Anteneh Roba, M.D.
October of 2003 was only my second time to visit Ethiopia in 25 years. It was an eye opening experience that would change my life completely. I left Ethiopia to pursue higher education and eventually became a practicing physician in the USA. I returned to find out about the health care system in my country of birth. In 2003, I joined a team of doctors who were traveling to Ethiopia for a couple of weeks to perform surgery. The plan was for me to assist the surgeons, which turned out not to be necessary. Instead, I ended up visiting various hospitals in the capital city of Addis Ababa. I was introduced to Dr. Tesfaye Bayleyegn, a local anesthesiologist, who graciously took time out of his busy schedule to accompany me.
We first visited the emergency room at the Black Lion Hospital. What immediately caught my attention was how the babies were bundled up and laying on makeshift dilapidated beds; six to seven of them in a row. One child was sicker than the next with serious communicable diseases that in the United States would have required them to be put in isolation rooms. Some were gasping for air; some were listless and lifeless. Most had their parents hovering over them, anxious and scared with their sacs of clothing and food on the floor at the foot of their babies’ beds. At the other hospitals we visited, the same scenario was repeated endlessly, revealing a health care system with totally inadequate infrastructure, equipment and supplies.
During our visits to the Zweditu and Menelik medical facilities, we met inspiring and dedicated doctors and health care professionals in all areas of medicine that were doing an outstanding, even heroic, job under very difficult circumstances. Their descriptions of the agonies they see every day and the ordeals of the patients were very chilling. The stories of the pediatricians about the children they had to struggle to keep alive were especially heartbreaking and kept me awake at night long after I left Ethiopia.
On a visit to the pediatric ward at Zweditu Hospital, accompanied by the pediatric section head, I noticed a nurse remove the oxygen tube from a baby. Seconds later the baby became agitated. Realizing what was happening, I myself became somewhat agitated and inquired why the nurse was removing the oxygen that the baby clearly needed so much. I was told that there was another baby with an even greater need for the oxygen; but, as the babies agitation got worse and my increasing distress over the situation was becoming evident to the doctor, he ordered the nurse to reattach the nasal oxygen to the baby, who immediately settled down.
During the next few days, I visited many other pediatric wards at the several hospitals and saw too much more of the same: babies with complications of HIV waiting to die because of lack of retroviral medications for infants; babies with extreme forms of rickets (vitamin D deficiency), their bones bent like pretzels because their mothers had deprived them of sunlight for years; children with kwashiorkor (severe swelling of the body due to severe protein deficiency) with minimal intravenous access to correct the deficiency; babies with huge hernias and other surgical problems that could not be operated because they would not survive. These are only some of the terrible problems I witnessed.
The endless suffering at these hospitals made me realize that, as an Ethiopia born physician residing in the USA and lucky enough to have the means and knowledge to make a difference, I had to get involved, and that no matter how small my contributions might be, I would find a way to make a difference.
After three years of consideration and investigation to find a way to help my fellow countrymen/ women, I and my cousin, Seble Nebiyeloul, co-founded the International Fund for Africa (IFA) in 2006, formerly called The Amsale Gessesse Memorial Foundation. Realizing the overwhelming needs of the health care system in Ethiopia alone, it was decided to narrow our focus to the improvement and modernization of neonatal and rural medical care. Although there is a great deal of anecdotal evidence of the huge health care problem in Ethiopia, there is also a good deal of evidenced-based statistical information available to provide a more comprehensive understanding of the magnitude of the health care problems facing this East African country.
The World Health Organization (WHO) defines “neonatal mortality” (NM) as the “death of a live born during the period which starts at birth and ends 28 completed days after birth”. Two-thirds of neonatal deaths take place in the first week of life (perinatal period). Of deaths occurring in the first week of life, two-thirds occur in the first 24 hours of life. Of all neonatal deaths in the world, 99% occur in developing countries like Ethiopia. Newborn health indicators are not recorded by global agencies although they form a great proportion of child mortality. The highest rates of neonatal mortality occur in Sub-Saharan Africa. Estimates indicate that one in every five women risks experiencing a neonatal death. The high rate of neonatal death in developing countries suggests that there is a relationship between socio-economic status and mortality.
Inability of pregnant women to recognize complications soon enough, followed by delay in seeking and getting appropriate help are among the major causes of neonatal mortality in Sub-Saharan Africa. It is estimated that 72% of neonatal deaths can be prevented through the implementation of simple and proven interventions such as good maternal hygiene and nutrition.
Although most hospitals in Addis Ababa have pediatric wards, all of them are ill equipped to handle sick babies. As of June 2009, none of the hospitals had pediatric or neonatal intensive care units. While most of the doctors are well trained and do a remarkable job under the circumstances, the lack of specialists is glaring. Currently, there are only a few neonatologists in the whole country. Issues that contribute to neonatal death are poor health of the mothers during pregnancy due to poor maternal nutrition causing such conditions as anemia, severe and serious infections caused by endemic diseases like Malaria, and untreated hypertension during pregnancy. Inaccessibility to health facilities, poor quality of care or non-existent care at health facilities, poor management of health facilities, misguided and harmful local beliefs and cultural practices such as early marriages and early child bearing, frequent pregnancies, and unsafe sex, also contribute to both maternal and neonatal mortality.
According to recent reports of the U.N, Ethiopia’s neonatal mortality rate is 39 per 1000 live births with neonatal deaths totaling 119,500 annually. Infections are the most common causes of death, followed by low birth weight due to poor nutrition, asphyxia, congenital problems and other causes. A neonate with a surgical emergency presents formidable challenges in patient care, particularly in the resource poor environment of most hospitals in the capital city. This stems in great measure from unavailable or inaccessible prenatal and obstetric care for the majority of the poor, minimal community support services for neonatal care, and inefficient and weak referral systems. To minimize the deaths of newborn babies, easy access to neonatal services must be available at the time of greatest risk, which is at birth and during the first few days of life. Having experienced the very difficult conditions in the pediatric wings of the hospitals in Addis Ababa,and the immense need for neonatal care, the International Fund for Africa, entered into a relationship with Yekatit 12 Hospital (one of the many government run health facilities in Addis Ababa) to develop, establish, and eventually upgrade neonatal services. Yekatit 12 Hospital was chosen because it already had a small unit established by a very determined neonatologist, Dr. Mulualem Gessesse. With only two rooms, a few beds, and limited and inadequate medical equipment and supplies to provide basic care, this determined neonatologist and her staff struggled to save the lives of babies. IFA first visited the Yekatit 12 hospital neonatal unit in 2007 to assess its needs. In order for this unit to have a viable capacity to save lives, Dr. Mulualem and her staff would require support on many levels. We decided to help build a self-sufficient state-of-the-art neonatal unit at Yekatit 12 Hospital.
In the first year of the project, IFA provided a sizeable donation of equipment and medical supplies including incubators, phototherapy machines, neonatal beds, oxygen concentrators, suction machines, pulse oximeters, ECG machine, cardiac monitor and IV cannulas. As a result, the unit was able to upgrade and expand to one of the more comprehensive neonatal units in the country. On four subsequent visits, IFA has provided basic supplies such as uniforms, stethoscopes, etc., and equipment including computers, slide projectors, etc. to assist the staff in its ongoing educational programs.
In June of 2009, IFA donated additional equipment and supplies necessary to create a functioning neonatal ICU, including three pediatric / neonatal ventilators donated by the New York Mt. Sinai Medical School Department of Neonatology through the good offices of Dr Ian R. Holzman, Professor of Pediatric Medicine and Chief of the Division of Newborn Medicine. Cardiopulmonary monitors, a blood gas, blood count and chemistry analyzer machine, portable x-ray machine with fluoroscopy capabilities, defibrillator, condensers, otoscopes/opthalmoscopes and accessories for respiratory care like laryngoscopes were also obtained. In addition, through the efforts of Dr Mulualem and the unwavering support of the hospital administration, the unit has been expanded to seven rooms with over 30 beds and a Neonatal Intensive Care Unit.
These efforts have lead to very encouraging results. The neonatal service has admitted 1,084 patients and discharged 956 (88.1%) with the total number of deaths being 128 or (11.8%) as ofJune 2009. As of December 2009 neonatal mortality was down to 4.8%. Of 605 newborn admissions, 522 (86%) were discharged in improved condition, whereas 8 (1.3%) cases with congenital malformation and surgically correctable problems were referred to the neonatology unit of the Black Lion Hospital. 75 (12 .5%) newborns died, the major causes being Asphyxia (33.4%), Hyaline Membrane Disease (24%) and Sepsis (21.3%).
Statistics alone do not tell the whole story of this miraculous decline in deaths, of newborn babies, and if a picture is worth a thousand words, a video must surely be worth a thousand statistics. View the heroic life-saving accomplishments of Dr Mulualem and her staff combined with the efforts of the International Fund for Africa at http://www.youtube.com/watch?v=PILrNY8ujX4.
Although the results have been very encouraging, the continuing challenges for Yekatit 12 Hospital are many. It stands as a stark example of the problems that most hospitals face in Ethiopia. Essential to a well-run health care system are increased and continued financial support from the government, allocation of budget for maintaining and upgrading health care facilities, and equipment donated by other organizations. Creating a management team at each health care facility that is knowledgeable, committed, and effective is a necessity. Field-based training of health care providers is also important.
Having had discussions with health care officers from nurse assistance all the way up to the minister of health has lead us to believe that the challenges that need to be addressed to improve both maternal and neonatal mortality are to build women’s clinics to provide ob/gyn and neonatology services and to also have ob/gyn and neonatal services in as many hospitals as possible, and where they do exist, to improve the quality of care by training and expanding the knowledge base of physicians and nurses in obstetrics and neonatology. Streamlining the continuity of care from pregnancy through delivery to the postnatal period, and from home to primary health care facilities and to hospitals is another important goal. Combating the growing number of HIV/AIDS victims that will eventually over-burden the system is also of paramount importance.
Our goals are lofty, but hopefully, with perseverance and hard work, they will be achieved. It will take the participation of Ethiopians in the Diaspora and the friends of Ethiopia all over the world as well as the commitment of the Ethiopian government, medical community and citizenry to turn the tide of death, hunger, despair and pain. We recognize the urge for some to politicize their grievances and to take a confrontational position on many of the issues that plague Ethiopia. In this case, an alternative approach is necessary. Everyday all over Ethiopia babies will die avoidable deaths, a children will go to bed hungry or become homeless because of the loss of one or both of their parents to AIDS. We can stop these and other atrocities by utilizing our time, effort, energy, and money in a cooperative effort by supporting organizations like ours that take an apolitical approach, and who deliver aid directly to those in need in our motherland.
IFA has plans to help establish new neonatal and pediatric services in city and rural hospitals, improve existing programs, and to establish an ongoing volunteer program for visiting U.S. doctors to participate in the delivery of health care and training of medical professionals to advance care of the newborn. In line with this goal, IFA has donated life saving equipment including 5 incubators, 3 phototherapy machines, 5 suction machines, and two oxygen concentrators to Ghandi Memorial Hospital (the oldest maternity hospital in the city) in Addis Ababa on April 14, 2010.
You can make a difference and your contribution now to the International Fund for Africa is a matter of life and death for these babies. A sick and dying baby is every mother’s nightmare. With your donation, you help change that nightmare into a dream come true for a happy, healthy child for that mother. Your support will make possible the further critical acquisition of needed medical equipment and supplies, and help equip and create a new state-of-the-art pediatric unit with an entire floor dedicated to neonatal care now under construction at Yekatit 12 Hospital.
To donate, and for more information about the International Fund for Africa, please visit www.ifundafrica.org.
(Anteneh Roba, MD, is President of International Fund for Africa)