaceful, lit-from-within smile. Soon Gebeyanesh, and a new mother, Abebach, followed.

Priest Tegegn and Health Development Army member Gebeyanesh

As we moved throughout the clinic, the Priest was the center of attention. Men stopped him every few meters, asking him to hold up his wooden cross as a blessing. The Priest was patient and quiet, stopping for everyone who asked. Attention from a Priest was clearly a big deal.

We snapped a picture of Abebach and her baby getting advice from the midwife. Gebayenesh told us that Abebach had had pregnancy complications, but that the prenatal checkups had caught the problem, allowing her plenty of time to arrange to deliver at a larger facility in Gondar. The baby boy, Bantegize, was healthy and growing.

Mom Abebach and baby Bantegize with the one of the midwives at Ayemba

As we continued taking pictures somewhere else, it was clear that the baby was Gebeyanesh’s center of attention. She doted on the mother and infant- making sure they were always in the shade, and that the mother’s shawl was ‘just right’. She seemed to echo the patient care of the Priest.

We thanked our photo subjects profusely, paid for their transportation to the clinic, and headed back to Gondar to work on the pictures. Simegnew will help us to select images which are easily understood here, and which convey the work that SCOPE does. After that, Simegnew explained, we will show our draft to people at a health center and ask them questions to make sure the images and text convey exactly what we intend.

I love how Simengew effortlessly blends his scientific training with his religious devotion, just as the Priest and Gebayenesh’s work easily bridges the care of a neighbor and Spiritual leader with the practical provision of health care services. It seems like such a natural combination. We hope that the final version of our poster conveys the beauty of this message so that all who see it will be inspired.

A MESSAGE FROM THE ABAWURAM HEALTH CENTER

Last week we conducted our 26th rural facility assessment at the Abawuram Health Center. We agreed that this was definitely one of our favorite days in Ethiopia, not only because we got to see the lush countryside, but because it brought to life in a fresh way many of the challenges the health center faces in trying to provide services for the rural community.

We drive south from Gondar, and within one hour we were faced with a river crossing that was impassable by car. Our driver threw up his hands and looked to us as if to say “what are we going to do now?” So we put on our sneakers, and set out to walk the remaining 10 kilometers to the Abawuram health center. The hike was beautiful – small river crossings and vast, green farmland. We frequently encountered local farmers and shepherds, asking them directions to guide our way on the crisscrossing trails, sometimes barely visible, through the meadows. The local residents were surprised to see ‘firenges’ (Amharic word for foreigners); curious to know where we were going and why we were in their community. We arrived at the health center in just under 2 hours, sweat dripping down our backs and eager to retrieve our water bottles. Walking the distance ourselves put into perspective the reality community members face in trying to access healthcare.

For us the hike was lovely- we had optimal conditions, such as transportation to the very end of the road and sunny but cool weather. But we could see how in the rain, or dark, when a family member is suffering or dying, the trail could be nightmarish. It is not uncommon for local women to walk much further than 10 kilometers, facing extreme rain or harsh sun during different seasons. Given these circumstances, merely arriving at the health center is a feat in and of itself.

The head nurse, Gebeyehu Kassie, greeted us warmly at the health center. He proudly showed us the maternity area and helped us gather the data we needed. When we took his picture, we asked his permission to post it on this blog, and he obliged, with one caveat.

“Please tell people what our challenges are here. They are three.”

As we anticipated, the first challenge was transportation. As the clinic head, he described how the long walk to the health center often left his patients exhausted upon arrival. But the problem didn’t end there. Because Abawuram is inaccessible by road, the clinic is often unable to keep a constant supply of life-saving medications in stock. It is nearly impossible to transfer new materials and equipment or build infrastructure.

We asked, “What do you do if a woman has an obstetric emergency and needs to go to a hospital?”

He described how they carry patients in a homemade, wooden stretcher the 10 kilometers to the nearest road. The midwife travels with the patient, trying to stave off further danger during the treacherous journey. In the best case scenario a woman would access emergency medical care in 3 hours.

The second challenge was running water. On the day we visited Abawuram, the health center did not have any water on its premises. Nothing in the delivery room- not even a bucket. There was a water tank in the corner of the facility, but upon further investigation, we could see that the tank was empty and the pipes were not connected to anything. When we asked about the water situation, Gebeyehu Kassie shook his head. The nearest water source, he said, was a borehole, a 20-minute walk from the health center. Staff traveled with a donkey to the community borehole, to fill up containers with water and then walk 20 minutes back to the health center. Given limited staff and resources, what this meant practically was that they often provide health services without clean water.

Delivery room sink, which hasn’t seen water in years

And the third challenge was electricity. The Abawuram health center has no electricity. In the evenings, they are forced to provide services by flashlight, whether that means delivering a child or simply looking for a medication. The picture below is of the delivery room, taken on a sunny afternoon, yet it is still quite dim. We could not imagine delivering a child in this very room in complete darkness, with only cell phone flashlights and one solar-powered light to assist, yet the dedicated staff at Abawuram do just that.

Additionally, lack of electricity impacts the health center’s ability to sterilize instruments. They use a kerosene-generated autoclave and charcoal-generated boiling water to clean medical materials. Given Abawuram’s remote location and their dependency on kerosene, having clean, safe tools for delivering a baby rests precariously on their capacity to carry this fuel in by hand, overland.

After hearing Gebeyehu Kassie describe the difficulties of operating the health center, we told him that yes; we would tell whomever we could about the obstacles faced at Abawuram. It reminded us that improving maternal care typically involves both push and pull factors. Community leaders can promote safe delivery and encourage women to come to the health center, but if the health center is not equipped with even basic supplies, or is impossible to reach, women may still opt for home birth, unsafe as it is.

The dim delivery room

For both of us, this was a beautiful day in Ethiopia, with the opportunity to spend time outdoors hiking with good company in a beautiful landscape, completing meaningful data collection, and engaging with local health professionals. However, we realize that if our roles were shifted, we would feel quite differently. If we were health care providers at Abawuram, the constant stock outs and lack of essential materials would be endlessly frustrating. And if we were seriously ill or in labor, this ‘beautiful walk’ would be an incredibly challenging, life-threatening journey.

GOING THE DISTANCE

When I first saw the list, I knew it would be an adventure. Thirty health centers had been randomly selected from within the North Gondar area. Some were easy to travel to, some were impossibly remote, but they all needed to be visited in person. Some seemed to exist only on the list itself, as maps of the area tended to be old or incomplete. An initial search of several paper and internet based maps held location clues for only half of the centers.

Adino (the SCOPE/FLAME project manager) and I planned trips and mapped routes. Some clinics were located in a mid-sized town or right on a paved road. Most required bumpy rides in the dirt, battling the mud during the rainy season and the choking dust after the rains ceased. I remember on one early visit, a rutted dirt road leading to the health center wound through a maze of dense village homes- many so close I wasn’t sure the car could pass. As the driver expertly

One of the hazards of travelling on rarely used roads

threaded our way through, we had to stop several times to allow clothes lines spanning the road to be lifted. It was clear that cars had been scarce here.

Still, there was one section on “the list” that worried me. The Woredas (districts) of East and West Belessa seemed to be a black hole of information. I could locate only one of the six places we needed to visit on any map. Adino worked the phones, calling contacts in the Ministry of Health, gathering information on the locations of health centers and the road conditions nearby. Google earth showed no evidence of paved roads anywhere in the Belessa area. It was arid, sparsely populated, and seemed almost impossible to access. If the goal of the FLAME study was to test whether the SCOPE intervention worked in more rural areas, farther from Gondar, we had certainly found an extreme example.

On the way to Belessa

After only 30 minutes on a paved road leading out of Gondar, we turned onto a dusty, single dirt lane heading into the eastern hills of Belessa. The rainy season ended in September, and the wild brush and planted fields alike were beginning to fade from a vibrant green to a parched beige. The ever-present child animal herders, with their goats, sheep, and cattle charges, scattered from the road as the driver tapped his horn to warn them. Usually this space belonged to the livestock.

We chugged up the side of an imposing hill, bare except for the low brush and lonely huts every few kilometers. It was noticeably hotter than Gondar, and the growing intensity of the sun reminded me how close we were to the equator. Emerging past the apex of the hill we caught our first glimpse of the wide, flat valley hosting the town of Arbaya, the capital of west Belessa.

We quickly gathered the data we needed from the health center in Arbaya and confirmed our directions to Jandeb, the next site on the list. However, outside of Arbaya, the conditions quickly worsened. We were the only car on the rocky, sloping terrain. We picked up locals to help us discern the road’s boundaries- the dirt spread

The road to Jandeb Health Center

in all directions, and an unexpected turn in the barely discernible road could go unnoticed. We crossed rivers and chugged up hillsides, getting out to push the tired vehicle every now and then. After many miles, we were faced with an incline the car could not handle, and we set off to complete the journey on foot.

In the tiny village of Jandeb, small clusters of huts clung to the side of a hill, and livestock wandered freely. The small health

SCOPE/Rotary Fellow Simegnew on the hike to Belessa

center was open for business, and a midwife helped us gather the data we needed. Despite the remoteness, the health center seemed fairly well supplied with the medicines and tools needed to tend to normal deliveries and provide basic medical care. Again, I was awed both by the difficulty of the terrain surrounding the clinic, as well as the strength and endurance of the local residents. Several times on our hike we were easily passed by women and children carrying unfathomably large loads, chatting as they navigated the rocky path in thin plastic shoes.

At the health center, the midwife motioned to a long building constructed out of mud and sticks. It was where the health center staff lived, since there was no housing available in the tiny village itself.

“Is it difficult to live in such a remote place?” I asked the midwife. I knew that health care workers typically trained in cities and were then placed wherever they were needed.

“Oh yes,” he sighed, “most people do not stay here for long.”

Staff housing at the Jandeb Health Center

On the way back to Arbaya, I thought about the effect that this high turnover must have on the people’s trust of their health care providers. I had just read a research article showing that trust in one’s midwife, and confidence that the midwife will act with professionalism and respect, is one of the biggest factors drawing Ethiopian pregnant women to give birth in safer places like the clinic in Jandeb. But how could the women trust a clinic when the staff was constantly changing?

I thought about the people in Jandeb who didn’t change. Local, trusted women, called Health Development Army members, liaised with the health center to make sure health messages reached the people. And priests- priests are the bedrock of society in places like these. As Dr. Getahun keeps reminding me, “rural people are very, very strong. And very, very religious.” Local Priests, or Soul Fathers, as they are called here, are the first ones called upon when a family has a need. They are trusted confidantes and respected advisors. And they invest long-term in the areas where they are based.

The clinic in Jandeb stands ready to serve, but the connection to the community may be hard to maintain with the high turnover of staff. In such remote locations, I believe it is even more important to connect quality health care to that which is permanent and trusted in the community. SCOPE trains Health Development Army members and Priests to work together to seek out pregnant women and provide advice and support, bridging their way to the health center. The people who live in rural areas are truly very strong. And they deserve to have a strong connection to, and strong trust in, the health care services that may mean the difference between life and death.

The SCOPE team completed three assessments in Belessa on that trip, though several more remote clinics still need to be visited. We’ll be back to Belessa soon, along with nearly every other Woreda in the North Gondar zone- no matter how remote.

PRIEST INTERVIEWS: BREASTFEEDING AND FASTING

For the past few weeks I have been working on a side project unrelated to the FLAME study. I am gathering information on breastfeeding knowledge and practices in Ethiopia, specifically the intersection between breastfeeding and religious fasting. To gather this knowledge, I am interviewing priests and midwives in the North Gondar Zone. This week I completed my interviews with priests and would like to share my experience and initial thoughts with you.

Religious fasting is an integral component of the Ethiopian Orthodox tradition and plays a vital role in Ethiopian culture and daily life. There are over 200 fasting days per year, including every Wednesday and Friday, where Christians abstain from meat and all animal products, and do not consume food or drink before lunch. In a city like Gondar where nearly 85% of the population belongs to the Ethiopian Orthodox Church, fasting is commonplace and integrated into the Gondarian culture.

Most of our friends and colleagues participate in religious fasting, and Elizabeth and I are often impressed by their commitment and strength. On multiple occasions we have departed from Gondar early in the morning to complete facility assessments, working in the heat of the lowlands gathering data for the FLAME study. Sweat dripping down our faces and backs, sometimes walking long distances, and our fellow data collectors will not consume any water or food until we return to Gondar in the afternoon. Never a single complaint; fasting is a part of their life and helps foster a deeper connection with God.

There are many reasons for why Ethiopian Orthodox Christians participate in religious fasting. Some of the primary reasons include: fasting is an order from God, fasting is an act of confession for your sins, fasting will bring you closer to God, fasting is an act of prayer, and fasting will encourage you to empathize with the poor and hungry. I admire Gondarians’ commitment to fasting and think it is really special that the entire Christian community practices religious fasting together on a weekly basis. I believe this ritual of fasting helps foster a deep sense of community.

Given this context and the integral role religion plays in Ethiopians’ lives, we wanted to investigate the relationship between religious fasting and breastfeeding – What does the Church teach about fasting for pregnant and lactating women? Do pregnant and lactating women participate in religious fasting? Why do women participate in religious fasting? Do priests feel comfortable discussing breastfeeding and nutrition with women? Etc.

I interviewed three priests in the Gondar community with the help of my colleague, Adino. Each interview was unique in its own way, and I feel incredibly honored to have had the opportunity to engage with respected, religious leaders in the community. The interviews were enlightening for me – I not only gained insight into fasting practices of women, but also learned a lot about the Ethiopian Orthodox tradition. The following three anecdotes share a bit about each interview, including what I learned and how the interaction influenced me.

My first interview was with Memhir Tsigemariam Tibebu, a priest from a Church located about 15 minutes walk from our office at the University. Memhir is a dynamic individual, very thorough and engaging in all his responses. As my first interview on fasting and breastfeeding, this discussion had an element of the ‘wow factor’ for me. I learned that all pregnant and lactating women participate in religious fasting. Only if a woman is feeling seriously ill will she forgo fasting. Even then, after recovering from her illness, she will speak with her Soul Father about how to compensate for the days she did not fast. Additionally, fasting is not simply a regulation of the Church; women genuinely desire to fast. Even if advised otherwise, pregnant and lactating women prefer to fast for it helps them feel spiritually connected to God and ensure that God will look over the health of her body and her child.

Adino and Memhir Tsigemariam Tibebu post-interview

My second interview was with Abune Elsa, the Archbishop of the North Gondar Diocese. It was an honor to meet the Archbishop and having his opinions on breastfeeding and fasting practices is valuable for SCOPE’s work. As a highly respected religious leader in the community, he is the true definition of a key informant! While conducting the interview was informative, the highlight of this encounter was merely spending time with Abune Elsa and basking in his presence and knowledge. Nearly 85% of Gondar looks up to Abune Elsa as a religious leader, but very few get the opportunity to personally meet him. This was a truly unique and special experience for both Adino and me. Abune Elsa seemed very pleased to spend the afternoon chatting with us; and after completing the interview we discussed a variety of topics, including American politics, the Church, and SCOPE’s work. After the meeting, Adino and I walked away feeling lucky and honored to have spent the afternoon with Abune Elsa. Adino said to me, “I would love to listen to Abune Elsa all day and all night if I could. I wish you could’ve heard his words in Amharic; my translation just doesn’t do it justice.”

Unfortunately, I did not take a photo during our visit but here is a photo of Adino and Abune Elsa from April 2017.

My third and final interview was with Kesis Tsega. One of our interview questions ask the priest to elaborate on his role as it pertains to the physical health and wellbeing of women, particularly whether the priest feels comfortable discussing breastfeeding and fasting practices with women. Kesis Tsega responded saying that of course he feels comfortable talking to women about breastfeeding and nutrition. He then elaborated on this statement with a metaphor that resonated with me. He said, “We priests are like farmers for our parishioners. This is our farm. We care for our parishioners the way farmers care for their land – make sure they are well fed, have water, and are cared for.” He feels it is his responsibility as a Soul Father to ensure his soul children are healthy. As such, discussing and advising pregnant women on breastfeeding and nutrition is his duty. Furthermore, women actively seek advice from their Soul Father when they have concerns with their physical health or family life. Kesis Tsega often converses with women about sensitive topics; he enjoys helping them, providing his advice and managing their problems. This is a perfect example of the integral role priests play in parishioners’ lives and the power of leveraging that influence to improve health outcomes.

Kesis Tsega and me post-interview

I hope these anecdotes shed light onto the fasting practices of pregnant and breastfeeding women. I feel honored to have had the opportunity to engage with religious leaders in the community and will forever remember this experience. Each priest was a pleasure to spend time with; they welcomed me into their holy space and took a genuine interest in my life and my learning. You could sense their desire to share their wisdom and knowledge with me.

After completing the final interview, Adino and I took a minibus taxi back to the University together. We discussed key findings from the three interviews and I shared with him how much I enjoyed our interactions with the priests over the past week. I told Adino that I was impressed by the wonderful sense of community I observed. I particularly loved witnessing the interaction between the priests and Adino, a deacon of the Ethiopian Orthodox Church. You could honestly feel the mutual camaraderie and respect they have for one another. Adino responded to my impression, saying that Gondar is a truly special place for the Church and that the Ethiopian Orthodox community here is unique.

** These interviews are separate from the FLAME study and not formal research. Information obtained from these interviews will be used internally to inform SCOPE’s future work.

SEEING SCOPE THROUGH NEW EYES

A few weeks ago, a group of seven SCOPE board members and supporters made the exhausting, two-day journey from Seattle to Gondar, to see where SCOPE has been working and to plan for the future. Hearing their first impressions and seeing their curiosity and wonder at meeting local health outreach and religious workers reminded me of just how special SCOPE is.

The group had barely gotten over their jet lag when I joined them in a minibus headed out of the city. Within minutes, the cars thinned and animals took over the road. I had long grown used to the rhythm of weaving and dodging; of the car swerving to avoid the ever-present sheep, cows and other livestock standing, staring at the sparse oncoming traffic. The visiting SCOPE team, however, were taken aback.

A typical traffic jam in the roads outside of Gondar

“Who is watching these animals?” They asked, laughing as the driver slammed on the brakes again to avoid an obstinate mule. From time to time a child would run out from the bushes beside the road, waving a stick furiously at the lazy livestock.

After 45 minutes of dodging animals and their keepers, we arrived at Ayemba Health Center, just off the main road past a field of yellow wildflowers and a dirt soccer field filled with squealing primary school students. SCOPE led a successful program at Ayemba, training community health workers and priests to work together to support pregnant women and encourage them to get prenatal care and deliver with a midwife. The clinic head was happy to see us and proudly showed us around. We toured the simple delivery room, sparse but well supplied, and smelling of diluted chlorine. The team explored the simple waiting area, which SCOPE helpedestablish, and chatted with the midwives.

Rahel, a midwife at Ayemba, accepts some SCOPE onesies

Soon we were escorted away from the clinic, through the adjacent village, to a very special place- the home of Gebeyanesh. Gebeyanesh worked with SCOPE and, together with a local priest, visited pregnant women to encourage and educate them about getting safe delivery care.

The road to Gebeyanesh’s house was far too narrow and rocky for our minibus. As the team walked through the village, a mob of children followed us- chatting, giggling, and posing for pictures. The path wound through a market filled with women selling grain in the midday sun. Sheep and goats wandered in loose herds, and chickens scurried out of the way as our small group swelled with a small army of hangers-on, eager to keep a front seat to the strange parade moving through the town.

The SCOPE team enjoying an Ethiopian meal served by Gebeyanesh

Gebeyanesh’s house was cool and dark, a respite after the walk. A local priest and several women, all of whom had worked with SCOPE, were waiting to offer us a warm welcome. Gebeyanesh’s children solemnly wound around the group with pitchers of water for hand washing before our hostess served up platter after platter of delicious, homemadeinjera– the local grain cooked into a fermented flat bread. She filled and refilled the injera ‘plates’ with steaming spiced lentils and peppery potato stew. Just when we could eat no more, a simple dessert of fresh popcorn was passed around as the central event, the coffee ceremony, began.

Coffee ceremonies represent the pinnacle of Ethiopian hospitality, and we felt deeply honored sharing in the slow, methodical experience.

Gebeyanesh started with a small bag of dried, greenish beans, emptying them into a flat pan over a small charcoal stove. As she slowly stirred the beans, her small home filled with the woody, heavy scent of roasting coffee, mingling with the smoke from the charcoal burner, topped off with a handful of local incense.

Gebeyanesh preparing coffee, with a priest and other guests in the background

While she ground and brewed the beans by hand, the SCOPE team chatted with the other guests. We passed around copies of SCOPE’s annual report, which contained pictures of some of the women present, taken during previous SCOPE events and trainings. The women giggled and pointed out their friends in the illustrations, smiling as we explained how proud we were of their work to help their neighbors stay healthy. The priest offered a blessing- the Lord’s prayer- as we relaxed with tiny cup after cup of fresh, local coffee.

The local women inquired about a previous SCOPE fellow, Anna, with whom they had worked closely. They reminisced about what they had learned and asked to learn more.

Much of my work here with SCOPE has involved visiting and assessing institutions. It is important work. Yet after seeing many health centers in countless small towns, it was veering towards becoming routine. Seeing the Ayemba clinic and Gebeyanesh’s home through the eyes of the visiting team was a fitting antidote to this repetition. Their surprise at the basic setting in which maternity care was provided, and their wonder at the rough terrain of the villages surrounding the clinic reminded me that the challenges here are real- and are often life and death. The warmth of Gebeyanesh and all our hosts, with their slow but easy hospitality, reminded me of the importance of connection and cultural engagement. The respect in our hosts’ eyes for the priest with whom we shared a meal helped me to understand, again, why incorporating faith leaders here is so meaningful.

As we walked back through the village for the car that would return us to Gondar, one of the team members and I chatted. He shook his head and said “wow, you can see all of the pictures and statistics, but seeing the need and experiencing the culture for myself makes it come so alive…”.

Members of Gebeyanesh’s extended family joined us for the meal and coffee ceremony

Seeing it through the eyes of this wonderful, tough team helped it to come alive anew for me as well.

LALIBELA

I had the distinct pleasure of joining a group of SCOPE board members and supporters in Lalibela for the weekend. Both the company and the location were wonderful.

The Company

A group of 7 Seattle-based SCOPE board members and supporters visited Ethiopia for about 1.5 weeks. They spent the bulk of their time in Gondar, meeting with SCOPE employees and stakeholders, visiting SCOPE program sites and health centers, and enjoying the local culture. Afterwards, they traveled to the Simien Mountains and Lalibela. Unfortunately, I was in the United States for my sister’s wedding during their time in Gondar and Simien Mountains, but was thankfully able to join them in Lalibela.

These 7 individuals were a true joy to spend time with. I must admit, I was a bit nervous to meet them as I wanted to ‘impress’ SCOPE board members and worried I wouldn’t be my best self after traveling across the world for over 24 hours. However, within minutes of meeting them, I felt completely comfortable and at ease. Each and every one of them took a special interest in Elizabeth and me – not only asking questions about our work as fellows, but also making an effort to get to know us on a personal level. Over the course of the weekend, we had wonderful conversations about SCOPE, their families and children, our work experiences, and our future goals. I really enjoyed spending time with this team and am incredibly grateful for their support. I look forward to a reunion when Elizabeth and I return in December!

 The Location

Lalibela is truly a magical place! With incredible views and ancient rock-hewn Churches, there is plenty to explore and love. There were three distinct highlights to this weekend trip for me – the Hudad, the Churches, and the market.

The Hudad is a community based, ecologically sustainable lodge on top of a mountain. The lodge is only accessibly by mule or foot. As you will see in the pictures below we hired mules to carry us, and our belongings, to the top of the mountain. There were many young, local Ethiopians who joined our group, helping us stay balanced on the rocky trail. When we reached the top, we were greeted by a large group of monkeys! I was particularly fascinated by their behavior and enjoyed watching them interact with one another. In the evening, we sat around a fire and enjoyed a delicious meal. Prior to retiring to bed, the local staff performed a traditional ‘welcome’ ceremony, in which they washed all our feet with warm water – it was fantastic! We woke in the morning to clear blue skies and hot coffee. Surrounded by cliffs on all sides, the Hudad was a truly spectacular and memorable experience.

We returned from the Hudad and spent the afternoon and following morning exploring the ancient rock-hewn Churches. There are eleven monolithic cave Churches in Lalibela, all of which are equally impressive and beautiful. They were built during the reign of King Lalibela in the 12th century. There is a system of pathways and tunnels that link the Churches together, which adds an element of exploration to the visit. The Churches are rectangular in form and were built top-down into the rock, providing a safe space for Christians to pray that was hidden from invaders. Inside the Churches, the floor is covered with rug and the space lit by candlelight. Some Churches have ancient paintings on the wall of biblical scenes. As detailed, the architecture and historical significance of these Churches is fascinating; however, what I found most remarkable is that these Churches are still a place of worship today, nearly nine centuries later. The rock steps at the entrance to some of the Churches are so smooth you can tell they have been walked on for hundreds and hundreds of years.

Lastly, I want to highlight Elizabeth and my trip to the Lalibela market. From our hotel window, we could see the bustling market from afar and all the locals walking up a dirt path to reach it. We decided to take the same path, which dipped into the valley and then up a steep hill to the market. Arriving at the market, we were greeted by swarms of people selling grains and livestock. We wandered through the donkeys and goats to the shopping stalls, where we thoroughly enjoyed admiring the local textiles. The traditional clothing and scarves are made of white woven cotton infused with colorful designs – they are really beautiful!

Needless to say, I had a great time in Lalibela! The combination of beautiful scenery with wonderful travel companions made for a memorable weekend getaway. I hope the pictures below help illustrate our experience.

ON THE ROAD AGAIN

We visited six more rural health centers this week, assessing their capacity to provide maternity care and their ability to absorb more patients. The staff at these remote health centers always seem happy to have visitors, and are eager to chat and show us around.

Here are some highlights from our visits this week.

Elizabeth the Midwife:

At one health center, a bubbly, beaming midwife was particularly eager to chat. We bonded over our shared name- Elizabeth. Elizabeth has worked as a midwife for four years, and told me that she had always wanted to work in a profession where she could help mothers- and see a lot of babies! In a typical day, she may offer basic family planning advice or conduct prenatal exams, while always being on call for a delivery. I asked her what she considered to be the toughest part of her job, and she mentioned that many mothers are anemic from a poor diet. Elizabeth was passionate about encouraging mothers to eat a wide variety of foods during their pregnancy. She even had samples of six different types of local grains on her desk, to use as a visual aid. We explained to Elizabeth about SCOPE’s work in mobilizing community leaders and faith leaders to support and inform pregnant women. She agreed that community support is vital to making sure that mothers and babies are safe and healthy.

Elizabeth the midwife- posing with a colleague

The Muddy Walk:

On another day, SCOPE data collector Mehari and I were trying to access a very remote health center south of Gondar. After nearly turning back several times due to poor road conditions, our car finally stopped- it could go no further. Mehari and I hopped out to continue on foot. The path was extremely wet and muddy. I don’t mind mud and dirt- but it was clear that balancing in the slippery muck would be difficult. The community immediately mobilized to help us. A shepherd lent me his staff to help me balance, and several strong men formed a sort of human chain to help Mehari and me across the worst parts. After about forty-five minutes, we reached the health center and were able to conduct our assessment.

On the path to the health center

As we were looking at the health center’s delivery room, I wondered how laboring mothers- not to mention those experiencing complications- would possibly have been able to make that trek. We only had to walk about a half-mile in the mud. Many families lived 10 miles or more from the health center. Again, in places like these, harnessing the power of community support is critical; ensuring that the community understands the importance of prenatal visits to detect problems early, and that the community has a plan for getting laboring women to the health center before problems arise. At several health centers throughout the week, we encountered homemade stretchers; simple frames for carrying sick people and laboring women to the health center. Even very poor, remote communities can do simple things like make these stretchers to ensure women are supported (literally) when they need health care.

SCOPE data collector Mehari gathering information from a health center staff member

The Young Mother:

A day after our muddy walk, we continued in another direction, deep into a tropical valley to the West of Gondar. Though the health center we visited was large, like many others, staff there were working with basic tools and dealing with broken infrastructure. A sink in the delivery area was nonfunctional and covered in spiderwebs. “Where is the handwashing station?” I asked. Two buildings away. “Where is the soap?” There hadn’t been any for awhile. It was also clear that the services which were available weren’t being fully accessed. For instance, of the women who came for a first prenatal visit, only about 20% completed all four of the recommended check-ups.

While we were waiting for the midwife to finish with a patient, we chatted with a young mother waiting in line to get prenatal vitamins. Tatugirman was pregnant with her second child, and was still early along. Her mother had accompanied her to the health center for her first prenatal visit. I asked her if she thought the care she was getting that day was valuable. Her face lit up, “Oh yes! They screen for so many problems at these visits. I think a lot of women, especially rural women, don’t realize how important this is.”

Tatugirman’s mother came along to support her during her prenatal care visit

We thanked Tatugirman and the Health Center staff and hit the road again. In all, the SCOPE/FLAME team is visiting thirty rural health centers this Summer. Next week will surely bring more adventures, fascinating conversations, and insights.

I RECEIVED PERMISSION FROM ELIZABETH, TATUGIRMAN, AND EVERYONE ELSE PICTURED TO USE THEIR IMAGE, NAME, AND/OR STORY

ADINO IN AMERICA!

Our dear friend and colleague, Adino, is off to America! He has been accepted to an intensive two-week Implementation Science course at the University of Washington in Seattle. The course will cover methods of improving global health implementation, including applied engineering, management tools, health systems, and policy research. We are excited for the skills and knowledge he will obtain; they will undoubtedly be useful for both his career development and SCOPE’s program implementation.

Adino grew up in Debark, a town located in northern Ethiopia, just 90 kilometers from Gondar. After completing high school, Adino enrolled in university, where he trained to become a public health officer. He graduated with the skills required to manage common clinical disorders and prevent public health issues in primary healthcare settings. After graduation, he was appointed to work as a health officer at a rural health center in Weynema for about ~ 1 year. Upon completion of his appointment, he returned to the University of Gondar to obtain his Masters in Epidemiology and Biostatistics. He is now a professor at the University and enjoys mentoring aspiring epidemiology and biostatistics students. Additionally, he is the project manager of SCOPE’s FLAME study.

As you can see, Adino is an accomplished global health professional with a wide range of skills and experiences. In addition to his qualifications, he is a charismatic individual and a true joy to be around. He was the first person Elizabeth and I met in Ethiopia, patiently waiting for us outside the Gondar airport gates. Adino always goes above and beyond to make sure we feel comfortable – helping us move in, giving us a tour of the Gondar castles, taking us to lunch, and always making us laugh at the office.

This will be his first time traveling outside Ethiopia and we hope America gives him a warm welcome! Bon voyage, Adino!

A WINDOW INTO RURAL MATERNITY CARE

This morning, the SCOPE team hit the road!

A team of data collectors from the University of Gondar joined Sheldon and me as we set out to visit and assess health centers in the rural areas near Gondar. The FLAME study, which is the research arm of SCOPE, is visiting 30 health centers to assess their current capacity for maternity care. Of those 30, many will be selected as sites for an upcoming project from the SCOPE team- training local priests and pairing them with health educators to encourage women to give birth in the safest way possible.

Early in the morning, we left the bustling city of Gondar, and headed out into the green hills to the north. The landscape was surprisingly rugged, with terraced fields hugging the sides of the endless steep slopes.

The hills north of Gondar

Ethiopian health centers typically consist of several simple concrete buildings, with open waiting areas in between. Most are run by a ‘health officer’- a clinician with three or four years of training, who is able to treat most common illnesses and refer more complex cases to doctors at regional hospitals. The health officer works with a team of nurses, midwives, and sometimes lab or pharmacy technicians.

Each of the health centers that we visited today served an area of about 35,000 people. Though they both had electricity, the facilities were basic. At one center, the local greenery was encroaching on the maternity clinic hall!

The recent rain has caused greenery to abound- here inches from the door to a maternity room

One of my jobs here is to assess for the presence of certain important supplies in the maternity areas. It was clear upon seeing the first space that the midwives were working with basic tools. Used instruments were rinsed in successive buckets and autoclaved. Plastic instruments such as suction catheters, which would have been considered disposable in the US, were being carefully cleaned for reuse. If the labor did not go as planned, the health officer advised us that an ambulance could take up to five hours to arrive. In the meantime, the midwives had limited options to stabilize patients with complications. The health centers were unable to perform cesarean sections, blood transfusions, or forcep assisted delivery.

At the second health center that we visited, the door to the delivery room was closed. The midwife was assisting a laboring woman inside as her excited family waited outside.

The door to the delivery room- inside, a mother was in labor, assisted by a midwife working with basic supplies

We introduced ourselves to the family members waiting patiently outside the delivery room- I recognized the joy tinged with worry that is universal among loved ones waiting to hear if a baby has arrived safely, especially in a basic environment such as this.

Family members wait for news about the birth

While waiting, the family was repeating an hourly ritual of making coffee from scratch. Coffee ceremonies are central to Ethiopian culture, and the family explained that they wanted to surround the laboring mother with the feeling of home- including the smell of fresh roasted coffee beans. As finished our assessment and left, the mother was still laboring and the family was still anxiously waiting.

As we headed back to Gondar, I thought about what I would do if I was working in a facility like this when an obstetrical emergency arose. Prenatal care is essential to screen for women who may be at a higher risk for complications during childbirth.  Yet many women in rural Ethiopia do not complete the recommended four prenatal visits. They often give birth at home with only relatives assisting, using the health center only as a backup if problems arise. Unfortunately, when women arrive at the health center with emergencies, their needs may already be beyond the basic capacity of the health center staff, and it may be too late to send for help.

It was clear how important it was to make sure women know to come to the health center throughout their pregnancy, and to make sure that women feel comfortable and supported by their community, including their faith leader, when accessing health care.

As the sign on the delivery room door boldly says- no mother (or baby) should die while giving birth!

AYMBA HEALTH CENTER VISIT

Last week, Elizabeth, Adino, and I had the pleasure of visiting one of SCOPE’s sites – Aymba Health Center. We took local minibus transport to Aymba village center, which is located about 40km outside of Gondar. We then walked across the river to the Aymba health center. Many children were bathing, swimming, and playing in the river water; it looked like a very ideal backyard!

SCOPE has implemented the Beruh Tesfa program at Aymba health center for the past ~1.5 years. To provide some context, the Beruh Tesfa program pairs Ethiopian Orthodox priests with members of the Health Development Army. These pairs are educated about the importance of prenatal care and supports them in conducting outreach to pregnant women, encouraging these women to access available antenatal care (ANC) and to deliver in the health facility. The Beruh Tesfa program has shown a significant increase in the number of women accessing antenatal care. Given this success, SCOPE would like to expand the program to rural health centers and assess its efficacy in rural settings. This expansion project will be implemented in a randomized control trial, so that we can accurately assess its impact on the community. This project is called FLAME (Faith Leaders Advocating for Maternal Empowerment) and is the primary focus of our fellowship. While Elizabeth and I will not be in Ethiopia for the implementation of the FLAME randomized control trial, we are currently assisting with baseline data collection, which will be used to inform the design and implementation of the program. I hope this provides you with some context and helps you understand the nature and importance of our work as SCOPE fellows.

During our visit to Aymba, we had the pleasure of meeting with and interviewing a member of the HDA and a woman who benefited from SCOPE’s community outreach. Both women were incredibly communicative and approachable, willing to answer any questions we had for them. It was inspiring to hear their stories and how SCOPE’s Beruh Tesfa program has impacted their lives. The women are pictured below with brief descriptions of their background and interview comments.

Gebeyanesh

Gebeyanesh is currently a member of the HDA and has been working in the Aymba community since 1994. She has been a member of the HDA for the past 12 years, providing health services and assisting health campaigns. Her favorite thing about being a member of the HDA is supporting pregnant women and ensuring they receive the support they need. When asked why women do not go to the health center during pregnancy, she said that the primary reason is cultural beliefs. However, thanks to SCOPE’s advocacy efforts, more women in Aymba are willing to visit the health center now.

Gebeyanesh is very grateful for SCOPE’s support and program activities. She says her community has suffered from maternal deaths for many years leaving children without a mother, including her aunt who died 4 days after giving birth. She hopes the SCOPE program continues and expands.

Tigist

Tigist is a mother who benefited from SCOPE’s outreach efforts. When she was 3 months pregnant with her third child, a trained SCOPE pair (member of HDA and a priest) confronted her at her home. They encouraged her to receive antenatal care (ANC) and continued to support her throughout her pregnancy. Tigist received ANC and delivered her child 40 days ago at the Aymba health center. She brought her baby with her to the interview; he was quietly sleeping on her back.

Tigist expressed her gratitude for SCOPE’s outreach and the advice she received from the HDA member and priest. Unfortunately, Tigist got a severe kidney infection while giving birth. Thankfully she was delivering at the Aymba health center, where she received the treatment she needed and recovered quickly. She said she would have been critically ill without this medical treatment and support.

AN EDUCATIONAL VISIT TO THE HOSPITAL

This week has been a bit slower around the SCOPE office for Sheldon and me, so we are taking the opportunity to see and learn more about the Ethiopian healthcare system.

The SCOPE intervention is all about prevention- trying to both prevent problems that might require urgent care, and also trying to make sure that health issues are taken care of before they become emergencies.

Shortly after we arrived, we had a very illuminating conversation with one of the members of the SCOPE board, Dr. Shitaye, who warned us that many people avoid the health care system until their problems are extreme. Sadly, this means that many diseases such as cancer and heart problems are not diagnosed until they are terminal.

I kept this in mind as Sheldon and I were provided with the tremendous opportunity yesterday to shadow the emergency room team at the University of Gondar Hospital. This was particularly meaningful for me- many years ago I did a nursing school rotation in Seattle’s own Harborview Emergency Department. I was eager to see how the staff in Gondar’s ER worked with considerably less space and fewer supplies.

The emergency room is divided into zones- red for the most critical patients, then orange, yellow and green. All of the rooms in the emergency department are painted with wide, colored stripes around the walls- a constant reminder of how sick the patients are in that room. The rooms are large and open, each holding about a dozen patients. We started in the red room, what would be considered critical care or the resuscitation bay in the US.

The physicians and residents were very systematic, reviewing each patient’s history, physical exam, labs, etc. But I was immediately reminded of Dr. Shitaye’s words- many of these patients appeared to have had little treatment prior to ending up here in the ER in critical condition. Several patients had been diagnosed that day with serious, likely terminal conditions such as cancer with metastases and kidney failure requiring long-term dialysis. It was clear that most of these patients also hailed from very rural areas- places where even very basic medical care may be many miles’ walk away.

I left the Emergency Department very impressed with the work ethic and thoroughness of the physicians working and training there. But it also reinforced in my mind the great need to focus on prevention and care at the local health center level. Travelling to a city center such as Gondar must represent an enormous effort and expense for many of these families. An accessible, culturally integrated health center, supported by local institutions such as the Ethiopian Orthodox Church, has the potential to address many of these issues before they need high levels of care.

I am looking forward to beginning the rural Health Center visits in the next days and weeks. Having seen the urban teaching hospital in Gondar, I am eager to complete my “picture” of the health care system here. And ultimately, I am eager to contribute to the prevention work that I believe is so very important.

GORGORA: A LITTLE PIECE OF PARADISE

This past weekend Elizabeth and I went on our first adventure outside Gondar to a village called Gorgora. Gorgora is located south of Gondar on the north shore of Lake Tana. It was a lovely weekend getaway and I wanted to share a glimpse of our experience with you.

We left the guesthouse bright and early on Saturday morning to get to the bus station by 5:30a. When we arrived at the bus station, it was dark and many people were standing outside the bus station’s gates waiting for them to open. When they eventually opened, everyone hurried into the station to find their bus. Elizabeth and I wandered about asking for ‘Gorgora’ and within minutes, we found the right minibus. We boarded the minibus and waited about an hour until the bus driver deemed the minibus ‘full’ and ready to depart for Gorgora. After a brief pit stop to fill the car’s tires with air, we were off!

At ~6:30a on a Saturday, most of Gondar is still sleeping and all the tuck shops are closed and roads empty. We quickly made our way through the city and out into the countryside. The drive was absolutely beautiful – very green, with rolling hills, farmland, and cattle. I enjoyed passing through the various villages along the way, watching women make coffee, children playing soccer in the street, and groups of older boys all huddled around a foosball table. It was nice to see the rural landscape and get a sense for the lifestyle in the surrounding villages.

Apparently the road to Gorgora was completed last year, so the drive only took about 1.5 hours. The paved road literally ends when you arrive in Gorgora and approach the lake. Elizabeth and I hopped out of the minibus and asked around for the location of our accommodation – Tim and Kim’s Lodge. A friendly local accompanied us on a 10-15 minute walk to the lodge, which is nestled on a hill with wonderful views of Lake Tana.

Elizabeth and I spent the next day and a half in awe of Gorgora – beautiful views, warm weather, and good company. We read books, laid on the rocks basking in the sun, went swimming, played board games, ate delicious food, and conversed with the other guests. It was very peaceful and relaxing!

On Sunday morning, I decided to go on a walk to explore the village and surrounding areas. When I approached the main village road, I could hear singing and music. I knew our fellow study coordinator, Adino, was in Gorgora for the weekend attending one of his friend’s weddings. I assumed the music was coming from the wedding and followed the dirt road until I reached the Church (and Adino!). When I arrived, the wedding guests and bride and groom were in a procession from the Church to the reception at a nearby hotel. I briefly said hello to Adino and then ventured to the Debre Sina Maryam Church, which was truly stunning and worth the visit. It was built in the 1600s and is located right on the shore of Lake Tana. The Church is still covered by a thatched roof, which gives it an impressive, ancient feel.

On Sunday afternoon, Elizabeth and I decided to return to Gondar. We again walked to the main road, where we waited about 10-15 minutes for a minibus to arrive. We piled into the minibus and returned to Gondar, picking up various passengers at villages along the way. It’s impressive (and somewhat concerning) how many people can be squeezed into one minibus.

When we arrived in Gondar, Elizabeth and I joked about how urban the city felt after spending 2 days in the countryside. A city we normally describe as very manageable and peaceful, seemed to be bustling with people, cars, shops, etc.! It’s funny how easily you can get accustomed to new scenery.

A DAY IN THE LIFE OF A SCOPE FELLOW

Elizabeth here- Sheldon and I have now been in Gondar for about a month, and we are settling into a steady work routine. This is a typical day:

In the morning, Sheldon and I wake up to energetic birdsong right outside our windows. The guesthouse where we live is peaceful in the mornings- with shade from the tall trees and quiet beauty before we head out the front gate and into the bustling neighborhood.

We can make a simple breakfast in our little kitchen, or go out, down the street and around the corner, for our beloved foul, the spiced fava bean mash on bread that always hits the spot.

After breakfast, we head to Dr. Getahun’s office at the University of Gondar, where we settle in for the days’ work. Right now, I am working closely with the FLAME project manager, Adino (FLAME is the research study run by SCOPE). Over the coming weeks and months, Adino and I will be personally visiting and assessing dozens of rural Health Centers, many of which will be included in the latest SCOPE/FLAME project. Some of the Health Centers are very remote, and we want to make sure our survey tools are well prepared and precise so the visits can be effective.

Adino and I preparing for the upcoming rural health center visits

When we break for lunch, Sheldon and I usually head to a small café a few minutes from campus. The café is usually packed with Ethiopian medical students, chatting and eating injera with delicious stews and sauces. Fortunately for us, the café has an espresso machine and a pool table too!

After work finishes in the afternoon, we walk back to the guest house, often stopping to pick up fresh mangoes or eggs from the market. If we are in the mood for a longer walk, there is an alternate route that offers spectacular views of the city.

Gondar is hilly- and particularly green this time of year

When we have electricity, we can cook on our little two-burner stove. Our latest efforts have included pasta with vegetables, rice with shiro sauce, and eggs (every way you can imagine!). I carve out time at least once a week to wash my clothes by hand, which I find very meditative. I got used to washing my clothes by hand several years ago when I was in the Peace Corps- but there I had to haul my water from a well, whereas here we have running water. The spigot in the outdoor washing station feels downright posh!

Washing clothes by hand

It gets dark at about seven, and Sheldon and I may spend our evenings catching up on work projects, watching a DVD, of just enjoying a good book. I try to do a bit of knitting or crocheting every day, much to the delight of just about any Ethiopian friend or co-worker who catches a glimpse. Several people have told me that my crocheting skills would make me quite sought after here as an Ethiopian housewife!

I go to sleep looking forward to what the next day may bring. Every day brings some sort of new adventure, whether it be greeting a wide-eyed child in Amharic, or searching the market to find a needed spice or kitchen tool. I love the pace of life in Africa and am happy that I can be here using my skills for SCOPE.