Henock Asaye

Farewell.

The past eight weeks have allowed for me to unlock something within myself that I haven’t seen in over a decade – my home country. I was able to return to the place where my entire family lineage came from and was able to divulge back into the culture that has shaped so many of the people in my past. This overwhelming sense of pride that this trip has given me has also awoken something else – the need to make sustainable change.

My research provided me the information necessary to conclude that there is an issue within the Ethiopian government and their approach to health care initiatives to the country. However, in order to alleviate the burdens that the country has in the first place is to replenish the supplies that they are in need of. This is through direct participation of Oasis Medical Relief or other organizations – such as Doctors Without Borders and others. The resources are available for these organizations out there, the only question is how will they be able to get it to there.

I also learned the importance of cultural relativism concerning ethics. Western influence in Ethiopia is clearly seen, however that influence stops when it infringes on the personal beliefs and morals of the Ethiopian people. When conducting research, it is important to understand the culture, history, and beliefs of the community in order to gain a better understanding of the culture. This allows for a greater understanding of the rationale behind many of the health care professionals decision-making when providing health care services for the community.

This week I have drafted a memo and will be sending it to the Ministry of Health and PFSA to improve distribution methods of medical supplies across the country. I hope to inform both of the organizations of the need to create sustainable change and bring to light the numerous problems that many rural hospitals face. In addition to this, I have solidified relationships with many hospitals across the country to continue to send medical supplies to the hospitals which continue to have shortages. If the Ministry of Health and PFSA are unable to make these changes, I hope that Oasis Medical Relief will continue to help the hospitals until the government intervenes to make changes. I hope that in the future these hospitals will have an influx of medical supplies so they will be able to give back and send supplies to hospitals in other countries that have shortages.

As my last day in this country looms, I have been asking myself the hard questions that will be daunting on me for the next couple of months. When will I return to this country? Will my efforts with the Ministry of Health and PFSA actually make a difference with distribution methods? Although I found the necessary information for my study, how will I be able to make sustainable differences with the hospitals that I visited? These are all questions that I hope to find the answer to as I begin the next chapter of my Duke career.

Till next time.

Change.

The one thing that humans fear more than death. The one thing that comes with time. Many people are afraid of change because it opens the door for uncharted territory – the idea that something can go terrible wrong (or terribly right). The Ethiopian culture is accepting to change, as long as it aligns with the social rules set by the country and is widely respected across the many religions. In order for there to be sustainable change, there needs to be a change to the society. There needs to be an opening of the possibility to creating positive change that revitalizes the country – through the work of the new prime minister and the entire population.

The issue with creating changes within governments is a lengthy process. It could take years and even decades for noticeable changes to be made. The main point is not to be discouraged by the effort put forth, but it is to look at the larger picture. Governments around the world have different issues that they face each day, but by trusting a democratic process that has the people’s best interests in mind, they will have no choice but to listen to nothing but what matters the most.

Creating massive sustainable change has always been a dream for political activists worldwide. The dream that hundreds of years of oppression or territory not rightfully given can be changed with a simple enactment is usually the end goal. These dreams are what keep people motivated to make changes in the world. Sadly, even within multiple generations this may not be accomplished. Even with an immense amount of resources available, it may never even occur. However, approaching issues in a gradualist approach can make issues become clearer and give a different sense to the issue at hand. By working towards smaller goals, and once accomplishing them to move forward to other small goals.

This is the case with the health disparities issues in Ethiopia. Using a gradualist approach, by providing the government with the research in order to create change, and impacting the hospitals will only do so much. There needs to be pressure to make changes to the government and for other organizations to intervene through the people. Through the work of the health care professionals in Ethiopia, the people, and individuals within the Ministry of Health, there can be monumental change that will change the tide for Ethiopians for the rest of the century. There needs to be things done on a larger scale, but creating realistic goals is much more of an effective manner to tackle the issues.

The important thing to take note with when dealing with health disparities is culture and tradition. If you want to make changes within the government, how will they feel moving towards a more aggressive manner in providing health care as opposed to promoting spiritual healing? In addition, will this change in distribution methods have any confounding factors that may be opposed by other underrepresented ethnic groups throughout the country. If so, how and why could this happen?

Culture.

This week, I travelled to Hawassa and nearby cities and visited hospitals in the rural areas outside of the city. I was able to visit neighboring attractions such as Burquito and Wondo Genet – these are natural hot spring waters. I was able to interact with an ethnic group in Ethiopia known as the Gurage people. They are notably known for their hard-working mentality and perseverance through spirituality.

During my travel, I realized the cultural differences I shared with the Gurage people the more that I interacted with. Many of the individuals in this area spoke a different language from me – Guragigna and had slightly different cultural practices and history. The group of individuals had an amazing historical background and proved their core values – bravery, loyalty, and love.

My visit to the neighboring hospital to this group proved to be interesting visit – although the Gurage people dominated in population of the surrounding area, many of them refused to be admitted to the hospital. As I interviewed the health care professionals, they were able to reveal the important of spiritual healing for the Gurage people. Many of the reasons why this occurs comes from the stigma at hospitals that many of the Gurage people believe. There is an innate distrust for the hospital, which drives them towards spiritual healing.

According to Health Progress, it was found that:

“While it is true that professionals in large urban facilities also have multiple responsibilities, small rural hospitals tend to have a limited number of professionals on staff, so these problems are exacerbated. Rural staff members may hesitate to use ethics committees because these health care professionals do not see many everyday problems as ethics issues. They also tend to favor informal supports, such as spouses or peers, rather than formal ethics committees.” (Health Progress, 2010)

From data taken from this hospital, this region had the lowest amount of medical supplies delivered. The hospital had many different issues, however many patients that they received travelled from farther rural areas to receive treatment. However, many of the patients were not able to receive adequate treatment. To make matters worse, many of the patients (the Gurage people) who need treatment do not rely on medical treatment from doctors.

Due to these circumstances, there is more of a communitarian belief in this aspect– a connection between the individual and the society working in harmony – that relies more on the community and peers as opposed to organized health care facilities. This is seen in both the rural areas of the United States and low and middle-income countries that lack the supplies necessary to provide quality treatment for their population. The cultural and communitarian values are much more embedded within systems that are not able to effectively rely on quality health care facilities providing supplies for their population.

All in all, in order for there to be an improvement to the process of having individuals, doctors must reinvest their confidence into the community that they are receiving the most quality treatment available. In addition, that the hospital is having their health care professionals using an ethical framework that provides adequate treatment for everyone.

Mental health.

As news circulates around the recent passing of Anthony Bourdain – a cultural phenomenon and a man who has inspired millions – it brings to light a subject that varies between cultures. Mental health continues to be a growing issue throughout the world across multiple cultures and countries.

This past week, I was able to visit hospitals and found an interesting fact:

Mental health patients are admitted to the hospital are the least across all sectors.

This is for a multitude of reasons. For starters, in Ethiopian culture they believe that mental health issues are directly related to their spiritual relationship with God. This results in a reliance in church and spiritual healing as opposed to a hospital visit. This is a common belief across many African countries and have been a growing concern throughout the years for the refusal of medical care. To make matters worse, the highest rates of these mental health conditions are in poverty-stricken areas in the rural areas of Ethiopia.

Through my findings with the government hospitals in Ethiopia, it was found that there was a great economic disparity between the rural and urban hospitals. In the urban hospitals, patients who were unable to pay for care and had no medical insurance were still able to receive emergency OPD treatment and other basic services. If the patient had expensive pharmaceutical drugs or supplies that were needed, the hospitals would cover the costs. However, in the rural hospitals if there was an emergency OPD patient that was admitted they would be able to be treated but in a non-emergency OPD situation – this would not be the case. If a patient in a rural hospital were seeking medical treatment or required medication that had to be purchased for another hospital and was unable to pay for treatment, they would not be able to receive treatment. This would only be in cases where the individual did not have medical insurance. In rare cases, where the patients had a personal relationship with one of the general practitioners in the hospital, they would be able to have fundraisers in order to pay for the patient.

Combining the inability of rural hospitals to provide care for low-income patients along with the majority of the Ethiopian population inhabiting rural areas creates a dangerous mix. For the millions that need treatment – regardless of the issue being mental health, neonatal care, or elderly care, the inability to the hospitals to provide adequate care puts pressure on communities to rely on spiritual care and healing.

For the hundreds of thousands of mental health patients that are unable to be treated because of this speaks to the importance for other organization to make an impact on these regions. In a country that has recently been a part of a state of emergency and has a history of discrimination towards ethnic groups and ware fare, mental health should be of high importance. In order for there to be an improvement to the health care system in Ethiopia, there needs to be an active participation from the local community and at the governmental level as well.

Let’s talk ethics.

The greats – Aristotle, Kant, and Socrates – all who were able to contribute to the transformation to the idea of human thought. Each of these lines of thought have influenced western medical ethics for centuries, however culture and religion are both some of the most influential aspects medical ethics in Ethiopia.

In order for there to be a greater understanding of the decision-making that the physicians made, I wanted to understand what ethical framework was used by physicians. The ethical framework that the physicians used will ultimately determine which individual will receive priority for treatment and which patient will have access to the limited medical supplies that are available.

Each hospital that I visited had similar value systems in order to give priority for patients. Some hospitals used a point system, while other hospitals used a triage system – a complex formula in order to determine which patient should have priority, or others as simple as red flag, yellow flag, and green flag in descending order. There are different modes of thinking in terms of providing health care service, however for many general practitioners the majority of decisions that are made are up to the physicians which specialize in certain fields.

As children, many of us are taught first come-first serve for various situations. However, this same framework is used in hospitals across the urban and rural hospitals in Ethiopia. This first-come, first-serve basis applies to any individuals who are admitted to the hospital. This first-come first-serve basis is problematic for low socio-economic patients who have travelled from hours away to receive treatment – often taking days to be treated without sleeping accommodations or nightly transportation available. Luckily, the only condition that supersedes the first-come, first-serve basis is the severity of the condition of the patient. If a patient is in need of immediate medical care and each second puts them at a higher risk of death, they will receive treatment first. Sadly, for a patient who has travelled days to be treated will have to wait many more for treatment due to this first-come first-serve framework.

Utilitarianism is a form of thought made famous by John Stuart Mill and Jeremy Bentham. This mode of thought is used in hospitals as well. Through multiple interviews, I found that many doctors – unknowingly using utilitarianism – used this framework to determine which individual will have priority for treatment. Many doctors would give adolescents and teenagers priority for treatment as opposed to older individuals and the elderly. This belief is based off of the higher chance of survival for the younger patient and greater years of life that the individual will be able to live as opposed to the elderly. This framework is both used for priority for treatment of patients and for access to the limited medical supplies that the hospital has available.

These forms of thought all contribute to the ethical framework that doctors use in order to give priority for treatment and use the limited supplies that they have available. The value system, first-come first-serve basis, and utilitarianism framework provide their own set of benefits and drawbacks; however, the root of the issues stems from the lack of ample medical supplies available in order to treat these patients. If these supplies were available, then the process would run much smoother. In summation, the last question asked to each doctor was whether their frameworks used was learned from medical school or personal beliefs and practices in order to give patients priority for treatment and access to medical supplies. The answers were spilt down the middle. Some physicians explained that this was taught in medical ethics during their time in school, while other individuals explained they it came from their personal religion or Ethiopian culture to treat the patients.

To take note, the one aspect that was shared across all hospitals throughout Ethiopia – both urban and rural is the quality of care in terms of time. Whenever the hospital was overwhelmed with patients, each doctor that was interviewed explained that the quality of care is lowered with less time spent per patient due to the influx of patients. This can pose as a problem when trying to diagnose a patient and things can be overlooked which may be detrimental longer-term for many patients. This is different from developed countries health care providers such as the United Kingdom and United States – where hospitals have enough medical doctors and supplies where there is not a time scarcity to treat patients.

It’s been 10 years. I traveled to Ethiopia for the first time that I can remember in 2008.

My second trip contained amazing experiences included visiting relatives I have never seen before, seeing historical monuments and visiting the site where Lucy—one of the oldest human remains found to date—was discovered. I traveled throughout the country to places such as Axum, Bahir Dar and Harar. In each of these places, I had different cultural experiences and met individuals from different ethnic backgrounds.

I will hold onto these memories until I grow old—but I also have other, less fond memories of that trip.

In 2008, I witnessed the poverty and famine that has ravaged Ethiopia for the past decade. The poverty conditions of a country are directly related to the health outcomes of the population. More than 36 percent of Ethiopians are either below the poverty line or vulnerable to falling into poverty. To make matters worse, preventable diseases account for 60 percent of the health problems in Ethiopia. Through further research, my hunch was correct: Ethiopia’s quality of care is among the lowest-rated throughout the world. In order to help reverse these conditions, I decided to make a change to the health outcomes of the country.

Many organizations—such as the United Nations and Doctors Without Borders—have programs to alleviate the burdens in Ethiopia, but their main focus is in the urban areas due to easier access. To add to this, the disparity between the urban and rural areas has been growing. A recent quote from the World Health Organization noted, “The main health concerns in Ethiopia include maternal mortality, malaria, tuberculosis and HIV/AIDS compounded by acute malnutrition and lack of access to clean water and sanitation. The limited number of health institutions, inefficient distribution of medical supplies and disparity between rural and urban areas due to severe under-funding of the health sector, make access to health-care services very difficult.”

Ethiopia needs intervention programs that help bridge the gap between these areas in order to provide adequate health services for all parts of the country.

My organization—Oasis Medical Relief—aims to increase human resources in many low-budget hospitals in Ethiopia. Yearly, there is an excess of a billion dollars’ worth of unused medical supplies in the United States. The scarcity of medical supplies creates an issue of distributing medical supplies and providing healthcare service in Ethiopia. Upon further understanding of the need for resources, I became more interested on the ethical framework that health care providers use to provide treatment when resources are scarce.

My project this summer will examine the disparities in available medical supplies and available medical professionals between the urban and rural areas. By taking this twofold approach, I will be able to see discrepancies in personal doctor-patient treatment and access to supply.

Will doctors whose ethnic groups (Amharas, Tigrayans, Gurage, Oromo) differ from their patients treat those patients differently? Will the quality of care drop? How do physicians allocate the limited number of medical supplies? How will overly-busy doctors distribute their time between patients? If there are limited health care professionals available to treat patients, how will hospitals provide adequate care for all patients? If they cannot, will race, socioeconomic status or culture impact the decision as to who receives treatment? These are the questions I’ll be exploring in both urban and rural areas—and seeing whether and how the answers differ in each context.

To find a solution to the problem, I will better understand why some hospitals lack supplies while others do not. Based on my findings at the hospital, I will work with the Ethiopian Ministry of Health to determine how to best distribute medical supplies between the urban and rural areas and give recommendations for future distribution methods.

As of now, I have set up meeting dates and times to meet with health care professionals at each of the designated hospitals. In addition, I have a list of medical supplies that these hospitals are lacking and will arrange shipments of these supplies to these hospitals based on their responses. I hope this fellowship experience will further allow for me to better understand how western medical ethics differs with other countries.

Till next time.