That’s what this entire week felt like, over and over: A leap of faith. While at the hospital on Monday, on the up-swing of my Ethiopian virus (Gunfan), Yilkal told me this would be the best week to travel to the capital to complete my seemingly endless paperwork. The goal of which would be to establish a bank account with the Bank of Ethiopia so the government could pay me for working here. But, in order to do that, various branches of government would need to agree on my role and position here in Ethiopia.
This post will speak about my experiences in the Ethiopian capital city this week and feature mostly my observations and opinions. There will be virtually no medical-related things. I’ll understand if you want to skip this one. However, if you want to experience what it feels like to be in Addis for the first time, read on my friend.
Now I hadn’t mentioned it before, but in the previous 3 weeks, we have made numerous trips to Mekelle university to fill out conflicting forms and to present original documentation that no one actually seemed to care about. I had Allie (from the IMR trip last week) bring my original diplomas from medical school, residency, fellowship and my board exam letters of certification. My mom handed her the documents when she passed through DC on her way to Ethiopia. Truly priceless pieces of paper representing a decade of sweat, tears and hundreds of thousands of dollars. So now, original documents and the blessing of Mekelle University in hand, Yilkal and I would venture to Addis Ababa and visit the Ministry of Health, the Ministry of Education, the Ministry of Labor, AND the Ministry of Immigration in an endless merry-go-round of bureaucracy.
Because I expected this week to be as dry as it sounds, I was going to skip a blog entry… but, of course, I was wrong and what should have been simple and boring turned into a gigantic leap of faith.
Tuesday was selected for the day of departure because it was a Muslim holiday and the clinic was closed and no surgeries scheduled. Additionally, this week was Ashenda, an Ethiopian celebration of women that centered in Mekelle. Although the clinics would be open, not many would show up and our big surgery for Thursday called to tell us he wouldn’t make it in for similar reasons.
I went to sleep Monday night febrile and the anterior rhinorrhea turned to max. Because I didn’t have to work, I slept in about 5 mins, awoken by the habitual loud hammering in the various construction sites around our house. My head pounded, my sinuses felt like they were somehow filled with pressurized liquid overnight, and my eyes ached. I popped 600mg of ibuprophen, chugged some water and retrieved a special concoction Yilkal’s maids had made for me the day before: a mixture of tea, honey, lemon and a splash of Ethiopia ouzo. I plopped down on the common room couch (I was alone, my roomies were out of town and Elisa was at her NGO) and started my “El Chapo” marathon I had downloaded before coming to Ethiopia. Slowly, as the ouzo and NSAIDs kicked in my strength returned and I cleaned up around the house before my departure. Before leaving, I had lunch with Yilkal and his family and the semi-familiar flight to Addis was uneventful.
There, Yilkal’s old medical school friend, now pediatric ophthalmologist picked us from the airport. With quick stops at Yilkal’s aunt’s place to drop off his bag and to my hotel to drop off mine, we ventured to the center of city (Bole) to their favorite traditional place. Although my fevers had returned and I was tired, we enjoyed delicious food and good conversation. They returned me to my hotel for the night, at which time I appreciated that the neon sign at the top featured a malfunctioning “B” and “L”. So, what was supposed to portray “Blue Birds,” instead read “ue Birds.” It made me smile, but despite this, the hotel which was a suggestion of Dr. Nega (one of the most senior ENTs in the country and someone I’d have the honor of meeting my last night in Addis) provided more than I could’ve hoped for.
Staggering up 3 flights of stairs I felt an acute shortness of breath and could feel my increased work of breathing. I knew Addis had a higher elevation, but this was much more likely the evolution of my virus. Once successfully in my room, sitting to allow my heart to catch up with my ventilation mismatch, I noticed that my suitcase’s handle had fractured and the mechanism held within, disabled. In that moment, I didn’t have the energy to care, popped two Nyquil and went to sleep.
The next morning it was clear my URI had converted to a LRI (upper to lower respiratory infection) and I awoke with a painful, wet cough. Dreading the cold shower ahead, I noticed the letter “H” on the shower handle. In a moment of excitement, I cranked the handle clockwise towards that letter I never thought I’d be so happy to see and opened the faucet. Within seconds, I was forced to retract my hand from the water. It was HOT…too hot in fact. I found a happy medium and jumped in. Theres no describing this sensation and although it had only been 4 weeks of cold showers, a hot shower was a luxury I have always taken for granted. Before I had enough time to feel stupid about being so happy in this moment, the steam induced an aggressive coughing fit productive of a giant mucous plug. I could immediately feel my alveoli expand in relief and I imagined each one gleefully releasing their trapped CO2 and inviting in the fresh O2 (or at least 21% O2). My heart slowed as I took several recruiting breaths. I was at peace in this moment.
Yilkal picked me up at 8am in a car he borrowed from someone (I didn’t ask). We ventured from my hotel toward the first governmental building.
We arrived at a branch of the Ministry of Health. The plan was semi-simple: Prove that I’m actually a doctor to the Ministry of Health and Ministry of Education, so they can write letters to the Ministry of Labor and the Ministry of Immigration, so that I can buy a resident permit which will allow me to get a letter to the Bank Of Ethiopia, so that I can open a bank account and the government can pay me for the work I’m doing here. I had come armed with near 30 pre-filled forms, stamped by Mekelle University, all with 2×2 photos of me, fingerprints and signatures. On top of that, I had my passport, copies of my passport, redundant 2×2 photos and plenty of $USD. I was ready for any bureaucratic bullshit they could throw at me.
I couldn’t have been more wrong. There was a sign written in Amharic on the door that Yilkal paused to read. I’ve spent enough time with him that I can read his facial expression now. This wasn’t a good sign. We spoke to about 6 different people in the building each directing us to another with the eventual conclusion that the department that is supposed to approve my physician credentials currently does not exist… and may not exist for at least a week.
Thus, without approval from the Ministry of Health, none of the other ministries would process my paperwork and nothing could be accomplished. The realization that the both of us took off from work and each paid 100 USD for nothing began to set it. I looked to Yilkal for answers, but he had none.
We staggered back into the car and headed toward the main office of the Ministry of Education to see if we could salvage something from the trip. Sitting down into the passenger seat, the fever’s grip on my mentation tightened forcing me to roll down the window in an attempt to feel comfortable. Instead of being greeted by crisp rainy-season air, my eyelashes became indebted with dust and gasoline soaked atmosphere. My nose, aided by the still-present copious rhinorrhea gathered the particles in such a high concentration that I could smell them through my edematous nasal mucosa. Diverting to open mouth breathing, my cough reflex was hyperactively triggered by whatever other caustic material was in the air. Without the aid of traffic laws or lights, our car nauseatingly weaved in and out, started and stopped, as we dogged various sorts of competing vehicles. That’s really what it felt and looked like: Driving was a competition to get to your destination and you felt lucky if you arrived.
Once at the Ministry of Education we navigated our way to the office we needed to be in. The government official wasn’t there. Where is he? In a meeting. When will be out? Tuesday. What?!
During a long conversation Yilkal had with the secretary I readied my paperwork to leave behind in a hopes some appropriate official would sign it in my absence. We packed up again, truly realizing that we have failed our mission and headed outside. The reality, it turns out, is since the new Prime Minister was elected, he has been actively flipping the government from the inside out. In an attempt to minimize redundancy, eliminate waste and snuff out corruption, entire departments were folding and those left were in laborious meetings to figure out how to restructure and survive. Since the only reason I was in this office at this moment was to obtain legitimacy for my desire to improve medical care in Mekelle, how could I get upset at the Prime Minister trying to do the same for his entire country. I was tired, sick, irritated and felt completely out of place, but I understood why my first exposure to Ethiopian bureaucracy was going to fail.
Defeated, Yilkal made the decision to make the best of a shitty situation and go to St. Paul Hospital to visit his cousin who’s child was having a tonsillectomy. Before a quick trip to the other side of town (it actually took an hour to go maybe 5 miles), he called the medical director of Ayder to see if he could intervene with the government on our behalf. He said he would try and get back to us. St. Paul, it turns out, has this 5 story tower off the main campus that houses the OPDs for Derm, Ophthal, OMFS and Otolaryngology including an OR on the 3rd floor completely separate from the main hospital. This allows Otolaryngology to have 4 full days in the OR compared to our 3 in Mekelle. Yilkal was able to get me in for a tour of this 3rd floor which, with the area the size of 4 rooms, they were able to fit in a pre-op area, 2 ORS, locker rooms (which doubled as a kitchen), a conference room and a 6 bed PACU. Featured in the PACU, at this moment, were 3 unfortunate adults with various head and neck bandages and one with an Ex-fix of his arm and mandibular wires (car accident victim, I assumed) and Yilkal’s little cousin s/p tonsillectomy. We said hello and I took stock of the surroundings. It looked like a beautiful place to operate and I hoped I’d have the opportunity to do so in the future. We said our good-lucks and left everyone to recover. We were to meet with the Chair of St. Paul’s Otolaryngology department and a local hospital’s Otolaryngologist for lunch.
During lunch, I learned a lot about the atmosphere of head and neck surgery in Ethiopia. Allow me to attempt to explain. Although there are a few private clinics and hospitals in the capital, all of the complicated academic medicine is divided between Black Lion Hospital and St. Paul Hospital. Black Lion has had a residency for a while now and was producing Ethiopia’s own Otolaryngologists and St. Paul is close to graduating it’s first class next year. With Ayder making the third and final training program, the countries entire allocation of residents will be divided among these three institutions. Ayder will graduate its first Otolaryngologist in 2020. However, because of some odd “fluke of paperwork,” Black Lion received 10 residents last year and rumor has it that they will receive none this year. This leaves 3 slots in St. Paul and 3 slots in Ayder (which would make a total of 11 residents at Ayder). Yilkal tells me that somewhere between 400 and 600 students will apply for these 6 positions this year. Although this is a new field of study here in Ethiopia, it’s just as competitive as in the States. It’s my goal to help turn Mekelle into the elite program it has all the potential to be.
Anyways, after lunch We decided to go see a movie in the theater. The Negotiator 2. It was strangely reminiscent of watching Harry Potter 10 years ago in a theater in Botswanna when I was developing pneumonia. I thought I had progressed a lot in my life over the last 10 years, but I guess not. In that moment, it felt all the same. Afterwards, Yilkal brought me to the iconic “American” restaurant that I will let the video speak for itself. We had a great meal and I retired for much needed sleep.
Sorry, I know its sideways….tilt your head!
I awoke the next morning with the sensation of a weight on my chest and in a pool of sweat. I couldn’t move from bed. Not 10 mins later, Yilkal called to say that we had some success accessing members of the Ministry of Health and that they wanted to meet with me now. I pulled myself out of bed, took another hot shower productive of large, thick mucous plugs. I choked down a piece of bread and Buna and met Yilkal downstairs. The drive I can’t recall other than struggling to absorb as much cool air as I could. We arrive and find out that his office is on the 5th floor. I make it up one flight before I actually have to stop to catch my breath. I wasn’t really sure what it felt to be hypoxic until that moment.
This meeting was encouraging, the government employee is supportive of my efforts (he actually calls me a “crazy american doctor” for wanting to practice in Mekelle for a year). He promises that he will personally see to the signing of the medical license and will make sure that the appropriate paperwork is sent to the correct places. He seems genuine and this is better than nothing so I didn’t argue. By the end of this meeting, I’m really struggling. I ask Yilkal to take me back to the hotel so I can sleep and hopefully improve. He was extra nice to find the Ethiopian version of Nyquil which I took and fell asleep for the rest of the day.
I awoke around 5pm with the fever gone. I took a warm shower to allow my chest to open up again and we made plans to meet with Dr. Nega (the senior ENT I mentioned before) for dinner. We went to his favorite place, which was a greek restaurant and he handed me the Ethiopian fix for Gunfan (the common cold); tea with Ethiopian Ouzo my new favorite beverage. He was a pleasant man and we had a nice dinner. I immediately went to bed again after dinner and the next morning, I was again feeling slightly better.
Now, without telling me, Yilkal went back to the Ministry of Education to see if any progress had been made. Well, surprise surprise, the papers we had left had mysteriously been signed. Armed with this precious paperwork, we made a bunch of calls to the other Ministries and convinced someone to meet us. Against my better judgement, we traveled to a random block in Addis (as pictured), parked the car and met a very nice lady who claimed to be a government official. She was able to list what she needed from me, so I begrudgingly handed over my hard-earned paperwork AND my original diplomas. This was a hard thing to do (and another leap of faith), but I know I could always buy these again if she somehow lost them. Look, I know this was stupid, but I honestly wasn’t thinking 100% clearly and I trusted Yilkal and he was confident that this was the correct thing to do.
After that sketchy meeting, we celebrated with a delicious lunch. A lunch that took slightly too long. Our plan before going to the airport was: 1. Get Yilkal’s bag from his home 2. Buy formula for his baby at home 3. Drop me off at my place 4. Drop off the car he borrowed. 5. Meet back at my hotel to take the shuttle to the airport.
Well, 1-3 went smoothly, but took a lot of time. Dropping off the car resulted in Yilkal breaking the lock of the garage to store the car (no one had the key) and me traveling to the airport solo with Yilkal’s bag fully stocked with baby formula. Nevertheless, it all worked out extremely well and we made the flight just on time.
Although we were only partially successful and I knew I would need to come back to the capital again soon, I was excited to return to Mekelle. As the propeller blades spit rain into the window and deafened me with their acceleration, I sat back and relaxed for the first time on this trip. I’m going home. Plus, this was my first time seeing Mekelle from the sky at night, it was pretty cool!
And….of course, no social update would be complete without the puppies!
Global Head and Neck Surgery 