Earlier this year, clinical staff from Ohio State’s Greif Neonatal Survival Program brought their expertise to Ethiopia during our One Health Summer Institute.
The team was recently featured in a news story from the College of Medicine about the program’s growth since its founding in 2012.
You can also read their Ethiopia-based blog posts here and here.
Congrats to the Greif Neonatal Survival Program for its impact on saving lives!
By Monica Terez, RN
Clinical Program Manager
The Ohio State University College of Medicine
The sixth floor of Black Lion Hospital in Addis Ababa is a bustling place.
One wing is dedicated to the care of laboring mothers, many of whom require complicated care provided by midwives and obstetrical residents.
Another wing houses approximately 45 infants, all requiring some degree of newborn intensive care. The infants are not arranged in rooms by chance, but rather by the level of care they require.
One large room is dedicated to the most fragile infants, often born weeks or months before the mother’s due date. Due to a lack of sufficient equipment, infants often share a bed or isolette. Babies are kept warm by space heaters positioned throughout the unit.
At any one time, each nurse may be assigned to care for as many as 10 sick neonates over the course of a 14-hour nightshift.
Considering how busy the unit is at any given moment, it would be easy to miss the most important care providers – the mothers of those infants – who desire to give their baby the best chance for survival.
With the support of the physicians and nurses in the neonatal intensive care unit, mothers provide Kangaroo Care for their babies for many hours. Kangaroo Care allows the mother to hold her baby, skin to skin on her chest, thereby regulating the infant’s temperature, calming the baby, enhancing growth and promoting maternal/infant attachment.
Three rooms of the neonatal unit are dedicated solely to mothers to rest, breast-feed, care for their infants, and just do what mothers do best – love their babies.
Black Lion has long realized the importance of maternal involvement in the health and growth of infants.
The unit’s equipment may be sparse and malfunctioning, nurses may be few and far between, the workflow may be less efficient than desired, but one thing is for sure. At Black Lion Hospital, the mother has taken her rightful place as an important care provider for her infant. THIS is newborn care at its best!
By Diane Gorgas, MD
Associate Professor of Emergency Medicine
The Ohio State University
In four days at Addis Ababa University, we educated more than 50 health care providers on basic neonatal resuscitation. These individuals spanned the spectrum from new pediatric nurses and labor-and-delivery scrub nurses, to neonatal nurses with decades of experience, to midwives, to pediatric residents.
What we discovered was a commitment to excellence and a dedication to providing the best patient care possible, even in a resource-poor environment. The baseline fund of knowledge in addition to the intellectual curiosity of the group impressed us. There was a drive and a passion to learn that spoke for itself and was manifest in insightful questions, enthusiastic interaction, and a resistance to let us leave at the end of the day.
Diane Gorgas demonstrates advanced resuscitation techniques at the Black Lion Hospital in Addis Ababa.
The refresher training began by framing the need for this knowledge and skill set. The Black Lion Hospital in Addis Ababa is the premier teaching and patient care site in this country of 92 million people. About 3,000 deliveries a year take place at the hospital. Being a tertiary care referral center, these are disproportionately more complicated and higher risk pregnancies than the general population.
Within an average, healthy population, 10% of babies will require some sort of support at delivery. In this high-risk population, estimates can be as high as 30-40% of newborns who will require resuscitation.
Our training started with a definition of the scope of the challenge, and nurse-midwife Sharon Ryan, CNM, DNP, discussed both maternal and labor and delivery risk factors which may compromise a newborn and necessitate resuscitation efforts.
Monica Terez, RN and life-time neonatal nurse took over and outlined the equipment needs and basic resuscitation algorithm for a newborn, including ventilator support through bag valve mask and chest compressions.
I finished the training with a discussion of more advanced resuscitation techniques including intubation and vascular access. The training received high praise for its interactive nature, and for the hands-on experience it afforded all the learners.
Ethiopia is a book-rich culture. They are an exceedingly motivated, bright, and industrious people who are struggling with the challenge of every developing country: how to educate and train its best yet retain them in country and not lose out to the developed world’s insatiable appetite for experienced health care workers.
The “brain drain” of trained physicians and nurses from Ethiopia to the U.S. and Europe is real. We have heard estimates that there are currently more Ethiopian-born physicians practicing in Chicago than there are in the entire country of Ethiopia. This creates a practitioner experience vacuum. Practical, clinical training is difficult to sustain as senior clinicians are wooed away to greener pastures, leaving the young to train the young.
The One Health Initiative is an excellent start towards bridging this gap, and the possibility of the three of us traveling to Ethiopia as supported by the Greif Foundation is making strides at providing these valuable experiences.
By Wondwossen Gebreyes, DVM, PhD
Ohio State College of Veterinary Medicine
As I said in my previous post, we learned many things from each other during this successful Summer Institute. Here are a few of my thoughts on specific topics.
Maximum flexibility and minimum expectations: This became the motto for the team members a couple of days after we arrived. Considering the resource limitations of Ethiopia, the high economic growth and resulting traffic jams, and limitations in communications, one may not be able to plan things well in advance, or keep your lane consistently in driving on the highways, or be able to arrive for meetings on time.
At the end of the day, we always achieve all the goals, and everyone gets to be happy, though not in the most efficient way.
The situation also made me realize how much building capacity in the area of effective communication could improve all the activities we conduct in this partnership, be it neurosurgery, nursing, or environmental health.
Effective communication and filling the gap within our partner institutes in Ethiopia is critical.
However, life in the U.S. made us become very sensitive. We often try to be perfect. Ethiopia was a great venue for most to realize the sky does not fall. It is OK to be a bit late.
Relax, and still achieve our goals!
Equipment. Equipment, Equipment: As we all witnessed during our several meetings at the various health science colleges of the two universities and also read in blogs, one key ingredient missing very much in the hospitals, research, and teaching settings is equipment.
During this trip, I learned first-hand that 44% of the patient cases at the nation’s premier referral hospital, the AAU Black Lion Hospital, were cancer cases. It was sickening to also learn that among these cases, 65% were pediatric. Yes, indeed there is lack of manpower, and so we launched the institute.
The partner universities are also building the physical infrastructures. While these address part of the issue, the lack of equipment is a major impediment for capacity-building. How can one radiotherapy machine can handle such a large cancer case burden for 85 million-plus population?
Equipping laboratories and clinical units remains a major challenge that partners in Ethiopia and Ohio State will have to tackle.
Maximum motivation: I never realized so clearly until this trip what drives my passion in global work, particularly the teaching aspects. Never fully understood what drives me to lecture several hours with only a short tea break and still have the full steam.
I observed my colleague, Dr. Bisesi, give his lecture on environmental health, and I saw the wide open-eyed trainees and their interaction. I noticed the high level of motivation by the trainees. The same was true for my course.
Students were so highly motivated that they even asked me to teach a full day on a Saturday. Some even suggested we keep going on Sunday, but that idea created a bit of a stir. “True,” I said in my heart, “that is a big NO in Ethiopia.”
You have to respect Sabbath day more than molecular epidemiology.
The Ferenji Effect: Ferenji is defined very loosely as “a foreigner,” particularly referring to a rich Caucasian. Its connotation is very positive. Ferenji is often considered as a nice, generous foreigner whose pocket carries endless amount of treasures … well, we all know the truth.
Typically Ferenjis are magnets to Ethiopian kids in urban and rural areas of Ethiopia; they often have chocolates, coins, and all kinds of fun things. At a minimum they have a digital camera to snap kids’ picture and show it back to them. The kids giggle seeing their own image in this small window. They followed Dr. Bisesi and Mr. Harrison as we traveled in a suburb of Addis.
During the Summer Institute, I witnessed the usual hospitality of the university security guards and others giving the due respect to our “guest Ferenjis” and I (the designated local chauffeur) also get a free ride.
Unlike what I stated above, about “Ferenji are magnets to local kids,” kids in the Woreta area acted differently. When we were collecting questionnaires for the rabies project, the kids would run away when they saw our giant, “tall-6-foot-some” great athlete and health science student, Korbin Smith. “They might have considered him as Goliath,” I thought to myself. I also hoped one of those little shepherd kids would not be like Dawit (David). Thankfully, we left the place with all fun and no fighting.
By Wondwossen Gebreyes, DVM, PhD
Ohio State College of Veterinary Medicine
It has been wonderful working with all the Ohio State and Ethiopian faculty and students during the One Health Summer activity that run from June 7th to this week.
First off, I am very much proud to be a Buckeye. Everyone from the Buckeye nation (Ohio State) showed wonderful professionalism throughout the Summer Institute.
I heard all positive words from our partners in Ethiopia. Students and faculty from five of our seven health science colleges and also School of Environment and Natural Resources have all been great to work with.
I am also proud to be born Ethiopian. I am sure all my colleagues tasted the ultimate hospitality and motivation both in classrooms and social settings and learned a great deal of variations in traditions.
The commitments from both student trainees and partner administrators has been unsurpassed. It gives me a great pleasure seeing the trainees’ eyes wide open in the various lectures, sharing the Ohio State students’ excitement for service learning (even some requested opportunities for next year before leaving Ethiopia), and reading all the blog posts from our students and faculty members.
Importantly, personally, I also learned few more things about Ethiopia and partnership along the way.
With respect to the scientific/ technical aspects of the Summer Institute, I am confident to say that we achieved the goals – in all aspects: coursework and trainings, pilot projects, and workshops. We were able to impact more than 200 professionals in these courses. And a number of scientific networks and new collaborative partnerships developed. Partner colleges were able to identify areas for further collaboration.
Both the Univeristy of Gondar (photo below) and Addis Ababa University partners as well as other institutes — such as the Ethiopian Health and Nutrition Research Institute (EHNRI) — were excited with the outcome.
It was humbling to hear from the dean of AAU School of Medicine, Dr Mahlet, I quote: “We thought Ohio State would be similar to many, many universities we signed MoU with before and never heard from them again. You made us feel guilty by showing your commitment in a short period of time. Thank you and we are also determined to show our commitment.”
As we move forward, the Ohio State Health Sciences task force will resume its activity in full force. On behalf of the Ohio State Health Sciences One Health task force, thank you to all those who participated in the Summer institute! Some of the upcoming activities will include visits by the Ethiopia partner universities delegation; continued pilot projects on cervical cancer screen-and-treat, rabies intervention, electronic capacity-building, and service-learning clinical activities by neurosurgery and nursing teams. Please stay tuned and follow our blog.
In my next post, I will share some specific thoughts and observations on these activities.
By Timothy Landers, RN, PhD
Ohio State College of Nursing
One of the things that has been most impressive in my visit to Gondar is the respect for people and for relationships that is present in every interaction. Every conversation begins with a greeting, ሰላም, “Selam!” Followed by some greeting such as “how are you”, “how is your day going”, or “how are you feeling?” Or more often, all three.
In a typical conversation, each person in the group is acknowledged and receives a handshake. The president of the university greets the department chair, the student, and the housekeeper.
There is a nonverbal conversation among Ethiopian men – what we’ve come to call the “ah-ha.” It is a brief gasp taken with force which is usually uttered when another is speaking. It says, “I am listening, I am interested, I am here.”
When I arrive at my office in the morning, I make it a point to say hello to the co-workers I meet – something I picked up from an airline pilot who told me he ALWAYS greets his flight attendants and co-pilot first thing.
However, it’s not the same kind of recognition and appreciation for the other person that I have seen in our visit to Ethiopia.
In the past two weeks in Ethiopia with each “Selam,” “good morning,” “how are you feeling?” and “how was your day?,” I’ve learned more about my co-workers than I could have in six months in Columbus.
But, I’d like to change.
When I leave Gondar, I am going to be more aware of how I greet those around me – everyone. It’s worth the time to let them know that I am interested in how they are doing. I am hoping to let them know that I value them and am interested in them.
How are you doing today? How are you feeling? Did you have a good night?
After that, I will unlock my door and get to work.
And there is lots of work to do.
By Timothy Landers, RN, PhD
Ohio State College of Nursing
and Gennit*, 9th grader from Atlanta, Ga.
*Gennit is not her real name but the story is true. Her mom gave us permission (from the row behind us) to use this story and photo. Hopefully, this counts as her “What I did over summer vacation” essay when school starts.
I’m sitting on the plane with Gennit, a 13-year old girl who was born in Ethiopia, but now lives in Atlanta with her brother and parents. Gennit is a nice and articulate 13-year girl, and we chatted during the 13-hour flight about our experiences in Ethiopia.
She had a lot of things to say, and I noticed that she was somewhat soft-spoken making it difficult to hear her at times. I asked her about my observation that many Ethiopian girls and women speak softly and what she thought about that.
Gennit told me she thought is was more “ladylike” to speak softly and, in Ethiopia, children are taught that it is wrong for a girl to talk loudly.
She spoke in her own dialect – the American southern teenager — and said, “Like, it’s like wrong for a girl to speak like that. Ok, like, it’s just like, everyone has, like, their own traditions and, like, it’s just how a girl is raised.”
At the same time, she had some very interesting and important opinions to share. It’s, like, totally cool that a 13-year-old gets this linguistics lesson.
I started thinking about what this means for nurses and for nursing. It is often difficult for us to articulate our contribution to health and health care. We are trained to be reserved and deferent. It’s considered respectful, but it means that our voices are not heard. This can be especially true at the table of health care decision-making.
As we work with our colleagues from the University of Gondar, we need to encourage them to represent nurses in a way that is culturally acceptable and to advocate for nursing’s contribution to patient outcomes — to speak up for what nurses mean to patient care.
This is true for us in Ohio, too. We should learn to make our voices heard.
REPRESENT!
What nurses do is, like, totally awesome!
Tim Landers of Ohio State’s College of Nursing shares this clip of what 5 a.m. sounds like in Gondar, Ethiopia, as he prepares for another day with the One Health Summer Institute.
By Tim Landers, RN, PhD
Ohio State College of Nursing
I’ve noticed some really excellent craftsmanship in Gondar.
Craftsmanship is evident in the way a napkin is carefully folded that turns an evening meal in to a “dinner.” And craftsmanship is the patience of our waitress giving me a lesson in napkin folding.
Craftsmanship is the way that the pharmacist carefully wrapped up a packet of medication she prescribed for me because of the cold I’ve acquired in my last days in Gondar. It says, “I hope you feel better” before you open it.
Craftsmanship is the certain way a bundle of straw is tied to the back of a donkey on the way to market or the way a cup of coffee is poured when the person actually cares. It’s the expert skill and flair a microbiologist uses to streak an agar plate or a nurse uses to comfort an ailing patient.
One of the great craftsmen I have met is Mr. Abebe Demise. Abebe has a small shoe-shine bench outside our hotel. What makes him a craftsman is not that he does a good job cleaning and shining shoes; he does a great job on shoes from the dusty streets of Gondar. 
What makes him a craftsman is that when Mr. Abebe is at work shining shoes, he is in the zone. His full attention is on the task at hand. He uses the tools of his trade – he uses all of his attention – to shine shoes. To watch him in action is to see a master craftsman at work.
Craftsmanship is a difficult concept to teach to students in our “Research Methods Course.” There is just a way that a carefully constructed title of a scientific paper can grab your attention. A well-written set of specific aims can explain the purpose of a research project in a way that extends beyond the words printed on the page. A well-organized literature review can make reviewers beg you to do your experiments.
This skill of craftsmanship in writing grants takes years to develop — and I am no pro. But I know good grants craftsmanship when I read it—and when I see it.
On my last day in Gondar, Abebe Demise called to me from his shoe-shine bench across the street. He had a small envelope for me with “For: Tim Landers, From: Abebe” written on the outside. Inside were two picture postcards of Gondar.
I’d like to think that maybe – just maybe – this was one craftsman’s way of acknowledging a fellow craftsman.
Professor Tim Landers and Mr. Abebe Demise, one of the great craftsman of Ethiopia.
By: Tim Landers, RN, PhD
Ohio State College of Nursing
This past weekend, we had a chance to take a hiking tour of the Simien mountains in Ethiopia. This has to be one of the most beautiful places on earth – the landscapes are gorgeous, the people are smiling and proud, and there is plenty of wildlife.
I have done quite a bit of hiking with my two sons and friends from Boy Scout Troop 33 in Columbus. As we were hiking across the Simien mountain pass, our guide and I chatted about our experiences hiking and guiding groups.
Melese Beza (of www.outstandingsimienmountainstours.com) grew up tending livestock as a shepherd and works as a professional tour guide through the mountains as he completes his bachelor’s degree in tourism management. He speaks English quite well and we began to talk about the types of health problems he encounters as a professional hiking guide.
We took a break as it began to rain and started a “show and tell” of our first aid kits. He had a basic kit ready for the main emergencies from African trekking – including what he adoringly called “potions” such as acetaminophen, wound disinfectant, and diarrheal medications.
Ohio State’s Tim Landers and Simien Mountain tour guide Melese Beza do a “show and tell” of their first aid kits during a rain break while trekking through the Simien Mountains north of Gondar, Ethiopia.
The two take turns with their “show and tell” on first aid.
He used somewhat different terms, but described several conditions which would be expected – ankle “dislocations” (strains/sprains), altitude sickness, injuries from rock falls (abrasions and cuts), and blood sugar emergencies. He also described unfortunate drowning victims he recalled from last summer and that they had attempted “breath blowing” with success in one victim.
In my training back home, we’ve prepared for emergency evacuation of wounded hikers by helicopter transport, extricating from deep woods by foot and by vehicle, and most of our Scouts have completed training in first aid and CPR.
In this region of Ethiopia, there is no such option. There are no helicopter evacuations from the Simien Mountains. Guides call for help and it will come as soon as word can reach the village by foot and a jeep, configured as an ambulance, can make it to the wounded person.
As we discussed how injured hikers are treated and our own experiences, I was impressed with his solid grasp on these conditions. He has been working with several other guides trying to organize a more formal training in first aid and CPR for Simien Mountain guides.
Because our group is exploring the possibility of working with nurses and health extension workers to do health education, I was able to direct him to some excellent training resources developed by my friends at Columbia University School of Nursing. They have developed a fine first aid training curriculum in first aid for health extension workers.
I left him with some supplies from my kit and he reciprocated by sharing knowledge of local plants and remedies.
He left me with an appreciation for the training and preparation it takes to safely enjoy the outdoors – whether it is in Ohio or in Ethiopia.